A new way to look at foot problems and pain

I wanted to write this in response to a New Year's Resolution post my cousin made the other day.  It was kind of a jab at me for a comment I made to her at our family's Christmas party.  What I noticed was that she had absolutely zero pressure on her toes while she was standing around talking barefoot.  Her toes were actually slightly elevated off of the ground.  She was shocked to realize that she was doing it.

As many people know I have had foot problems since my senior year of high school when I sprained my big toe in a football game.  I could still run after I taping it, so I just kept playing.  I re-injured it again badly my sophomore year of college and subsequently developed a serious case of turf toe which plagued me throughout my college career.  I never did any therapy.  I put it in the ice bucket, taped it and wrestled when I could.  I had 9 cortisone injections over an 18 month period. I couldn't push off on that side and frequently re-injured even walking up the stairs.  The cortisone took the pain away but my function never improved because I didn't do anything to try to improve.  My toe will never be the same but I have now seriously improved my function and virtually have no pain.  

This is a current picture of my feet.  It was taken after I sprained my right ankle in May.  As you can see my left big toe is now structurally altered forever.  I couldn't push off my big toe, I started pushing off the inside of it.  There was little to no muscle controlling it and I developed hallux valgus, meaning my big toe pushes out towards my pinky toe.  I also developed a large bunion which is basically a bone spur. Bone spurs occur from repetitive trauma, instability and stress to a joint because the body is trying to strengthen the area by laying down calcium deposits.  Unfortunately the body's response only makes the problem worse!



Since I have become a physical therapist, it would be obvious that I would seek methods to fix my problems.  In the past few years I have taken a new approach to training my feet.  During that time, I have noticed that people with problems of the low back, and legs often have impairments in their feet. Most of our movements, especially in athletics are performed on our feet.  Our feet create a base of support for our postural stability, alignment and locomotion.  Impairments in the feet will cause many different types of compensations in which some practitioners believe can be seen the whole way up to the neck (cervical spine).  If the impairments in the feet are not addressed, the whole movement system will be flawed.

The Sport Science Lab Neuromuscular Intensification Training Program(NIT) focuses on strengthening and stabilizing the feet.  For years, many people have told me that the big toe is one of the most important parts of the body.  However no other programs focus on strengthening the feet.  When I evaluate my athletes and PT patients, I thoroughly examine their feet.  I do look for difference in shapes and structures such as fallen or high arches which are associated with many lower extremity issues.  However, the main thing I look at is balance, muscular control, strength, and plantar pressure(how pressure is distributed on the bottom of the feet).

I have really begun to recognize two things.

1. The best athletes I have trained will press their toes, especially their big toe, into the ground while standing, doing heel raises, balancing and jumping.

2. The other thing I have noticed is people with common overuse foot injuries, especially plantar fasciitis, do not press their toes into the ground even while standing let alone the other movements. These people also have a poor ability to curl their toes and have very weak muscles that help them to curl their toes, about 50% or less of what my athletes demonstrate.

The bottom of the arch of the foot is supported by the plantar fascia.  The plantar fascia is attached to the muscles that cause the toes to curl.  In standing, walking and other forms of locomotion the plantar fascia becomes taut in order to help support the arch.  The muscles that curl the toes run along the bottom of the foot and also help to support the arch.

Many people believe that simply having abnormal structure (versus function) of the foot is the cause of injury and poor performance in activities such as running.  I used to believe this too.  I still think it plays a role but it fails to recognize that our bodies are not just a bag of bones.  The nervous system and our muscles control our movements and ultimately the forces we can create and absorb.  I believe poor postural control, dynamic biomechanics (body positions during movement), force creation and force absorption are more of the culprit.

Why do I believe this?  I have trained many athletes with many different shapes and sizes that have structural abnormalities with minimal movement dysfunction nor pain.  I worked with a football player from the University of Cincinnati, which made it to the NFL, that ran a 4.3 second forty yard dash and had the flattest feet I had ever seen.

The arch of the foot is formed by many tiny bones and ligaments. It is truly a marvelous biologically engineered structure which allows humans to effectively transmit forces through the foot to the ground to push us forward during walking and running and upward during jumping.  The ends of the arch are in contact with the ground.  The back end is formed by the heel or calcaneus.  The front of the arch is formed by the metatarsal heads and toes.  As you can see in the picture below(D), the person with the lowest arches also tends to place more pressure, during weight bearing,behind their toes on the metatarsals and the arch of the foot.

This creates several problems.  First it causes a change in our center of gravity and therefore places extra stress to our joints, ligaments and tendons as they try to compensate.  It also causes the arch of our foot to be less supported by the muscles of the foot placing extra force on the plantar fascia, muscles and other tendons of the foot and ankle such as the achilles tendon.  Poor strength and control of the toe flexors also causes us to place more pressure on the metatarsal heads during the push of phase of gait and jumping instead of pushing off the toes.  Most people actually lift their foot off of the ground early, which limits the push off or propuslion forward or upward.  Walking, running and jumping effectively incorporates full utilization of the toes for push off(see the youtube link below to see the feet in action).  Also, as the toes bend(extend) during push off the plantar fascia is taut to support the arch but will have less support if there is weakness or poor control of the toe flexors.

http://www.youtube.com/watch?v=Pc-Hfz459zw&feature=mfu_in_order&list=UL

The arch needs to be stable to limit excessive forces to the rest of the foot and ankle.  The arch has to be stable at both the front and the back, the toes and the heel.  If the toes do not exert a downward pressure in to the floor or weight bearing surface the arch will be more mobile, less stable and poorly controlled.  This can be associated with but not limited to plantar fasciitis, achilles tendonitis, metatarsalgia, and poor athletic performance in running and jumping sports.

You can check this yourself.  Stand in your bare feet on a firm surface.  Where is most of the pressure?  Are you pushing your toes into the floor?  If so, raise your heels off of the ground.  Are your toes still firmly pressing into the ground.  If not, you could be at risk for foot and ankle injuries.

For starters you can perform towels scrunches.  I do these for 1 minute on each foot after I get out of the shower.  Also stand on one foot in your bare feet.  Do 10 sets of 10 seconds. 1 x per day.  Finally, do 3 sets of 10 heel or calf raises(some people call these toe raises although the toes never raise) barefoot.  Slowly lower yourself down each time for 2 seconds and concentrate on keeping your toes pressed into the ground.  Hope this helps.  If you are experiencing pain, have any balance issues or have any other reason to not perform these exercises at this time, please consult your doctor or physical therapist about this prior to attempting.

Hope this helps and thank you for your time,

Lyneil Mitchell, DPT