Coming off of our post on knee pain, we are going to move just below the knee to the foot and ankle. With all of the regions that we have previously clinically discussed, there may not be a more important one than the foot and ankle. The foot and ankle are literally our bottom block as they are the first part of the body to hit the ground with walking. As such, this region is vital to proper function of all the other joints the lie above, including the knee, hip, lower back, and even our shoulders!
Foot and Ankle Anatomy & Function
Anatomically the foot is made up of 33 joints, 26 bones, and over 100 muscles! We will not go into the full depth of all of these joints, bones, and muscles, but it is important to understand that the foot is a very complex area of our body. We will review some anatomy of the foot. 7 of the 26 bones of our foot are known as the tarsal bones, which make up the rear section of our foot. One of the tarsal bones, the talus, attaches (through ligaments) to our lower leg bones, the tibia and fibula, to form our ankle. Another of the tarsal bones, the calcaneus, is our heel bone. Our mid foot is formed by our metatarsal bones, which are 5 bones formed in a row that are numbered 1 through 5 with the 1st metatarsal being closest to the arch and the 5th metatarsal sitting on the outer edge of the foot. The other 14 bones of the foot are our phalanges, which are the bones that make up the toes. All of our toes but our big toe consist of 3 phalanges. The big toe consists of 2 phalanges.
As stated above there are 33 joints in the foot, in other words, there are many moving parts in our foot! As joint mobility requires muscles to move bones, there are over 100 muscles in the foot! We will not go into detail with the joints and muscles of the foot, as it is beyond the scope of this post.
The ankle joint is formed by 3 bones: the two lower leg bones, tibia and fibula, and one of the tarsal bones, the talus. The talus connects to the tibia (as well as the calcaneus and navicular, 2 other tarsal bones) medially through 4 ligaments collectively known as the deltoid ligament and it connects to the fibula (and calcaneus) laterally through 3 ligaments: the anterior talofibular ligament, the posterior talofibular ligament, and the calcaneofibular ligament. There are 5 primary muscles of the ankle joint: the tibialis anterior, the peroneus longus, peroneus brevis, gastrocnemius, and soleus. There are 4 primary movements of the ankle joint: dorsiflexion, plantarflexion, eversion, and inversion.
Looking back at the joint-by-joint approach we will see that the foot is a primarily stable region of the body, which makes a lot of sense as we need a very stable base to roam the surface of the earth through our foot. However, in order to keep the foot a more predominantly stable, we need the ankle to be a mobile joint. The good news is that the ankle is a mobile joint. The bad news is that limited, or restricted mobility is often found in the ankle, which has significant impacts not only locally to the foot and ankle, but to our entire kinetic change including the hip, knee, lower back, and shoulders. Restricted mobility in the ankle is common as a result of the impact and stress that is displaced to this joint associated with reactive force that comes from the ground with walking and running. Tension in our calf muscles, which tends to be a common area of tension related to the amount of stress to these muscles with walking, running, and jumping can also create stiffness and restricted mobility in our ankles. The motion of the ankle that most commonly becomes restricted and tends to have the greatest impact on our kinetic chain is dorsiflexion.
Another factor that needs to be discussed from a functional perspective of the foot and ankle is positioning of our foot with walking or running, which plays a significant role in how our weight is distributed with walking and running. The two terms that are used to describe foot position are pronation and supination. Pronation means that when you walk, your weight tends to be more on the inside of your foot. Supination means that when you walk, your weight tends to be more on the outside of your foot.
Balance: Why the Foot & Ankle are so Important
The foot and ankle are full of receptors that provide information to our brain to help our brain understand how to control muscle activation and sequencing with running, walking, and with balancing ourselves. This ability of our brain to receive this information from local joint receptors and process it to understand position and orientation to allow the body to move and balance effectively is known as proprioception. Proprioception can be disrupted and negatively affected with foot and ankle injuries, particularly ankle sprains, which damage ligaments in the ankle, home to many of these receptors that are responsible to transmit information to the brain. This is one of the most important reasons to have an injury, such as an ankle sprain, properly rehabilitated.
In addition to its importance to proprioception, the foot and ankle is also extremely important to activation of our core stabilizers to help with trunk and pelvic stability. This connection is through a fascial line, known as our deep frontal line. Fascia is a thin connective tissue that connects all of our muscles together, similar to ligaments connecting our bones together to form our skeleton, fascia connects our muscles together into fascial lines to help muscles work together to allow for motion of the body. Through the deep frontal line, the muscles of our feet are connected to the muscles of our core! One of the first thing we teach our patients, who are rehabilitating from an injury and require improved ability to activate their core, is how to properly use their feet to engage their core. The cores ability to provide trunk and pelvic stability are extremely important to our body’s ability to balance.
Common Injuries of the Foot & Ankle
Issues with the foot and ankle may not always show up as pain in these regions. Often functional issues, such as limited ankle mobility, will show up as knee, hip, or lower back pain as there will be increased stress to these areas from compensation necessary for the loss of ankle mobility. However, there are some common functional related injuries of the foot and ankle region, let’s discuss some of them.
Plantar Fasciitis
Plantar Fasciitis is one of the most common injuries of the foot. It involves inflammation of a band of thick connective tissue that runs across the bottom of our foot from the heel to the toes, known as the plantar fascia. From a symptomatic standpoint plantar fasciitis typically results in a burning pain in the bottom of the foot, most commonly at the heel. The pain is often worse in the morning upon rising and standing from bed and with prolonged standing and walking activity. These symptoms are very similar to a heel spur, which often needs to be ruled out if symptoms are not responding to treatment for plantar fasciitis.
The plantar fascia is part of another fascial line, known as our superficial back line. Though, the cause of plantar fasciitis is scientifically poorly understood. My experience with plantar fasciitis is that there tends to be restriction and tension of the superficial back line or what is often referred to as our posterior (backside) chain. As shown, this line runs from the forehead all the way to the plantar fascia, with our plantar fascia acting as one of the anchor points of this chain. Tension or restriction anywhere in this fascial line (which is not uncommon as it involves the neck, lower back, hamstrings, and calves; all of which are common areas of tension), can displace more stress to the plantar fascia as it is an anchor to this chain. As a result, it makes sense that though we experience pain in the plantar fascia region that the actual problem lies in another region of this fascial line (such as the neck, lower back, hamstring, or calf).
Any easy way to determine if you have tension in this line is to attempt to reach your toes from a standing position and then from a seated position while keeping your knees straight without any bend. If you can touch your toes in either position, it is unlikely that you have a restriction in your superficial back line. If you cannot it is likely that you do have a restriction somewhere in this line. In addition, if you are experiencing pain consistent with that of plantar fasciitis (burning pain in the heel upon standing or with prolonged standing or walking) this likely is contributing to your pain. We offer a number of proven conservative methods to help with treating plantar fasciitis including using ice, changing your footwear (buying a new pair of shoes), reducing tension in your superficial back line, eating an anti-inflammatory diet, or improving your foot mechanics. Soft tissue treatment with massage and soft tissue mobilizations can be very beneficial for plantar fasciitis. Sometimes, anti-inflammatory medication, a steroid injection, and even surgery may be necessary.
Achilles Tendinosis/Tendinitis
Achilles tendinosis and Achilles tendinitis has some similar characteristics to plantar fasciitis. The Achilles tendon connects our calf muscles (gastrocnemius, soleus) to our heel bone. The Achilles tendon is also a portion of our superficial back line, just like the plantar fascia. In fact, the plantar fascia is a direct continuation of the Achilles tendon through this fascial connection! Achilles tendinitis typically causes pain in the backside of the heel (compared to plantar fasciitis, which causes pain in the bottom of the heel) that is more noticeable with walking, running, and jumping. Just like plantar fasciitis, Achilles tendinosis and tendinitis are frequently a result of repetitive stress and overuse. They can also be directly related to tension in any portion of the superficial back line that displaces a disproportionate amount of stress to the Achilles tendon with the above noted activities. Achilles Tendonisis differs from Achilles Tendinitis in that tendinosis results from a weakening of the tendon over time due to improper healing of micro-tears of the tendon. Tendinitis is an acute injury of the tendon that causes pain and inflammation. Both conditions have similar mechanisms of repetitive stress, which can result from activities such as running or jumping. Both conditions are frequently treated conservatively with stretching and strengthening based exercises, particularly eccentric based strengthening exercises. Mobilization and manipulation of the foot and ankle can be helpful along with modalities to help promote tissue healing, such as ultrasound or laser therapy. In addition, anti-inflammatory medication can be benefical to reduce inflammation in Achilles tendinitis. Just as with plantar fasciitis, a change of footwear and reducing tension in the superficial back line can be very beneficial as well. Often there is a period of reducing or temporarily eliminating the aggravating activity such as running or jumping to allow the tendon to rest. Medication and surgery are sometimes necessary with the most difficult of cases.
Retrocalcaneal (Heel) Bursitis
Retrocalcaneal bursitis is similar to Achilles tendinitis in its pain presentation. The retrocalcaneal bursa lies between the back of the heel bone (calcaneus) and the front of the Achilles tendon. A bursa is a fluid filled sac that helps to cushion areas of our body particularly from friction. They often lie between areas of muscle and bone. We have approximately 160 of them located throughout our body. Symptoms of retrocalcaneal bursitis are similar to those of Achilles tendinitis including pain, tenderness, and/or swelling in the back of our heel. Pain can be worse with running, especially uphill and when rising onto our toes (activities that increase the use of the calf muscles). As a result, in can be difficult to differentiate these two conditions. Palpation of the region can sometimes help to differentiate these two conditions and more specifically imaging such as MRI can help to differentiate. Common causes of retrocalcaneal bursitis include repetitive stress, commonly seen in runners, and tight-fitting shoes. Treatment of retrocalcaneal bursitis includes improving or changing footwear (if shoes are too tight fitting), and most commonly conservative treatment to help reduce stress to this area through stretching and strengthening exercises along with therapeutic modalities such as ultrasound or laser therapy that can assist with tissue healing. Sometimes, anti-inflammatory medications such as prednisone (steroids) can be used and in rare cases, surgery.
Tarsal Tunnel Syndrome
Tarsal tunnel syndrome is a condition that involves compression of nerves in our lower leg and foot, known as the posterior tibial nerve. Think of it as the carpal tunnel syndrome (which occurs in the wrist) of our foot. The tarsal tunnel provides a passage for the posterior tibial nerve on the inside of our ankle. Symptoms of tarsal tunnel syndrome include tingling, burning, pain, and/or numbness on the inside of the ankle and/or the bottom of the foot. Common causes of tarsal tunnel syndrome include flat feet (pes planus), ankle sprains, arthritis, and diabetes. Flat feet increase more stress to the inside of our foot and ankle region and displace more stress to the posterior tibial nerve. Swelling associated with ankle sprains can result in compression to the posterior tibial nerve. Systemic conditions such as arthritis can result in narrowing of this tunnel displacing compression to the nerve; diabetes can negatively affect our nerves and result in neuropathy which often involves nerves in our peripheral areas such as the hands and feet. Tarsal tunnel can often be treated through conservative measures including foot orthoses (to improve flat feet), soft tissue treatment (massage, soft tissue mobilization), and manipulative therapy to the foot and ankle has been shown to be effective in treating tarsal tunnel (all things that we specialize in). At times, this condition may not respond to conservative therapy and may require more invasive care in the form of steroid injections and surgery.
Other injuries and pathologies of the foot and ankle
Obviously, injuries due to trauma of the ankle and/or foot can occur. In fact, ankles are one of the most commonly sprained joints in our body. These are common amongst sports that involve jumping such as volleyball and basketball. They also occur as a result of walking and stepping onto an uneven surface, which can force us to roll our ankle leading to an ankle sprain. Sprains come in 3 different grades: with grade 1 being the least severe and grade 3 being the most severe. Grade 1 results in a disruption to the ligament, grade 2 is a partial tear of the ligament, and grade 3 is a rupture of the ligament. Grade 1 and often grade 2 sprains can be treated through conservative measures to help reduce inflammation and promote tissue healing with a restoration of function. Grade 3 sprains require surgery to reconstruct the torn ligament.
Fractures of the foot and ankle obviously can occur due to blunt trauma. These types of injuries will require immobilization and often surgery to help repair the fractured bone. Given the importance of the foot and ankle to proprioception and our ability to control movements such as walking, running, and jumping along with balance it is advisable to rehabilitate an injury such as a fracture once the fracture has healed.
Arthritis of the ankle and joints of the foot, especially our toe joints (interphalangeal), can be impacted by arthritis. The most common form of arthritis in this area is osteoarthritis. Osteoarthritis can occur as a result of having a prior injury to the foot or ankle or as a result of overuse to these areas that results in a breakdown of the connective tissue and ultimately arthritis. It is important to note that osteoarthritis is more prevalent and common with age. It can also occur as a result of other pathological conditions such as rheumatoid arthritis. Treatment of arthritis is dependent upon the type of arthritis and can vary from conservative treatment such as manual therapy or therapeutic exercise to anti-inflammatory medication to in its most advanced stages, surgery.
Foot Orthotics: Are they necessary to help correct flat feet?
The use of foot orthotics to help correct flat feet is a common practice by many therapists and podiatrists. However, research is controversial at best for the use of foot orthotics to correct flat feet. Most commonly this is used to help with pain in the heel or arch of the foot, which can commonly occur from conditions such as plantar fasciitis. Flat feet, known as pes planus, has been referred to as a common cause of plantar fasciitis as it is thought to over stretch the plantar fascia resulting in increase stress to its insertional point in the heel bone (calcaneus). As a result, it has been common practice to use a foot orthotic to help with the thought of unloading the plantar fascia and helping to decrease stress to this tissue and the pain associated with plantar fasciitis.
Another theory for the use of foot orthotics is that helping to correct flat feet will help to reduce knee pain, hip pain, and lower back pain. Research has shown that flat feet are a risk factor for knee pain, hip pain, and low back pain. As a result, the use of foot orthotics may be useful in helping to reduce unnecessary strain to these regions. However, it is unlikely that the use of foot orthotics alone will be corrective and effective in reducing pain in these areas, which is also supported by current evidence. They should be used in combination with other conservative treatments including therapeutic exercise and manual therapy. Of course, treatment should always be guided through an appropriate evaluation to determine and understand causes of pain to the above-described areas.
In my experience, I think foot orthotics can be helpful to improve stability to the foot in those with flat feet. As we have previously discussed in our joint-by-joint approach post, the foot should be a stable region of the body (makes sense as it is our contact point to the ground). One of the ways the foot is stabilized is through its medial arch. For those who anatomically do not have a good medial arch (as a result of flat feet), there is a potential loss of stability. Without the required stability in our foot, the ankle will often compensate and forfeit some mobility to provide more stability to this region of the body. Limited ankle mobility will force compensation up the entire kinetic chain increasing our risk of knee pain, hip pain, and back pain. For those who have flat feet and limited ankle mobility, I think orthotics can be useful to help improve foot stability and maintain better ankle mobility in combination with therapeutic exercises to assist with foot stability and ankle mobility.
Experiencing Ankle Pain?
If you are experiencing ankle pain and want to know if there are other options besides pain management (anti-inflammatory medications, cortisone injections) or surgery that may be able to help you and restore your ability to move and live a more active life, please consider scheduling an appointment with our office. Let us help you get back to the life that you deserve! In the meantime, check out the following posts to get a jump start on some exercises that can be very beneficial to your foot and ankle!
…Till Next Time!
