Foot and Ankle Pain

Ankle Joint:

The ankle joint, which connects the foot with the lower leg, is one of the most frequently injured joints in the body. Normal injuries occur due to an unnatural twisting motion when the foot is planted awkwardly, when the ground is uneven, or when an unusual amount of force is applied to the joint.

After an ankle injury or sprain, there is usually significant tension on the extensor tendons, sheaths, and the retinaculae on the front of the ankle. As in other parts of the body, the increased tension will cause pressure and friction between the many different layers of tissues in the ankle, and cause an adhesion.

Such injuries happen during athletic events, while running or walking, or even doing something as simple as getting out of bed. Ankle injuries can be painful and can make it hard to carry out your daily activities. The ankle joint is very complex with very small ligaments, muscles, tendons and bones holding it together. Once an ankle has been injuried, it may re-injure easily.

A Review of the Important Parts of the Ankle:

• The ankle joint is made up of three (3) bones.
• The tibia is the major bone of the lower leg as it bears most of the body's weight. Its bottom portion forms the medial malleolus, the inside bump of the ankle.
• The fibula is the smaller of the 2 bones in the lower leg. Its lower end forms the outer bump of the ankle.
• The talus is the top bone of the foot.
• Fractures are breaks in these bones.

Tendons connect muscles to bones. Several muscles control motion at the ankle and each has a tendon connecting it to one or more of the bones of the foot. Tendons can be stretched or torn when the joint is subjected to more than normal stress. Tendons also can be pulled off the bone to which they attach. An example of an injury of this type would be an Achilles tendon rupture.

Ligaments provide connection between bones. Injuries to the ligaments are called sprains. The ankle has many ligaments holding it together. Stress on these ligaments can cause them to stretch or tear. The most commonly injured ligament is the anterior talofibular ligament that connects the front part of the fibula to the talus bone.

Plantar Fasciitis:

Plantar Fasciitis refers to a condition where the fibrous band of tissue that runs from the heel along the arch of the foot becomes inflamed and adhered. This strong fibrous tissue contributes to maintaining the arch of the foot and is also one of the major transmitters of weight across the foot during a normal running/walking gait.

Plantar Fasciitis is caused by straining the ligament that supports your arch. Repeated strain can cause tiny tears in the ligament. These can lead to pain and swelling. This is more likely to happen under the following circumstances: your feet roll inward too much when you walk (excessive pronation); you have high arches or flat feet; you walk, stand, or run for long periods of time, especially on hard surfaces; you are overweight; you wear shoes that don't fit well or are worn out; or you have tight Achilles tendons or calf muscles.

Symptoms of Plantar Fasciitis:

Classically there is pain well localized over the heel/arch area of the bottom of the foot. Often the pain is most severe when you first stand on your feet in the morning, and it feels as though the bottom of the foot is tearing apart. Prolonged standing or walking can also exacerbate the symptoms.

Diagnosis of Plantar Fasciitis:

Your doctor will check your feet and watch you stand and walk. He or she will also ask questions about the following: your past health, illnesses or injuries you have had; your symptoms, such as where the pain is and what time of day your foot hurts the most; your activity level; and what types of physical activity you perform. Your doctor may take an X-ray of your foot if he or she suspects a problem with the bones of your foot, such as a stress fracture.

Treatment of Plantar Fasciitis:

• Active Release Techniques® - ART® restores the pliability and functional capacity of the tissue by breaking adhesions formed during the inflammatory process.
• Ice - Ice helps to decrease and control inflammation. Clinical pearl! Ice the Plantar Fascia by rolling a frozen water bottle back and forth under the foot.
• Stretching - After the tissues have been freed of adhesions through ART®, stretching of the plantar fascia promotes proper healing. A stretching routine will also help prevent future flair ups.
• Orthotics - Having an insert cast to your feet will provide the proper support for the arch of the foot, thus relieving some of the tension put on the Plantar Fascia.
• Night Splints - These splints are worn at night to help keep the Plantar Fascia in a stretched position, thus preventing the tissue from becoming tightened at night.
• Cortisone Injection - This injection is a powerful anti-inflammatory that should be used when other more conservative approaches fail. Because the injection only addresses the inflammation and not the change in the tissue, in most cases, the pain will reappear when the shot wears off.
• Surgical release of the Plantar Fascia - Surgery is only used in extreme cases where months of conservative treatment has not resolved the symptoms. The outcome of these surgeries can not be reliably predicted by the surgeons; therefore, it is possible for symptoms to persist after the surgery. Other possible side effects of the surgery are over release of the fascia, injury to nerves of the foot, and/or infection.

This is a condition where the arch or instep of the foot collapses and comes into contact with the ground.

Symptoms of Pes Planus or "Flat Feet":

Pes Planus is easily detected by a visual inspection of the bare foot; there will be an absence of the medial longitudinal arch. Although this is not usually painful in and of itself, it can contribute to other injuries such as over pronation, foot pain, shin splints, knee, or hip pain.

Treatment of Pes Planus or "Flat Feet":

• Active Release Technique® - ART® is considered to be the best soft tissue treatment.
• Orthotics - Having an insert cast to your feet provides the proper support for the arch of the foot, thus holding the arch in the proper biomechanical position.
• Strengthening - With proper instruction and exercising the muscles supporting the arch, the functional capacity can be improved.
• Chiropractic Manipulative Therapy - Chiropractic Manipulative Therapy restores the biomechanical motion to the joints of the foot.

Achilles Tendonitis:

Achilles Tendonitis is a condition of irritation and inflammation of the large tendon on the back of the ankle, usually caused by overuse. Clinical pearl! Overuse injuries are most often caused by increasing your workout load too much in too short a period of time. "Too much too soon..."

Symptoms of Achilles Tendonitis:

There is usually pain and stiffness felt over the Achilles tendon during use, but this is relieved by rest. The pain is often felt most when running uphill or jumping. Redness of the skin and swelling around the Achilles tendon may be visible.

Treatment of Achilles Tendonitis:

• Active Release Technique - ART® restores the pliability and functional capacity of the tissue by breaking adhesions formed during the inflammatory process.
• Chiropractic Manipulative Therapy - This restores the biomechanical motion to the joints of the foot.
• Ice - Ice helps to decrease and control inflammation.
• Stretching - Instruction on proper stretching can help relieve the tension on the tendon.
• Rest - Rest allows the tendon time to heal with a decreased workload. Depending upon the severity of the tendonitis, necessary rest could range from modifying workouts to taking time off.
• Rehabilitation - After the dysfunction in the tissue is addressed, Physical Therapy sessions help to prepare the tissue for load and to avoid future injury. This would include such things as Range of Motion exercises, strengthening, and proprioceptive training.
• Heel Wedge - A heel wedge, which temporarily shortens the calf muscles, can be inserted into the shoe thus minimizing the stress on the Achilles tendon. This should only be used temporarily along with other treatments as it does not fix the source of the injury.
• Night Splints - These are worn at night to help keep the Plantar Fascia and Achilles tendon in a stretched position, thus preventing the tissue from becoming tightened at night.
• Cortisone Injection - This injection is a powerful anti-inflammatory that should be used when other more conservative approaches fail. Because the injection only addresses the inflammation-- not the change in the tissue fibers-- in most cases the pain will reappear when the injection wears off.

Ankle Sprain:

An ankle sprain is an injury to the ligaments and muscles of the ankle, often a result of an awkward step leading to abnormal load on and tearing of the ligaments. The most common is an inversion sprain where the ankle turns inwards and damages the ligaments on the outside of the ankle. A medial ligament sprain is rare but can occur particularly with a fracture. Ankle sprains divide into three categories: Grade I (first degree) ankle sprains cause stretching of the ligament with only a few fibers tearing; Grade II (second degree) ankle sprains result in partial tearing of the ligament but no significant instability of the joint; Grade III (third degree) ankle sprains result in complete tears of the ligaments and significant instability of the joint.

Symptoms of Ankle Sprain:

Common symptoms associated with an ankle sprain are pain, swelling, and bruising. With Grade I ankle sprains the symptoms tend to be limited to pain and mild or no swelling. Most patients can walk without crutches, but they may not be able to jog or jump. With Grade II ankle sprains there is usually more significant swelling and bruising, along with increased difficulty walking. With Grade III ankle sprains there is severe swelling and severe initial pain followed by a large drop in pain.

Treatment of Ankle Sprain:

• Initial first aid - Initial first aid consists of rest, ice, compression, and elevation. It is important to rest the injury initially to reduce pain and prevent further damage. Icing the ankle for twenty (20) minutes every hour helps to decrease and control inflammation. Compression with an ace bandage helps reduce bleeding and reduce swelling. Elevating the ankle higher than the heart will also help control swelling and bruising.
• Active Release Technique® - ART® restores the pliability and functional capacity of the tissue by breaking adhesions formed during the inflammatory process.
• Chiropractic Manipulative Therapy - This restores the biomechanical motion to the joints of the foot and ankle.
• Rehabilitation - After the dysfunction in the tissue is addressed, Physical Therapy sessions help to prepare the tissue for load and to avoid future injury. This would include such things as Range of Motion exercises, strengthening, and proprioceptive training.

Medial Tibial Stress Syndrome or "Shin Splints":

Medial Tibial Stress Syndrome is a dysfunction and irritation of the soft tissue along and the periostium of the shin bone (tibia). It is usually caused by a rapid increase in duration/intensity of workouts (overuse) or abnormal biomechanics (such as "flat feet").

Symptoms of Tibial Stress Syndrome:

The pain is commonly described as a dull aching type of pain on the inside of the shin; this area is often tender if palpated. Patients may or may not have a small amount of detectible swelling over this part of the tibia. Early on, the pain is usually only present during activity, but as the condition progresses, it will be painful constantly.

Treatment of Tibial Stress Syndrome:

• Active Release Technique® - ART® restores the pliability and functional capacity of the tissue by breaking adhesions formed during the inflammatory process.
• Orthotics - Having an insert cast to your feet provides the proper support for the arch of the foot, thus holding the arch in the proper biomechanical position.
• Ice - Ice helps to decrease and control inflammation.
• Rehabilitation - After the dysfunction in the tissue is addressed, Physical Therapy sessions help to prepare the tissue for load and to avoid future injury. This would include such things as Range of Motion exercises, strengthening, and proprioceptive training.
• Rest - If the condition is severe enough, rest may be necessary to allow healing. Depending on the severity of the condition, necessary rest could range from modifying workouts to taking time off.

Calluses and Corns:

Home treatment may help relieve discomfort from corns, calluses, or other thickened skin. To thin a corn or callus, rub the thickened skin with a towel after a shower or a bath. Use a pumice stone after bathing to reduce the tissue. Do not do this if you have diabetes, peripheral arterial disease, an immune system problem, or have poor circulation in your feet. Pad the pressure areas with doughnut-shaped felt, moleskin patches, or lamb's wool. Never cut corns or calluses because infection may develop. Some lotions and moisturizers may also relieve symptoms from corns and calluses.

Blisters:

Blisters are caused by friction bwtween two surfaces. Home treatment for blisters depends upon whether the blister is small or large and whether it has broken open. It is often recommened that you pop a blister with a sharp point and then put duct-tape over the blister to prevent it from becoming larger. This is a good idea if you are in need of a quick fix.

Swollen Ankles and Feet:

To reduce swelling in your ankles and feet, try the following home treatment measures. When sitting for any length of time, elevate swollen feet and ankles on a footstool or pillows and keep your feet elevated above the level of your heart, Get up and walk around for a few minutes every hour if you sit for any length of time. Cut down on your salt (sodium) intake. Remember that sodium can be hidden in foods such as cheese, canned soups, and salad dressing. Consider making your own salt substitute.

Varicose Veins are swollen or uncomfortable; see the topic "Varicose Veins."

Symptoms to Watch for with Home Treatment:

See the "Check Your Symptoms" section to evaluate your symptoms if any of the following signs occur during home treatment: numbness; tingling; or cool, pale skin. If your feet are peeling, cracking, itching, and burning from athlete's foot, see the topic "Athlete's Foot." If you have warts on your feet, see the topic "Warts and Plantar Warts." If you have heel pain, see the topic "Achilles Tendon Problems." If you have bent toes, see the topic "Hammer, Claw, and Mallet Toes." If you have calluses or corns, see the topic "Calluses and Corns." If you have pain in the arch of your foot, see the topic "Plantar Fasciitis." If you have pain in the mid-foot or arch, see the topic "Pes Planus - 'Flat Foot'." Be aware if symptoms continue despite home treatment or if symptoms become more severe or frequent.

Heel Spur:

A heel spur is an outgrowth of bone at the base of the heel. It causes pressure on the heel that leads to inflammation (swelling, tenderness, warmth) and eventually intense pain and difficulty when walking. It is common in adults, especially joggers and people who work standing up for prolonged periods of time.

Those with risk factors for heel spur include: runners; dancers; diabetics; overweight persons; persons who wear ill-fitting shoes or high heels daily; persons with previous injuries or strain; and persons with a breakdown of the heel fat pad due to aging.

Symptoms of Heel Spur:

• Pain on the bottom, middle, and pad of the heel, especially when walking, running or standing
• Pain with dorsiflexion (bending the foot back toward the knee)
• Severe pain common upon awakening and bearing weight
• Weakness and numbness in the foot

What Your Doctor Can Do:

• Diagnose the disease by asking about your symptoms, completing a physical exam, and ordering x-rays of the foot
• Rule out other diseases or conditions like arthritis, gout, nerve entrapment, bone fracture (break), presence of a foreign body (e.g. wood splinter) or cancer
• Recommend evaluation by a podiatrist who will prescribe custom-made shoe inserts called orthotics, elastic heel pads, arch supports, heel wedges, night splints (supports that hold the foot at a 90 degree angle), or a leg cast/boot with crutches
• Inject cortisone into the heel to reduce the pain and inflammation
• Recommend surgery to remove the spurs if supports fail to resolve pain after six (6) months

What You Can Do:

• Wear foot supports in both shoes daily.
• Try to walk normally; do not put too much weight on your toes.
• Apply cold compresses to the heel for ten to fifteen (10-15) minutes various times per day.
• Use acetaminophen (Tylenol), aspirin or ibuprofen (Advil, Motrin) to reduce pain.
• Rest your feet as much as possible; avoid standing for prolonged periods of time.
• Often elevate your feet above the level of your heart to reduce swelling.
• Stretch your foot by sitting on the floor with legs straight out in front of you and pulling toes toward you.
• Wear comfortable shoes with low heels and with good heel support .
• Reduce your weight if you are overweight.

What You Can Expect:

• Most people recover with ART®, supportive treatments, rest, and, if severe enough, surgery.
• Some complications may include stress to knees, hips, spine and arthritis of the heel.
• Contact your doctor if you develop symptoms of a heel spur or if symptoms continue despite receiving treatment.
• Seek immediate medical assistance if after surgery you suffer symptoms of an infection (increased pain and inflammation, fever, pus discharge, or excess bleeding) or if you develop side effects from the medication.