Total Care Podiatry

Many people, at some time in their life, experience a period of lower back pain. Ongoing back pain can be really debilitating, so if you experience lower back pain frequently, even if it is not severe, it should be addressed before it does become so.

There are many causes of lower back pain. These include structural misalignment, hereditary disorders, disc degeneration in the spine, nerve damage, muscle imbalance and dysfunction of the lower back / pelvic region caused by poor timing or function of the feet and legs when walking. Very often it is a combination of a number of these factors and that’s why if only one area is treated the condition improves but doesn’t completely resolve.

Timing issues of foot function

Walking should be a fluid motion from the time the heel hits the ground to the point where we step forward and off the foot. Sometimes, if the forefoot and especially the big toe joint becomes jammed, the forward movement is blocked for a very short time, forcing other joints to compensate. The blockage is not significant in itself, but it recurs with every step and this repetition, in a normal day’s walking, is enough to place the strain and stress on the muscles and joints leading to inflammation and increased risk of injury. You can test this out yourself by starting to walk and then stopping just before you step off. Be careful you don’t fall over!

Poor function of the foot due to excessive rolling-in (pronation)

If your foot works in an excessively rolled in position, especially as it lifts off the ground, it causes the leg to remain in an internal rotator position, resulting in a forward tilt of the pelvis which in turn increases the curvature of the spine and places strain on the muscles and ligaments of the lower back.

Poor function of the foot due to leg length difference

Most people have a slight difference in the length of each leg but if this becomes marked through dysfunction of the pelvis or injury and sometimes surgery, (for example hip surgery), it will force the foot to compensate. Usually this causes one foot to function rolled-in and the other to function in a rolled-out position. This places strain on the foot, leg and pelvis and may result in a pelvic tilt and twisting of the spine, placing strain on the associated muscle and ligaments.

Treatment options

In cases where you suspect the way your foot and leg works is having an impact on your lower back pain, it is best to have the podiatrist work together with the health professional of your choice. This may be your osteopath, physiotherapist, chiropractor, myotherapist or massage therapist. Marked improvements can be achieved over time when working with other health professionals to address the issues occurring around the lower back such as joint dysfunction and muscle imbalance.

At Total Care Podiatry the podiatrist will ascertain what dysfunction is occurring in your feet, how this is interacting with the muscles in your back, pelvis and legs and will see what areas in your lifestyle may be placing you at risk of continuing the injury; Eg your sport, posture and even footwear.

Total Care Podiatry aims at a thorough diagnosis and careplan to address complex conditions such as lower back pain. We often use orthotics to assist the foot to place the body weight through the foot so that it is in the right place at the right time. These orthotics significantly improve the foot and leg function which inturn can make a marked difference in the pain you have. This and other treatment stratergies working together with you and other health professionals can offer a complete resolution or at least a significant improvement

Please note: this advice is very general and an accurate diagnosis on the function of your legs and feet can only be made after consulting a podiatrist.

What exactly is Plantar fasciitis

Plantar faciitis

The plantar fascia is a flat ligament type tissue made up of three bands that travel from the heel bone under the arch to just in front of the ball of the foot. Like other ligaments, it does not stretch but is designed to maintain the curvature of the arch of our feet and provide stability to our foot as we step off. While it is incredibly strong,  we regularly see people complaining of pain in the heel because of injury to the plantar fascia. The most common reason is where small tears have developed in the plantar fascia, which have become inflamed: this condition is usually called plantar fasciitis, (the ‘itis’ at the in meaning inflammation). While it is normally a overuse condition and may develop gradually, multiple small injuries to the plantar fascia, (for which the person is unaware of), can be exacerbated and further injured by a single episode of high-pressure, (e.g. walking around town all day in the wrong shoes or standing on a ladder or jumping out of a truck.)

Factors that will increase your risk of having plantar fasciitis

a. Tight calf muscles

b. Moderate to marked lower leg and foot biomechanical misalignments

c. Poor functioning joints in the midfoot and especially the big toe joint,
   leading a condition called functional hallux limitus (Fhl)

d. Lifestyle stresses: e.g. new sport that is placing higher stress on the foot

e. Poor Footwear choices

The symptoms you can feel

The most common presenting symptom with plantar fasciitis is in severe pain first thing out of bed in the morning or taking the first few steps after sitting for long period of time. This can be due to many reasons, but often it is due to the connect tissue linkage between the plantar fasciitis and (tight) calf muscles. Most people, as they sleep in bed, position themselves in a fetal position, (curled up on their side, with feet pointing down). This allows the calf muscles to tighten up, so when you get out of bed and stand up, the calf muscle is not able to stretch out immediately. This causes the foot to compensate usually by rolling in, resulting in huge stress being placed on the plantar fascia. After some time of walking around or after a hot shower, the calf muscle stretches out, relieving the pressure on the plantar fascia and so the symptoms improve.

Is this you? Try this simple exercise to see if it helps:

• before getting out of bed, while still under the warm bedclothes, gently prepare the calf muscle by bringing your toes towards your leg, but gently now!

• Repeat this 20 times, slightly increasing on the 6th, 11th and 16th time

• this will help the calf muscle be ready to function and increase the blood supply to the area as well as help lubricate the joints of the foot

I hope this helps!

Less common symptoms can be burning, tearing, aching that can become very sharp and a bruising feeling under the heel.

Treating this condition

The most difficult part of a successful treatment of plantar fasciitis is the correct diagnosis of what is causing the pain. The reason why there is so many treatments available for heel pain is that it does vary from person to person and it can be caused by a number of reasons. SO there is no one treatment that solves every plantarfascitis condition: no matter what the ads say!

My first advice would be to save you money and consult a podiatrist who regularly sees and treats heel pain. Once a thorough examination has done you may be offered the following treatment options:

• rest: no sport, lessening activities requiring walking up and down stairs, no standing on ladders, wearing shoes with a small heel, lessening your day-to-day activities
  

• direct resting of the injury: rigid sports taping (this can also be used to see if the pain is mechanical in nature), CAM Walker boots, plaster casts

• mobilisation and manipulation of the joints of the ankle and foot: these may be ‘out of place’ and so not working properly. This can place high pressures on the plantar fascia as we walk, run and even with prolonged periods of holding the foot in the same position, such as when you are driving your car

• ice massage: either through direct massaging with ice or rolling your foot over a bottle filled with frozen water for 10 minutes twice daily. To do this fill a plastic soft drink bottle, (ones with waists are the best) with water to three-quarter full and then freeze overnight

• stretching: stretching the plantarfascia and calf muscles to improve their flexibility is a great way to reduce the pressure off the plantarfascia,

• Improving the function of the foot: correctly prescribed orthotics can significantly improve the pain you feel, how your foot works and reduce the risk of that occurring again

• anti-inflammatory tablets and cortisone injections: anti-inflammatory tablets are a powerful means to reduce the pain you feel because of the injury and inflammation. While many people are scared to take tablets, often over a very short period of time it is a good idea as it will stop you walking away from the pain which can sometimes lead to inflammation of other parts of the leg and feet, so long as you are actively addressing the issue that caused the plantar fasciitis in the first place. A cortisone injection is one of the most powerful anti-inflammatory measures we have wear a single injection can give up to three months pain relief. It has to be noted however, that this is not addressing the issues rather giving you relief from the pain, so the other areas still need to be addressed

• other options include: acupuncture, night splints, surgery, Extracorporeal shock wave therapy, or ESWT, huge number of ‘ guaranteed successful’ treatments of the Internet

What is it?

Achilles Tendinopathy refers to the degeneration of the tissue making up the Achilles tendon, with the loss of normal fibre structure.

It can present as an acute condition, meaning it occurs over a period of a few days, following an increase in training, or chronic, which occurs over a longer period of time. In addition to being either chronic or acute, the condition can also be either at the attachment point to the heel or in the mid-portion of the tendon (typically around 4cm above the heel). Healing of the achilles tendon is often slow, due to its poor blood supply.

What causes it?

An Achilles Tendinopathy is typically an overuse injury. Too much too soon is the basic cause of overuse injuries, however below are some other factors that can contribute to developing the condition:

• Increase in the frequency and intensity of activity
• Reduced recovery time between exercise and activities
• A change of footwear, or in the surface that you train on
• Weak calf muscles
• A decreased range in motion at the ankle joint, often caused by tight calf muscles
• Type of activity and exercise done, e.g. Running up hills will stretch the Achilles tendon more than normal on every stride. This causes the tendon to fatigue quicker, which leaves it more prone to injury.
• If your feet pronate or roll inwards when running. This can increase the stress on the tendon through twisting and ‘abnormal’ strain.
• When heels are worn regularly they can cause the Achilles tendon to shorten, then when flat shoes are worn for exercise the tendon has to stretch further than normal under increased stress causing the likelihood of injury to be higher.

How is it treated?

There are a number of things that can be used to treat Achilles Tendinopathies:

• rest and cold therapies to reduce any associated swelling or inflammation
• wearing a heel raise to reduce the strain on the tendon
• taking a prescribed anti-inflammatory medicine to releive any associated inflammation
• taping of the ankle and foot
• proper diagnosis of foot function addressed  with orthotics to address abnormal function
• ultrasound treatment
• surgery is sometime indicated if conservative treatments fail.

What is it?

Metatarsalgia is a common overuse injury described as pain in the forefoot that is associated with increased stress over the metatarsal head region. Metatarsalgia is often referred to as a symptom, rather than as a specific disease.

What causes them?

Common causes of metatarsalgia include:

• metatarsophalangeal synovitis
• avascular necrosis
• sesamoiditis
• inflammatory arthritis
• Morton’s neuroma
• Prominent metatarsal heads
• Hypermobile foot joints
• Excessive pronation
• Forefoot equinus

Each is diagnosed separately, often with the aid of X-rays and diagnostic ultrasound. Diagnosis is the key to ensuring the treatment matches the actual condition

How are they treated?

Once the cause of the metatarsalgia is known the appropriate treatment can be given. These may include:

• Trailing Felt padding to offload high pressure areas, which when successful will be replaced with an insole of some type.

• Orthotic devices to aid the foot to function correctly thus normalising the forces.

• Short-term relief may be from the removal of callus or corns under the metatarsal area.

• Footwear advice and footwear modifications

• Splinting all movement to completely rest the tissues

What is it?

This is a common condition of runners, which occurs when the cartilage of the patella (kneecap) softens, and the cartilage found under the patella become rough. Discomfort and often grinding or crunching sensations can be felt in the knee joint. This condition can affect any age group.

The condition may be referred to as ‘Runner knee’, Patellofemoral Syndrome, or Chondromalacia Patella.

What causes it?

This condition develops overtime from the poor tracking of the patella over the knee joint. This can occur because a number of factors, including:

• excessive pronation, or flattening of the foot as you run or walk
• poor, structurally unsupportive footwear
• mechanical conditions including wide hips (especially in females) knock knees, patella alta (high  patella) and subluxating patella
• weakness of the quadriceps muscles, especially the VMO (Vastus Medialis Oblique Muscle) which runs along the inner aspect of the thigh and connects at the knee specific types of training and exercise, e.g. downhill running, or running up stairs as part of training

How is it treated?

The simplest and most effective treatment plans often involve:

• rest
• specific leg muscle stretches to decrease pressure and strain on the kneecap
• strengthening exercises to the quadriceps muscles to improve the control of the kneecap as it    glides over the knee joint
• proper diagnosis of foot function, addressed with orthotics to correct abnormal function
• avoiding particular exercises
• physical therapies can also help, such as ultrasound, patella mobilisation, and strapping.