Foot and ankle health is a particularly important aspect of personal wellbeing, although it is often overlooked as an essential part of a healthy lifestyle. When we experience pain from chronic ankle instability, a sprain, or even just a tweak from an old injury, it can affect every aspect of our daily lives and even prevent us from maintaining our usual level of physical activity. Most people will suffer a sprained ankle at some point in their lives, and when the ankle is not properly rehabilitated, it can lead to chronic instability. This can have further-reaching effects, causing a ‘domino effect’ of problems in other areas of the body due to overcompensation for the unstable ankle. Therefore, the importance of seeking help and guidance from health professionals when suffering from ankle pain or injury is crucial in preventing further damage and reducing the risk of re-injury. Step by Step Chiropractic is a holistic healthcare facility and chiropractic office in Bellingham, WA. The alignment of the chiropractic office and the subject of this essay will be discussed further during section 3. Failure to address the ankle problem and changes in the way a person walks due to pain often lead to accelerated damage in the joint, ultimately resulting in ankle arthritis. Ankle arthritis is a disabling condition that often goes undiagnosed and is an important cause of persistent disability. Studies show that 70% of people suffering from arthritis in the ankle are unable to walk more than 4 blocks when compared with those of similar age and health without ankle pain. This essay discusses the significance of understanding the link between foot and ankle pain and posture and provides tips for realignment.
Importance of Foot and Ankle Health
Adequate and appropriate functioning of our foot and ankle complex is important for good posture and efficient movement patterns. Our feet act as our body’s shock absorbers, and they need to be able to accept the forces from the ground and adapt to different surfaces. This helps our body to maintain proper balance and alignment. When our foot and ankle complex does not function well, it may lead to compensations further up the chain and cause a variety of postural deviations. An example of this is when someone has an ankle sprain. This person will often avoid pain and prevent re-occurrence of the injury by walking with their foot turned out. This will lead to increased wear and tear of the medial (inner) aspect of the knee and has been associated with the development of osteoarthritis in the knee.
Your feet are the building blocks of your body; the foundation from which all of our movements occur. The human foot is a complex structure consisting of 26 bones, 33 joints, and 100+ muscles, tendons, and ligaments that provide support, balance, and mobility. It’s no secret that when our feet hurt, we hurt all over. Most foot pain occurs when we overuse our feet by standing on hard surfaces for long periods of time or when we do an activity that our feet are not used to. Systemic conditions such as diabetes or obesity can also lead to foot pain. But there is a bigger picture to foot pain; it’s not just about the foot! The way our foot functions can have a huge impact on the rest of our musculoskeletal system, and if the foot does not function well, it can lead to problems such as knee, hip, and back pain. High-arched people often have foot pain, but they are also prone to knee pain because the high arch causes a decrease in shock absorption. The same can be said for overpronators, but their pain is generally felt in the foot and ankle.
Impact of Posture on Foot and Ankle
Our posture, good or bad, has a real impact on our health. But did you know that it can affect the health of our feet and ankles as well? These often overlooked body parts can be greatly affected by the way we carry ourselves. People with higher, cavus types of foot deformity often have ankle instability and more upper body and lower leg injuries due to postural deviations. Those with abnormally high arches are more likely to have a pattern of outwardly rotated feet. This is a biological adaptation to aid in keeping their balance as well as provide a better shock absorption system. Unfortunately, this will often lead to pain and damage done to the ankle joint. The most common foot deformity is the flat foot, or lower than normal arch height. This condition is most often caused by postural deviations as a way to compensate for more major joint misalignments such as the hip and knee. These misalignments can cause leg pain as well as degenerative joint disease in the ankle. Did you know that bad posture can even affect the health of the bones in your feet? Stress response is an adaptation that bones will take on due to high load or stress. If the stress is in an abnormal direction because of joint misalignment, the bone structure will change in order to better dissipate the high stress area. This happens very often in the tarsal and metatarsal bones of the foot due to joint misalignment between the ankle and rear or mid-foot. High incidence of bone stress response will lead to pain and muscle inhibition around the affected joints.
Common Causes of Foot and Ankle Pain
Tendonitis is also a common overuse injury, yet there are many different forms of tendonitis that affect the foot, and each has a specific cause and symptoms. An example of a structural abnormality that can cause secondary pain and discomfort is a bunion. This is where the big toe deviates towards the lesser toes and an enlargement of the joint at the base of the big toe, forming a bony bump. This can be very painful as it is a form of arthritis in the joint, and the added stress from the joint not functioning properly can cause inflammation and pain in the lesser toes. In more severe cases, this may also require surgical repair.
High-impact aerobic activities or sports, such as basketball or distance running, can place added stress on the joints and cause aggravation or microtrauma to the area. This can lead to stress fractures or bone bruises, which may be small in nature but very painful and disabling. In severe cases, this may require immobilization of the foot and possibly surgery.
Overuse and poor mechanics occur when an activity or sport is performed with poor technique or equipment, or when the individual is unconditioned or unfit for the activity. This can cause a series of events to occur, including muscle imbalance, where some muscles are overworked while others are weaker. If this occurs at the foot and ankle, there will be an abnormal transfer of weight and added stress on the inner or outer part of the foot. Often, this leads to inflammation in the soft tissue as well as joint problems.
Overuse and Repetitive Motion
Overuse and repetitive motion is also a common cause of foot and ankle pain, especially in active individuals. Repetitive motion during high-impact activities can aggravate the bones and joints of the foot. This is a problem for athletes and people who have to stand or walk on the job. Many sports and activities put a large amount of stress on the muscles, joints, and tendons in the lower leg, which in turn cause medial shin splints or pain in the arch of the foot. Frequently, pain or injury in one area of the body can cause a person to compensate or alter the way they perform an activity, leading to overuse of other areas. An example of this is people who have one bad knee will limp or avoid putting weight on that extremity, thus putting more stress on the opposite foot and leg. The increased stress frequently causes pain in the foot or ankle. High heels are an example of footwear that can cause problems in this category. The foot is forced into a position where it is constantly plantar flexed. This shortens and contracts the calf muscles and places increased load on the forefoot and toes. This can cause pain on the ball of the foot due to increased pressure and force on the metatarsal heads or can lead to joint pain or cramps in the toes.
Injury and Trauma
An acute injury which can occur from a direct blow to the foot or from a force coming down on the foot or ankle can cause soft tissue damage, musculoskeletal damage, or fractures in the bones. These can have many residual effects, some of which may not present for years after the injury has occurred. Damage to the joints and ligaments can also lead to long-term pain and future joint inflammation such as arthritis. Any sort of trauma or injury should be well managed from the start to prevent long-term problems occurring.
Inversion or eversion sprains can lead to serious long-term problems on the lateral or medial sides of the ankle. When the sprain has occurred, there is a high rate of recurrence in that same location. High ankle sprains, known as syndesmotic sprains, are less common but a lot more severe injury which can really obstruct normal function. These are injuries commonly sustained in contact or extreme sports such as rugby, football, and snowboarding. The sprains can be treated conservatively if it’s a 1st or 2nd-degree sprain. If more severe, the healing time can be up to 3 months and may require surgical intervention.
Fractures in the bones are serious injuries which can cause long-term foot and ankle pain if they are not managed correctly from the start. The fracture can occur from a simple injury such as missing a step to more complex injuries caused by car accidents. It is important to get a correct diagnosis, for ongoing problems can be caused by undetected fractures or fractures not treated correctly. Understanding the severity of the injury and correct management from the start should minimize the risk of harmful outcomes.
Structural Abnormalities
The severity of structural abnormality can vary massively from mild to completely debilitating. The way in which structural abnormality affects an individual can be extremely varied and can exacerbate into overuse, repetitive motion, and injury. The body is extremely adaptable and will often compensate for a structural abnormality with alternative movement of other areas. This, in turn, can lead to pain and dysfunction in the affected and surrounding areas.
There are a number of congenital abnormalities of the foot and lower limb. These range from a clubfoot deformity to the rare and more severe Charcot Marie Tooth’s disease. For example, clubfoot is a congenital abnormality where a tight tendon on the inside of the ankle causes the foot to be excessively inverted. This will often lead to excessive supination of the foot and problems with balance. This may go unnoticed in childhood but may present problems later in life.
A common structural abnormality of the foot is the bunion (hallux valgus) which is a malalignment of the big toe joint. This causes the foot to become wider and can alter toe positioning. Individuals with a bunion will often experience pain in the 1st MPJ due to the metatarsal becoming prominent on the inside of the foot. Bunions can be extremely painful and debilitating and can have a significant impact on postural alignment further up the kinetic chain.
Though often less common than overuse and injury, structural abnormalities can have a serious impact on postural alignment and mechanics. The majority of structural abnormalities are a result of genetics, but often become exacerbated over time. For example, any abnormality in foot structure will often cause excessive pronation. This can increase stress on the surrounding soft tissues and lead to functional problems.
The Relationship Between Foot and Ankle Pain and Posture
This type of case is just one of many. The more you understand about your pain and what is happening, the better we can try to get you an accurate diagnosis and effective treatment as demonstrated in the next few sections.
Over time, an improper alignment of the foot and ankle can lead to damage in the joint or surrounding tissues and osteoarthritis. This irregular alignment of the foot and ankle is oftentimes due to a dysfunction in the posterior tibialis tendon. Oftentimes, it is the flat flexible foot that progresses to dysfunction of the posterior tibialis tendon and adult acquired flat foot – a painful and common progressive deformity in the foot and ankle. Again, the issue is further complicated if failing to compensate by lifting the outside of the ankle. This causes an increased arch in the foot, shifting the weight to the lateral aspect of the foot. This change in weight and force distribution of the foot leads to an entirely new problem with the outside of the foot and ankle.
The normal ‘alignment’ of the foot and ankle is best described when looking at the body as a whole. Ideally, the weight of the body is evenly distributed to the front and back and both sides of the foot. The foot and ankle should be neutral – neither turned in nor out. The body’s center of mass is located within the body, which is depicted by the plumb line. Pain on the plumb line indicates that there is an issue with foot alignment but not always at the location of pain.
Many patients seek medical help for chronic pain in the feet and ankles. Often the problem is focused on an isolated area such as the big toe or the inner portion of the ankle. Yet, the foot and ankle are relatively simple in structure. They have 26 bones, which is a quarter of the bones in the human body. The bones of the ankle and foot are connected by their shape and interlocking ligaments. The muscles and tendons then move the bones to accomplish the various motions of the foot. The bones are held in place by a strong, but deformable tissue called cartilage.
How Posture Affects Foot and Ankle Alignment
What is posture? Posture is the position in which you hold your body upright against gravity while standing, sitting or lying down. Good posture is the correct alignment of body parts supported by the right amount of muscle tension against gravity. Without posture and the muscles that control it, we would simply fall to the ground. Usually we do not think about our posture when we are in a good position, it is when we slouch or feel pain that we become aware of it. But why should we care? It requires energy to hold ourselves in good posture. Our bodies are designed to be most efficient when using the least amount of energy, therefore the best posture is the most comfortable one. Typically, muscles will do their job to keep us upright with minimal force, this is best achieved when muscles are balanced on both sides of the spine. Posture can affect many things including bodily alignment, how well we use our muscles and the total amount of energy expended, therefore good posture is important for health and function. It is the topic of bodily alignment that is of most interest to us, because it is intimately linked with the misalignment of foot and ankle.
Foot and Ankle Alignment and Pain
This increased demand for movement at the ankle joint can be more explicit in the presence of pathology at a specific joint. For example, those suffering from osteoarthritis of the knee are likely to force extra movement at the ankle joint to avoid painful knee flexion during gait. Muscular weakness and imbalance at the ankle joint can also contribute to pain. The most common example of this is an inversion ankle sprain, in which there is damage to the lateral ligaments usually because of a fast forced movement at the ankle joint due to inadequate muscle support. This can be extrapolated to pain further up the kinetic chain, as an ankle sprain can inhibit muscular activity around the knee, which can lead to knee pain and further compensation at the hip joint.
The alignment of the foot and ankle can be quite complex, but understanding it can be very beneficial when determining if it could be a potential cause for postural pain. The foot has 26 bones, thus making it quite flexible, but can be compromised by lack of strength, excess weight, and use of improper footwear. The bones of the ankle and rearfoot are arranged in a complex in which weight is transferred from the tibia to the foot, allowing movement in a variety of planes. If there is an increased load on the foot or a problem with a specific joint in the rear or midfoot, this will also increase the demand for compensatory movement at the ankle joint, which can influence the line of pull of muscles acting at this joint.
Correcting Posture for Pain Relief
Changing posture involves changing habits, and this is rarely easy. One must begin by being mindful of one’s alignment and making a conscious postural correction whenever the old habit is noticed. At first, new postures will seem forced and unnatural, but by repetition in the absence of the old habit, the new posture will itself become a habit. It is essential to practice new postures not only during activities but also while in “static” positions such as sitting or standing. A useful aid to making postural changes can be to take a look at the postural changes that occur in a pain-free person doing the same activities – often simply mimicking efficient postures can be quite effective. It may also be necessary to arrange things in one’s environment to make the better postures more convenient and to eliminate cues to the old postures. Success will be greatly assisted by enlisting the help of friends, teachers, or family members, as it is difficult to change a habit without someone there to point out when you are reverting to the old ways. Above all, keep in mind the potential benefits and the end goal – more efficient postures will generally become comfortable in time, and the knowledge and feeling of moving in an improved manner is in itself quite gratifying.
At this point, I should add a word of caution and mention that sometimes pain relief should be the first priority, and sometimes it should not. This is often difficult for patients and professionals alike to assess, and an experienced therapist is essential in determining the appropriate course of action. However, in many cases, the cause of the pain is an inefficient alignment, and relieving the pain without addressing the cause will simply lead to a recurrence of the same problem. In such cases, the most efficient approach is to address the postural problems as soon as is comfortably possible. This will involve changes not only to one’s standing posture but also the postures maintained during various activities and exercises.
Tips for Aligning Foot and Ankle for Pain Relief
Foot muscle strengthening is a very passive process which occurs from the ground up and is something that becomes increasingly important the further your feet are from functioning in an efficient way. Basically, all the movements of the foot are controlled by muscles in the lower leg, and these movements are what should be corrected. For example, an overly pronated foot is caused by the ankle rolling inwards. This is because the peroneal muscles on the outside of the lower leg are too weak to hold the ankle stable. So, to progressively correct this, you want to start with a single leg stand. Try to rise the inner part of your foot so it’s in line with your big toe and hold this position for 10-15 seconds. This can be progressed or regressed simply by increasing or decreasing the time limit. For an inverted ankle, the same principle applies but attempting to raise the outside of the foot.
Strengthening Exercises
If you are able to perform these exercises without pain, you are likely safe to add some more aggressive strengthening exercises for the muscles mentioned. Evidence shows that isometric exercises are the most effective way to increase strength and endurance of a tendon that is injured. This can simply be done by contracting the muscle and holding it in a set position. Isotonic contractions involve movement of the muscle and can also be effective, but also have the potential to cause further injury. Be sure to start with isometric exercises and gradually progress to isotonic exercises if possible.
Ankle inversion/eversion: Sit in a chair with your affected foot resting on a round object, such as a can of soup. Roll the foot inwards and then back outwards to move the object. Do this until your foot and ankle become fatigued.
Toe curls: Loop a thick elastic band around all five toes. Spread your toes apart and then bring them back together against the resistance of the elastic band. This is an excellent exercise that simulates the toe off phase of gait and should be done in multiple directions.
Intrinsic foot muscles: While sitting barefoot, try to scrunch up a towel using only your toes. You should see the longitudinal arch of your foot increase. This is a good exercise for people with flat feet.
By working to increase the strength in certain muscle groups within your foot and ankle complex, you can effectively decrease the forces of abnormal mechanics, ultimately decreasing pain. Here are some examples of how to increase strength of the muscles that maintain your foot arch and help invert and evert your foot at the subtalar joint. A word of caution: While these exercises are effective, they can also cause significant pain if performed too aggressively. It is important to use pain as your guide, and to remain in control of the degree of intensity. Over time, you will be able to increase the difficulty without increasing pain. Consider obtaining instruction from a physical therapist for guidance and supervision.
Proper Footwear and Orthotics
Off-the-shelf inserts range from Superfeet and Spenco inserts to basic Dr. Scholl’s inserts. These can be found at a local sporting goods or shoe store and are much less expensive than custom-molded orthotics. The range of brands and types have varying degrees of effectiveness but overall are a good way to improve foot support in regular shoes.
Orthotics are another option for pain relief. The use of orthotics has been proven to improve overall foot and ankle alignment. There are various types of orthotics ranging from custom-molded to off-the-shelf inserts. Custom-molded orthotics are soft plastic insoles that are actually molded to the individual’s foot using heat and pressure. These types of orthotics can be expensive and may not be covered by insurance, however, they are the best option as they are specifically made for each individual.
New shoes should be broken in gradually by wearing them in the house for short periods before wearing them for a full day. This will allow gradual adaptation of the shoes to the feet and will allow the feet to adapt to a new level of support.
An ideal fitting shoe should be no more than 1/2 inch longer than the longest toe. There should be adequate width for the foot. The ball of the foot should fit comfortably into the widest part of the shoe and the heel should fit comfortably, without slipping. Shoes should be fitted on both feet, as they may often vary in size.
Proper footwear is essential for proper foot and ankle alignment and pain relief. Shoes should be stable and supportive, avoiding high heels and shoes with excessive wear on the inside or outside of the heel. Deformities in the ankles and feet may require a prescription for custom-molded shoes. A proper fit is essential, so be sure to have your feet measured before purchasing new shoes as an individual’s foot size often changes as he or she ages.
Stretching and Flexibility Exercises
In any stretching exercises to enhance flexibility, it is important that you aim to stretch the joint/muscle within its recommended physiological limits. This means that the stretch should be only to the extent where you can feel tightness in the muscle. Any pain is a sign that you are trying to stretch too far and can cause damage to the muscle. This is particularly important when stretching the foot and ankle, as these joints can be difficult to isolate particular muscles, making the movement more difficult to control. This shouldn’t mean that you avoid stretching the foot. It is well-documented that after immobilization of the lower leg due to fractures or soft tissue injuries, reductions in dorsiflexion and plantarflexion can affect the overall function of the joint and cause more instances of injury in the future. In these cases, it will be necessary to apply the principles of stretching muscles in isolation but should only be done once normal function is regained in the joint.