Arch Pain and Heel Pain
Arch pain is commonly either plantar fasciitis or posterior tibial tendonitis.
The Plantar Fascia is a long band on the bottom of the foot that can be overstretched or strained. It is believed, if not due to an acute strain of the foot to be from faulty biomechanics. Chronic irritation of the fascia can lead to post static dyskinesia (pain after sitting or resting). The number of treatments are countless but the most common treatment is some sort of arch support along with physical therapy. If pain persists, then it is best to get a diagnosis from a foot & ankle specialist.
Posterior Tibial Tendonitis
The Posterior Tibial Tendon is a long tendon that runs from the leg to the inside of the ankle and arch. It pulls the foot into a higher arch position with walking and running. It is a major supporting structure of the foot. Over straining, usually due to abnormal biomechanics can cause arch pain with increased activity. Rest may help it.
Posterior tibial tendon dysfunction is a condition caused by changes or degeneraation within the tendon itself, impairing its ability to support the arch. This results in flattening of the foot. Posterior tibial tendon dysfunction is usually progressive, it can also come on rather quickly. If so, then aggressive treatment should be sought sooner than later. If left untreated, it could leave you with an extremely flat foot, painful arthritis, and increase limitations with physical activity. Symptoms: Flattening of the arch, inward rolling of the ankle, pain, swelling, etc. As rest may help, it is usually better to obtain an aggressive supportive orthotic to address the cause. In severe cases, some may be placed in an ankle foot orthotic (afo). However, I have found afo’s to be bulky, causing you to obtain larger shoes as well as most are made like a brace, eliminating muscular function leading to atrophy. In most cases, functional foot orthotics should be the first line of choice.
Achilles Tendonitis is inflammation of the achilles tendon either at the heel bone area or above it in the tendon itself. The Achilles tendon attaches your calf muscles to the heel bone. This tendon is used to jump, walk, run, and stand on the balls of your feet. Continuous excessive tension to this tendon can cause inflammation known as Achilles tendonitis. Symptoms may include pain, swelling, tight calf muscles, warm to the touch. Current research shows that immobilizing the tendon is not the best for it. It is important to have it diagnosed and treated accordingly to your biomechanics.
Faulty biomechanics is commonly a main contributory cause of much of the arch and heel pain. Dr. Sables can help immediately with taping immobilization, therapy, etc. followed by biomechanical correction to alleviate and prevent further injury.
Note: Sometimes Plantar fasciitis is considered plantar fasciosis or vise versa. One is actually an inflammation and one is a degeneration of the fascia. Some will say after 2 weeks it is degenerating and thus can take longer to heal. I have found that even at 2 years of “Plantar Fasciitis” we are able to obtain relief without surgery, injections nor the advanced therapy injections, etc.
There are other things that can cause arch and heel pain like systemic conditions, compressed nerves, stress fractures, etc. that can be the cause of your pain as well.
Heel Pain in Children
In children, usually around 10-12 years old, it is commonly Severs Disease. This is not really a disease but rather abnormal pulling on the heel. It is NOT growing pains (have you ever heard of growing pains in the upper extremities?) If arch pain persists beyond a few days or frequently recurs with activity, see a foot and ankle specialist for treatment to prevent this condition from worsening. Remember, it typically does not take months for the pain to subside if biomechanics are addressed.
Arch pain and heel pain rarely requires surgery or outpatient procedures.
In order to walk or run we need to pronate. Pronation (sometimes as referred to “Rolling In” of the arch) is a normal function. Pronation is something like a shock absorber in a car. When the foot pronates, it absorbs the weight of our body like a spring. It is thought that over pronation leads to many painful conditions musculo-skeletally. Many times if the over pronation is limited, the painful condition subsides and development of arthritis, bunion, bone spurs, etc. is diminished.
However, recent research has some questions about this. First, they can’t define overpronation. Second, control of “overpronation” has not been shown (proof positive) to reduce injury in runners. Key words are injury and runners (as well as just because something is not proven by man, does not mean it does not exist and thus should not be ignored). Many of these studies are simply determining injury, not other maladies that come about with abnormal alignment. Further, runner mechanics cannot be compared to average standing/ walking and even running of the average Joe or Mary, who are not elite athletes. Finally, many of these studies are not comparing apples to apples not only within their subjects studied but also within the devices used in which they then compare them to all devices.
If you are “overpronating” or “rolling in” excessively, your body alignment may be off and most likely it may cause problems from the feet to the back.
Flat Feet & Low Arches
How flat should it be? Should it at all? Should it be limited? If so how much? Confused? Understandably so. Current research is not only unable to define what it is but unable to agree or “Prove” that anything from ignoring it to full motion control of a flat foot is helpful.
However, it is known that one cannot walk without supination and pronation (raising and lowering of the arches respectively). What is known is that everyone is different, not only with the foot but also the rest of the body.
I am often asked “Am I flat footed?” My answer is, in most cases, it is not weather your feet are flat nor how high your arches are, but rather “How much are your feet Flattening during your activity?” The verb, the motion of flattening is what’s most important. What is found is if any part of the foot during motion is not pronating or supinating as it should be along with being completely symmetrical in timing, trajectory and speed of motion, then you probably will end up with a problem somewhere along the kinetic chain (the foot to the back). We are essentially walking robots. Machines that move require all the above.
Some feet look like “flat feet” and some like “high arches”. The appearance is very subjective, but of course when you see it flattening or flattened with stance, you’ll know it. Again, usually, what’s most important is the action of the body during the activity.
So should “flat feet” be biomechanically treated with appropriate shoes and foot orthotics? Yes, in many cases, starting with the shoes and orthotics along with therapeutic modalities as needed with an individually tailored plan.
High arches or cavus feet can be troubling as the feet cannot absorb the shock of weight-bearing as well as the average foot does. There are different types of cavus feet (high arches). Some are rigid and some are flexible. Most will still pronate when needed but it can lead to jamming of the joints. Lack of appropriate pronation may cause problems with walking on hard surfaces causing either the balls of the feet and/or the heels tol hurt. They are also susceptible to plantar fasciitis and strain in the arches. Other problems commonly associated with cavus feet are low back, sacroiliitis, ankle instability, neuromas and peroneal tendonitis. Many times spurs can develop on top of the midfoot area as well. Sometimes cushioning is all that is needed but it does not really address the imbalance in the foot. Also, most over the counter inserts will not go high enough in the arches which is necessary to relieve abnormal pressures causing pain and arthritis. Some will apply a wedge laterally (on the outside of the foot) to shift the weight to the inside of the foot but this can place a strain on the ankle joint long term. the best treatment is to balance the foot out with custom molded orthoses. They not only aid in better osseous alignment but also redistribute pressure more evenly for comfort.
Bunions and Hammertoes
Bunions and Hammertoes are common problems aggravated by shoe wear. Both are deformities that develop over time as most of us are not born with them. The deformity will develop into arthritis which can cause the area to become painful and inflamed, especially if rubbed on shoes. Bunions and hammertoes are signs of biomechanical faults in the foot so it is best to obtain the ideal insert to realign the feet. Of course, shoe fit is important but it is not the cause. Simple padding and appropriate footwear may relieve the pain. Especially if it is a 2nd hammertoe or a bunion, it is best to obtain a custom molded orthotic to address the cause.
A heel spur is an abnormal growth of bone at the area where the plantar fascia attaches to the heel bone. It is cause by a long term strain on the plantar fascia and muscles of the foot, especially in people who suffer from obesity, runners, and joggers. Similar to plantar fasciitis, shoes that are worn out, poorly fitting or poorly constructed can aggravate the problem. Heel spurs may not be the cause of heel pain even when seen on an x-ray. In fact, they may develop as a reaction to plantar fasciitis.
When a toenail is ingrown, it is curved and grows into the skin, usually at the nail borders (the sides of the nail). This “digging in” of the nail irritates the skin, often creating pain, redness, swelling, and warmth in the toe. If an ingrown nail causes a break in the skin, bacteria may enter and cause infection in the area. This is usually marked by draining and a foul odor. However, even if the toe isn’t experiencing any of these symptoms, a nail that curves downward into the skin can progress into an infection.
Metatarsalgia is pain at the ball of your foot, singularly or in multiple areas across your foot. The pain is an inflammation that occurs at the metatarsal heads/the base of the toes. It is a common problem from too much pressure applied on the metatarsal heads, usually from abnormal biomechanics. Metatarsalgia can occur from poor footwear, poor foot function or systemic conditions such as arthritis. Metatarsalgia may also be called capsulitis, tendonitis and 2nd mpj syndrome. If it is associated with a callous, a biomechanical fault does exist and if so, then it is best to seek professional help- especially if it is on the 2nd area. Callous and or pain about the 2nd mpj/2nd toe base can lead to significant problems causing stress fractures or dislocation of the toe turning into a deformed hammertoe. Symptoms may be an aching, dull to a burning pain. This can also cause tingling or shooting pain in the toes. Sometimes simple metatarsal pads or gel may help but if there is a callous, then it is best to get a custom molded orthotic to redistribute the pressures. Rarely does it require surgery.
A neuroma is a benign tumor of the nerve but in actuality, in most cases, is an inflammation of the nerve with a thickening of nerve tissues that may develop in various areas of the foot. The most common neuroma in the foot is Morton’s neuroma. This occurs between the third and fourth toes (bases of). It is sometimes referred to as an inter metatarsal neuroma.
The thickening or enlargement of the nerve is thought to be the result of compression and irritation of the nerve. It can get displaced under the bone and even trapped in fibrous, scar like tissue. Even though it can be palpated, it doesn’t always mean it is painful.
However, if it is palpable, something is probably wrong mechanically as something is irritating the nerve. When it does become painful or symptomatic, you will know it. Over the years, you name the symptom, I have probably heard it: throbbing, aching, burning, electrical, stinging. Ive also heard, “I stepped down and felt a knife in and out of my foot,” ” I have to take my shoe off and rub it, there is a marble growing between my toes,” etc..
People with higher arches and other deformities are at a higher risk for developing a neuroma(s). Treatment can vary as much as the symptoms. A metatarsal pad, wider shoes, etc. in my experience are a 50-50 chance. One simple treatment for a neuroma is massaging. This loosens the surrounding tissues and increases blood flow for healing.
Side Note: Of course, one should not wear shoes too narrow. However, a patient once told me the neuroma felt better the tighter the shoe was. This is due to the shoe re-positioning the bones and joints into a more supinated position like an orthotic may do.
In order to have a higher success rate, it is important to get at the cause of the irritation. I have found that utilizing custom functional foot orthotics, along with simple to advanced physical therapy modalities, will address what is causing the irritation. The orthotics should be coordinated with the appropriate shoe based on your foot type, ideal fit and needs. Improve the osseous (bone and joint) alignment as well as muscular function begets less irritation to the nerve.
Morton’s Toe is a common condition where the second toe is larger than the big toe. This leads to excessive pressure on the second metatarsal head resulting in pain similar to metatarsalgia. Morton’s Toe impacts the whole body because it changes your posture and the way you walk and run. This is known to cause and perpetuate musculoskeletal problems. Ideally fit shoes and inserts can aid in controlling the many conditions and relieve pain without surgery.
Neuropathy or loss of feeling (but also burning, pins and needles) is seen with a number of different underlying medical conditions. It can also exist without the cause being known. This is called ‘idiopathic’ neuropathy. This idiopathic neuropathy conditions seems to be becoming more and more prevalent. It can affect the autonomic nerves, motor nerves and sensory nerves but sensory is typically the main complaint. Most cases of neuropathy are found in people who have diabetes. About half of those who suffer with diabetes have neuropathy but are without symptoms or do not know it. Testing for neuropathy should be a routine part of diabetic exams. Treatment consists of addressing the underlying cause as well as various medications. There are also some supplements that can help the nerves regenerate and thus some feeling and color comes back.
At ArchMasters, we have found many patients with neuropathy tell us that their conditions improved with the use of our orthotics. This is a because of improved foot function better distributes pressure under the feet and thus improves blood flow to the nerves, as well as reduces abnormal shearing forces on the feet.
Name the tendon and add “itis” to it. Example, tibialis anterior tendonitis, peroneal tendonitis, etc. All are an inflammation of the tendon. Although it can come about from overuse, there typically is an abnormal mechanical reason why it occurs. Anything that reduces the inflammation will help but the most recent research shows straight immobilization is not always best. It appears that tendons need some load (pull) on them to better stimulate healing -not too much and not too little. Mechanically, I have found that reducing abnormal forces on the tendon thru functional orthotics is best not only in the short but also the long term.
Foot Pain During Pregnancy
It is common for women to have foot pain while pregnant. Due to the natural weight gain during pregnancy, a woman’s center of gravity can be altered. This causes a new weight bearing stance and added pressure to the knees and feet. Two of the most common foot problems experienced by pregnant woman are over pronation and edema. These problems can lead to pain at the heel, arch, or the ball of the foot. Many women may also experience leg cramping and varicose veins due to weight gain. It is important for pregnant women to learn more about foot health during their pregnancy to help make the nine month period more comfortable.
There are effective ways to treat both over pronation and edema during pregnancy. Over pronation can be treated conservatively with orthotics. Proper fitting footwear is also very important. It is important to treat over pronation for pain relief but also to prevent other foot conditions from developing such as plantar fasciitis, heel spurs, metatarsalgia, post tibial tendon dysfunction and bunions. Edema in the feet can be minimized by elevating your feet as much as possible and wearing well fitted footwear. Drink plenty of water and eat a well balanced diet to help reduce swelling. If swelling is not symmetrical in both feet, this many be a sign of a vascular problem and a doctor should be contacted immediately.
Sesamoiditis is a common ailment that affects the forefoot, typically in young people who engage in physical activities like running or dancing. The most common symptom is pain in the ball of the foot, especially of the medial or inner side. The term is a general description for any irritation of the sesamoid bone, which are tiny bones within the tendons that run to the big toe. Similar to the kneecap, the sesamoids function as a pulley, increasing the leverage of the tendons controlling the toe. When you push off against the toes, the sesamoids are involved and eventually become irritated, even fractured.
Shin splints are a type of “overuse injury” to the legs. Shin splints are not the shin bone fracturing or splintering. It is actually the muscle pulling excessively on its attachment to the bone. The pain is characteristic and usually located on the edge of the mid region of the leg usually next to the shin bone (tibia). It can be in different areas of the leg as well. It can be extreme and halt workouts. A multi-faceted approach of “relative rest” can restore a pain free level of activity and return to activity. Treatment includes changes in workouts, ice, rest, anti inflammatory medication, etc. As shin splints are typically caused by abnormal excessive pull of the muscle off the bone, addressing the faulty biomechanics long term can be best.
If you’re not born with it, toe deformity develops as you grow and age. If so, this typically a sign of an abnormal alignment of your feet causing the muscles and tendons to abnormally contract the toes which can lead to hammer, mallet, or claw toe deformities. This can eventually lead to arthritis in the joints. Eventually the toes will not be able to be straightened out manually. Shoes do not necessarily cause hammertoes but rather can aggravate them if the shoe is not ideally fit. If you suffer with toe deformities, it is recommended you get checked for biomechanical causes.
There are three layers of the nail plate itself. The fungus can get in any layer or a combination of the layers. Nail fungus could be a simple discoloration on the top layer or if it starts involving the other layers it can cause abnormal thickening of the nail. It can also provide a foul odor. Toenails are vulnerable around damp areas where you are likely to be walking barefoot, such as a swimming pool, locker rooms, and showers. Injury to the nail bed may make more susceptible to all types of infection. Those who suffer from chronic disease such as diabetes, circulatory problems, or immune deficiency conditions, are especially prone to fungal nails. Hereditary factors are involved as well but it is typically not indicative to poor hygiene.
Callus or Callous
A corn or a callous is thick skin. It is a defensive mechanism of your skin trying to protect itself from abnormal pressure, friction or shearing forces. It is usually over a bone prominence. If you have one, there is a problem. Trimming, padding and appropriate shoe wear is sometimes helpful. Addressing the cause by offloading the area with padding or orthotics is usually best. Even if you file or trim it off, it will reoccur because you have to get at the cause of it.
Having callouses is not normal, especially if it is on the side of the big toe or under the ball of the foot or heel area. I commonly hear runners “need to build up their skin to form callouses.” In general, thickening of the skin from over pounding your feet with running may be OK but not if a single or multiple single solitary callous forms. The latter is usually a mechanical fault that can lead to other problems such as stress fractures, etc.
Finely, be careful not to confuse the callous with a wart. They sometimes can look similar as both build up skin tissue and get crushed with weight-bearing. To differentiate a wart vs. a callous, squeeze it and if it is a wart, it will usually hurt alot more to squeeze it (as it has nerve endings in it) verses simply applying direct pressure onto it. The wart will typically have black dots in it and appear more like “crushed cauliflower.”
The feet were designed to absorb shock with landing and then to become a propulsive mechanism. In order for this to occur, one will pronate with landing and then re supinate with push off. Doing all of this, requires the bones in the foot to the hips to rotate in and out with exact timing, trajectory and symmetry of motion. Any changes that occur within these motions, for example to compensate for a joint that is not ready to bend at a certain time of gait, will cause strain some where in the kinetic chain (areas of movement thru your body). The resultant lack of shock absorbtion can transfer to your back or as in most cases, the back pain typically results from abnormal muscle pull caused by the abnormal compensations during the propulsive phase of gait. Long term this can cause leg length discrepencies, etc. as well. Realigning the foot to obtain equal timing trajectory and motion within the kinetic chain will typically reduce the back pain rather rapidly. I’ve seen patients that achieve relieve as soon as they put their custom orthotics on!
Like back pain, knee pain results from abnormal pull about the knee or twisting of the knee. When we pronate and supinate, the tibial (leg bone) will twist in and out respectively. If the femur (thigh bone) is not aligning with the tibia, then strain on the knee joint can occur, resulting in knee pain. Strain can also occur about the tendons about the knee joint causing bursitis as well as IT band syndrome and patellofemoral pain. Realigning the feet with custom orthotics will typically aid in realigning the tibia femur motion at the knee joint, thus relieving pain and helping long term.
Like the back and knee pain one can get, abnormal biomechanics is usually the cause. Most cases I see are hip pain on the side which is usually bursitis, tendonitis like pain. Typically caused by faulty mechanics. If the pain is anterior in the hip, it can be from actual arthritis in the hip. Realigning the feet, addressing the cause of the excess pressures and motions within and on the hip will address the cause, resulting in reduction or elimination of pain.
NOTE: With any musculoskeletal condition. physical therapy thru stretching, strengthening and other modalities as needed are usually helpful. However, I have found addressing the cause of these problems will aid in sometimes faster resolution of pain as well as longer term prevention of such. Address the cause and our bodies will heal.
Fibroma & Plantar Fibroma
Fibromas are rubbery like bumps on the foot. Somewhat like a ball of scar tissue. They can be small and grow, singular or multiple. They usually form within or about tendons. Sometimes it is hereditary. Many times they form from a “hyper repair” response to micro damage to tendons or fascia with daily activity.
Plantar fibroma simply means it is on the bottom of the feet. It can be singular or multiple as well. When it involves the plantar fascia, it typically is due to micro-tears of the fascia from too much strain. They may or may not become painful.
We have had success time and time again with treatment with custom orthotics that not only address the abnormal strain on the tendon or fascia but also by contouring or off loading the pressure to the fibroma. Massage is sometimes helpful along with topical noninflammatory but addressing the mechanics is usually the best long term solution. Surgery should be a last resort, especially as they can reoccur at the site.
Arthritis can be local such as from repetitive use of the joint (osteoarthritis) or systemically from problems such as rheumatoid, psoriatic, gout and seronegative spondyloarthritidies. Whether local or systemic, unfortunately the joint is breaking down. Arthritis is not always painful but it will typically lead to pain.
Localized arthritis from “wear and tear” (osteoarthritis) is frequently found in the big toe joint. It is formed not only with bunions but also with hallux rigidus. Bottom line is there are abnormal forces thru the joint and the result is breakdown. Realign the forces thru the joint and many times the pain will resolve as well as prevent the need for surgery. We have helped many who were told they needed a joint fusion to relieve the pain- even in extreme painful arthritic cases.
Custom orthotics have been found to reduce the amount of flare ups in rheumatoid arthritis. Again, minimize pressures and pain will decrease.