FOOT CONDITIONS
The Foot
The foot is composed of 26 bones, 4 arches, and countless muscles, veins, arteries, nerves, joints, and fascia. Beyond that, we rely on the foot repeatedly throughout the day to walk, run and stand. The feet take a lot of abuse, it's easy to understand why they're so prone to injury. We've outlined some of the most common injuries we see and treat in our clinic.
Achilles Tendonitis/Tendonosis: The Achilles tendon is made up of the tendons from two muscles in the lower leg, the gastrocnemius and the soleus. It attaches onto the top/back portion of the calcaneus (heel bone) and is the largest tendon in the body, being able to withstand over 1,000 lbs. of pressure. Although it is strong, it is also the most commonly ruptured tendon. Micro tears occur in the tendon causing inflammation in the area. The patient feels pain at the back of the heel, typically after periods of rest or during jumping, and starting/stopping activities. Inflexible lower leg muscles, over pronation of the feet, and changes in footwear and training schedules are all causes of this condition.
Bunions: Bunions are seen at the side of the base of the big toe. It looks like an enlargement of the joint. They form when the big toe bends laterally towards the other toes, a condition also known as Hallux Abducto Valgus. Bunions can result from abnormal bone formation in the first metatarsalphalangeal joint. Poor foot mechanics are often genetic and can lead to this problem. Other things such as injuries to the foot and 1st toe, flat/pronated feet, and poor footwear can also be a cause. People with bunions complain of pain from the pressure of their footwear, redness and swelling in and around the joint, the motion of the first toe is very restricted, and their other toes are affected either by hammer toes, calluses or corns.
Compartment Syndrome: Compartments are seen in the limbs of the body and are made of muscles, nerves, and blood vessels all bundled up by fascia. Compartment syndrome occurs when pressure builds up inside a compartment (usually one of the two in the lower leg), this pressure prevents nourishment (oxygen etc.) from reaching the tissues. There are two different types of CS, acute and chronic.
Acute Compartment Syndrome:
- can take several hours to develop
- when the pressure exceeds the blood pressure within the compartment, the blood vessels collapse
- without nutrients the tissues can die within hours
- common causes of ACS include badly bruised muscles, complications after surgery, circulation blockage, crushed foot, and major changes in activity levels.
Chronic Compartment Syndrome:
- pain and swelling typically due to exercise
- improves with rest
- numbness and difficulty moving foot
- muscles feel "tight" or "full"
- the pain stops relatively quickly after ending activity but the pressure can remain elevated for some time
Corns:
The formation of dead skin cells that develop on the top, sides and tips
of the toes. The core of the corn is usually cone shaped with the point
facing down. With pressure, the tip can press onto a nerve, making it
even more painful. Corns may also become inflamed due to friction from
footwear.
Gout: Gout occurs most often in the big toe but can affect any joint of t he body. It usually occurs overnight (within 12-24 hours). It involves painful swelling of one joint at a time, sometimes two. After the first attack a person may go anywhere from one week to years without having another, growing more frequent and more severe with every attack. Without treatment, gout may cause chronic or continuous joint problems and damage.
Uric acid is a natural chemical produced by the kidneys and is key in breaking down and building up food and body tissues. It is normally dissolved in the blood, but in the case of gout, crystal deposits form in the joint causing an inflammatory response.
Genetics play a role in this disease as well as obesity, sudden weight gain, abnormal kidney function, excessive alcohol consumption, and some cancers. The relationship between uric acid levels in the blood stream and gout is unclear. People with high levels of uric acid in their blood do not always have gout and visa versa.
Hammer Toes: Hammer toes can affect any of the toes except the big toe and is most commonly seen in the second toe. It happens when the ligaments and tendons tighten and pull the toe downwards. The bend occurs in the proximal inter phalangeal joint (PIP) with the base of the toe pointing up and the bottom of the toe pointing down. Most people will not notice the inital signs of a hammer toe until a corn appears on the top of the bend in the toe. The corn develops due to the pressure and friction on the joint, typically from footwear. It will be noticeably painful while wearing tight fitting shoes. There are two seperate types of Hammer Toes. a) Flexible - can move actively and straighten passively (with help from fingers) and b) Rigid - movement in this case would be limited and painful. Hammer Toes can be hereditary but tight shoes are mostly the cause. Weak muscles in the foot and ankle can also be a factor.
Morton's Neuroma: A condition where nerve(s) are being "squeezed" by the toes and surrounding tissues of the foot, typically between the 3rd and 4th toe. Symptoms of this condition include sharp pain, burning, and even a lack of feeling in the affected area. Morton's Neuroma may also cause numbness, tingling, or cramping in the forefoot. You may experience this after prolonged walking or standing.
Metatarsalgia: A painful condition in the metatarsal area of the foot (the ball of the foot). Pain is typically located under the 2nd, 3rd and 4th toes and is most prominent under the 1st toe (big toe). One or more of the metatarsal heads become inflamed due to extended pressure on the forefoot. Improper fitting shoes are a common cause.
Plantar Fasciitis: The plantar fascia is a band of connective tissue running from the heel into the toes and serves to support the bottom of the foot. It takes a bulk of the load when you are weight bearing. When the fascia and surrounding tissues aren't stretched/used regularly there are allowed to shorten. A shortened plantar fascia is more likely to tear when asked to stretch past it's capacity (sometimes all it takes is weight bearing). The most common symptom of this condition is pain in the heel on 1st step, in the morning or after a period of rest.
The calcaneus is the largest bone in your foot and takes the most pressure when weight bearing. A heel spur can develop at the lower frontal area of the calcaneus, where the plantar fascia attaches. When under stress, the plantar fascia pulls away from the bone causing your body to lay down calcium (building block for bone) in an attempt to strengthen the area.
Many people have a spur and don't know it because a spur alone does not cause pain. Rarely are there cases of the spur "poking" into tissue resulting in pain. A spur is mainly just evidence that you may have plantar fasciitis.
Sever's Disease (Calcaneal Apophysitis): The bones of the body start out as cartilage during fetal development. As we age they ossify into the bones we have as adults. The heel bone is no exception. It is made up of two bones with cartilage in the middle. The bones fuse together at around 16 years of age. Sever's Disease occurs when there is a disturbance of growth in this area and therefore is common in adolescents age 10 to 14. Pain in the heel is usually present during sports, especially ones that involve running and jumping. Common risks are obesity, over activity, tight calf muscles and over pronated feet.
Shin Splints: Characterized by inflammation of the sheath of the periosteum (bone) of the tibia (shin bone). This may happen on the outer side (lateral) or the inside/back of the tibia. Most describe the onset of pain as gradual, starting as a dull ache after walking or running. The area of pain is typically localized, being 4-6 inches in length on the mid region of the bone. The muscles that attach to the tibia (soleus, flexor digitorum longus, tibialis anterior) often feel sore as well. Causes may include overuse, running on hard surfaces, tip toe running, high arches, and bad shoes and arch support. There is an increased risk of stress fractures occurring if this condition is left untreated.
Sprains: An overstretching or tearing of a ligament. The most commonly damaged ligament is the anterior talo-fibular ligament of the ankle. Risks of injury include poor rehabilitation of a previous sprain, poor proprioception of a previously sprained ankle, and weak ankle muscles. There are three different types of sprains:
1. 1st Degree Sprain: There is some overstretching and tearing of the ligament and little or no functional loss of the ankle. There is mild pain on weight bearing and some swelling and stiffness.
2. 2nd Degree Sprain: There is more tearing than a first degree sprain, moderate instability, moderate to severe pain on rest and severe pain on weight bearing. Swelling and stiffness are also present.
3. 3rd Degree Sprain: The ligament is completely ruptured, there is functional loss and gross instability. Many times there is severe pain right after the injury followed by no pain at all. Swelling is typically severe.
Tarsal Tunnel Syndrome: Signified
by the entrapment of the tibial nerve inside the ankle. Patient has tingling
and numbness in the sole of the foot that worsens throughout the day.
Rest and elevation lessen the symptoms. The tibial nerve BENDS around
behind the medial malleolus, making it more prone to injury. Surrounding
structures can also impinge the nerve if they are swollen or inflamed.
Things like flat pronated feet, a cyst or lesion in the area, Rheumatoid
Arthritis, fractures or other misalignments to a joint can cause this
condition.
Plantar Fasciitis is characterized by the inflammation of the plantar fascia, although inflammation is not always present which we'll get into shortly. Stress, strain and or trauma can cause micro tears in the fascial tissue leading to heel pain, arch pain and potential lower leg pain.
Although the condition seems to be abundant in athletes, they are not
the only ones at risk. Any activity that promotes excessive or extreme dorsi/plantar
flexion such as running or jumping could potentially lead to plantar fa
sciitis. Sudden weight gain, tight muscles in the lower leg, commencing
exercise after a long period of dormancy, even structural problems such
as flat feet or high arches play a role.
We all know that when an elastic is stretched with force that it will tear at a certain point, imagine that same force being put on a shorter elastic. The breaking point would be much sooner. When the muscles of your lower leg become "tight" they shorten, causing your foot to rest in a more flexed position.This flexed position puts strain on the surrounding tissues of the foot and allows them, along with your plantar fascia to shorten. As a result the tissue is more susceptible to injury. One of your best defenses is stretching.
The most common symptom of plantar fasciitis is pain in the heel or arch of the foot with the first few steps taken in the morning or after a long rest period (first-step pain). This is because the tissue is being forcefully stretched after it's had time to shorten. Other symptoms may include; localized pain at the front of the heel, pain in and around the achilled tendon area, the pain typically starts gradually, worsening as the condition becomes chronic.
The conventional treatment for plantar fasciitis tends to involve the use of non steroidal anti-inflammatory drugs (NSAID's). As previously mentioned, this condition doesn't always involve inflammation, that may seem strange because the suffix "itis" pertains to inflammation. The tissue may receive tears that are not traumatic enough to cause a vascular disruption necessary for an inflammatory response and should end in the suffix "osis" meaning condition of. So why give anti-inflammatory medication when inflammation isn't present? Good question. Unfortunately, plantar fasciitis is very often mistreated and misdiagnosed.
Conditions that are acute and involve inflammation are typically "easy" to treat and patients recover in a relatively short period of time (4-6 weeks), where as non-inflammatory conditions tend to take longer (3-12 months).
Definitions
Plantar Fascia: A fibrous aponeurosis (ligament-like) structure that extends from the front of the heel into the base of the toes. It provides static support to the longitudinal arch of the foot and aids in shock absorption.
Gastrocnemius: A large, superficial (close to the surface)
muscle of the lower leg which serves to plantar flex the foot and flex
the leg at the knee.
Soleus : A flat, broad muscle of the lower leg that serves to plantar
flex the foot. Deep muscle compared to the gastrocnemius.
Achilles Tendon: The tendon of the gastrocnemius and
the soleus muscles of the lower leg.
Plantar
flexion: The motion of pointing the toes away from the body (towards
the floor)
Dorsi flexion : The motion of pointing the toes towards
the body (upwards)
Plantar Fasciitis Facts
- One disturbing fact about plantar fasciitis is that it sometimes takes
many months to resolve. Indeed, it takes approximately 6 months for
75% of people to recover from this problem. 98% of people seem to be
better at 12 months.
- Studies suggest that approximately 10% of individuals who see a doctor
for plantar fasciitis have the problem for more than a year. Chronics
plantar fasciitis is defined as plantar fasciitis symptoms persisting
for 6 months or more.
- An estimated 10% of all running injuries are inflammations of the
fascia, an incidence rate which in the U.S. would produce more than
200,000 cases of plantar fasciitis per year, just from the running population.
- A recent study determined that 77% of its sample of 411 plantar fasciitis (heel spurs) patients were overweight. Another study found that 23% of overweight women had plantar fasciitis (heel spurs) compared to 8% of the normal body-weight group.
Heel Spurs
The calcaneus is the largest bone in your foot and takes the most pressure when weight bearing. A heel spur can develop at the lower frontal area of the calcaneus, where the plantar fascia attaches. When under stress, the plantar fascia pulls away from the bone causing your body to lay down calcium (building block for bone) in an attempt to strengthen the area.
Many people have a spur and don't know it because a spur alone does not cause pain. Rarely are there cases of the spur "poking" into tissue resulting in pain. A spur is mainly just evidence that you may have plantar fasciitis
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