How to evaluate and treat heel and foot pain.
Since I have become a chiropractor One of the things I love is treating complicated situations that are not the typical chiropractic case. I also love treating the spine and it is the bread and butter of the chiropractic industry, but some times you just need a change and challenge to keep life interesting.
One of theses areas is the treatment of heel or foot pain, in many cases this may be diagnosed as Planter fasciitis. A study was performed by Daniels and Morrell on plantar fasciitis and they found it “improved after a course of a multimodal treatment approach using chiropractic manipulation and soft tissue therapy in addition to exercise and stretching therapies.”(Daniels CJ, Morrell AP. Chiropractic management of pediatric plantar fasciitis: a case report.J Chiropr Med, 2012 Mar;11(1):58-63)
Many of my patients come in complaining of foot pain and this may also have an affect on there back and neck pain. In my 10 years of practice I have treated many athletes for back, shoulder, wrist, elbow, hip and Knee pain but as well as these complaints 10-15 percent also have heel and foot pain complaints at one time or another.
II have found that in some cases the foot pain may resolver with a few adjustments but in many cases this requires a multi modality approach. This approach often includes chiropractic adjustments of the foot and ankle joints, facial release techniques such as trigger-point, cold laser, and stretching as well as strengthening exercises. As a last resort special shoe inserts night be needed but not until the foot is aligned more normally. At this point
Anatomy of the Heel
The prominence at the posterior end of the foot is the heel and is crested by a projection from the calcaneus or heel bone. Other articulating bones of the ankle are the mortise (tibia and talus). When weight is applied to the foot the forces are distributed along the five toes or metatarsals. The lateral support stretches over the cuboid bone in the front to the heel and the medial support moves over the three cuneiform bones and the navicular to the heel. These bones form the three functional arches of the foot which are the medial longitudinal, lateral longitudinal, transverse arches. It is these arches that distribute compressive forces across an uneven terrain across the foot. Often when patients have foot pain they go to the drug store and buy arch supports but many of these supports only account for the main arch in the foot and as we know see there are three arches that need to be supported as well as the navicular bone and this is why in my office when arch supports are needed we recommend custom made orthodic supports. They are more expensive but worth the cost they many last up to 5 years if treated properly. Orthodics often help with the biomechanics of the foot. The heel is the actual point of contact during the heel-strike portion of the gait cycle. It is also an important point on which weight must be equally balanced from the forefoot and heel. When walking there needs to be a 50/50 weight distribution at the forefoot and hindfoot. Without this 50/50 distribution the gait and the standing positions are unhealthy.
When the foot is healthy the arches are working well together during gait and the heel strikes the ground in a slightly supinated position and during the gait cycle it moves into a slightly pronated position. Stand up and walk a few paces do you notice how it feels. A healthy gait is present in only only in about 10 percent of patients that I see. More often I see patient who are over pronating. This excessive pronation results in flattening of the arches and collapsing of the foot, this causes the heel to strike the ground in an over supinated position altered the heel-strike pattern and creating stress in the heel, but also altered biomechanical patterns of the foot. In the end this can lead to pain in the foot and heel. Excessive supination occurs much less frequently, most statistics suggest less than 5 percent, so its effects on the heel are not as profound.
First there is the condition of Achilles tendinitis. This is due to excessive pronation of the feet and affects the tendon of the triceps surae. The collapse of the foot creates tension in the Achilles tendon, causing it to bow inward and this bowing is happening every time the foot over pronates creating microtrauma and stress to the Achilles tendon. If the Patient supinates, the bowing of the Achilles tendons is outward and creates similare strain and stress on the bones and soft tissue. Over time the body calcifies these tendons to support the joints that are unstable and spurs can develop on the posterior, superior portion of the calcaneus bone. Tight muscles and trigger-points may also form in the gastrocnemius and soleus muscles of the foot and lower leg. Achilles tendonitis is often debilitating due to the the pain and this continues to alter gait and mobility patterns to the point that it prohibits walking for any amount of time without pain. According to Papa “A combination of conservative rehabilitation strategies may be used by chiropractors to treat midportion Achilles tendinopathy and allow an individual to return to pain-free activities of daily living (ADLs) in a timely manner.” (Papa JA. Conservative management of Achilles tendinopathy: a case report.J Can Chiropr Assoc, 2012 Sep;56(3):216-24.)
Another common condition of the foot and heel is plantar fasciitis. A healthy plantar fascia ligament exhibits elastic properties but over time,the three arches of the foot tend to collapse. Over time this leads to excessive pronation and stresses the plantar fascia chronically. This causes the ligament to stay overstretched and it loose its elasticity and becomes longer due to the plastic deformation. Supination creates a thinner, tighter foot due to the tendency of the foot to roll outward creating a high instep with collapsed transverse and lateral arches in these patients. In either case, we can note biomechanical instability and irritation to the plantar fascia from its origin at the calcaneal tubercle across to the insertion on the metatarsal heads. In these patients symptoms begin as a dull ache in the underside of the heel that is more of an annoyance. Patients can still perform normal activities and sports, but over time the pain becomes more intense and sharp, these patients have to curtail or eventually stop their activities. In the later phases, pain can move off the heel and into the middle of the fascia, or at the insertion on the metatarsal heads.
We have all known some one with a sprained ankle. Ankle sprains range from the very mild kind to the severe, grades 1 through 3. The milder types are suggested when a patient complains of “turning the ankle.” This is like when someone missteps off a curb or a step. The opposite extreme is when ligaments and tendons are torn due to a traumatic injury. Either way, biomechanics, particularly of the calcaneus and talus, are compromised. The most common type an inversion ankle sprain, the calcaneus bone moves medial while the talus tends to move lateral. There is also an eversion sprain, where the talus bone moves medial while the calcaneus tends to move lateral. Recall that the bony anatomy allows inversion ankle sprains to occur much more frequently. In either case, the movement of the bones inhibits normal mobility. Since most people do not see a chiropractor after a sprained ankle, the bones stay out of alignment, leading to a slow rate of healing, chronic degree of tenderness and decreased function, and a tendency to repeatedly sprain the ankle in the future. Thus, it is imperative that chiropractors intervene and break this cycle. A 2004 study suggested “high velocity, low amplitude chiropractic manipulative therapy to the spine, pelvis, and extremities, particularly at the ankle, should be considered when managing young recreational athletes with functional chronic, recurrent, ankle inversion sprains.” (Gillman SF. The impact of chiropractic manipulative therapy on chronic recurrent lateral ankle sprain syndrome in two young athletes. J Chiropr Med, 2004 Autumn;3(4):153-9.)
Heel Spurs are a painful and common problem of the heel. As previously discussed, a heel spur forms at the posterior, superior calcaneus bone courtesy of Achilles tendinitis. The most common place we see a spur is on the underside of the foot at the calcaneal tubercle where the plantar fascia originates. The worse the chronic pull on the bone, the worse the spur. Spurs form when the body tries to stabilize an unstable joint. According to Wolf’s Law the Body will remove calcium from places where it is not needed and deposit it in areas were force and instability requirer it. We can’t take the spur away, of course, but we can help it from getting worse and if the joint stabilizes the body may even re-absorb some of the calcium reducing the size of the spur. Depending on how quickly you seek treatment for one or more of the above ailments, the faster they heal. If a patient is acute enough and there is sharp pain and inflammation, modalities like cold laser, ultrasound, ice, etc., are indicated. You can also provide light, soft-tissue therapy at this stage, making sure you apply the appropriate amount of pressure.
Chiropractic treatment for foot and ankle injuries!
Adjusting the bones of the feet to restore healthy biomechanics is extremely important. Adjusting the calcaneus, talus, navicular and cuboid bones is particularly helpful. If you don’t get in there and move those bones, they will not heal very well and will be prone to future injuries.
Another helpful tool is stabilizing orthotics. These are flexible, have all three arches and are custom molded and help to support the patient’s feet as well as the rest of their body. A 2002 study suggests the effectiveness of applying orthotics and ankle braces during the acute and subacute phases of ankle rehabilitation. (Mattacola CG, Dwyer MK. Rehabilitation of the ankle after acute sprain or chronic instability. J Athl Train, 2002 Dec;37(4):413-429.) The use of orthotics, when necessary, has been a part of chiropractic practice as well as my practice. They help to maintain proper biomechanics and structural integrate as well as helping hold the adjustments longer.
Ankle stretches and stabilization exercises also can be provided, and they are helpful as well as easy. A passive exercise (Doctor performs) would be to have the patient cross the affected ankle over the opposite leg and passively dorsiflex, plantarflex, invert and evert the foot. Another exercise is to have the patient stand on the edge of a step or a door frame and stretch the calf muscles, each repetition should be held for 30 seconds. Stabilization exercises should be performed with elastic tubing. The patient performs the following active movements of the foot and ankle dorsiflexion, plantarflexion, eversion and inversion. Elastic tubing is easy and convenient, and you can change the resistance quickly.
It is common for patients to walk into our office complaining of ankle and foot pain. At our office we take a few moments to listen, look and feel so we can help them in a manner that isn’t complicated or time consuming. Since the ankle is such an important stability structure for the entire body, our patients benefit tremendously from our expertise and care of their ankle and their entire body.
By: Dr. Paul R. Mahler