Sunday, September 28, 2008

Heel Spurs, Heel Pain and Fasciitis: The Causes and the Treatment

When ever a patient comes into the office complaining of heel pain my first question is, "Is the pain worse with the first few steps in the morning and then again when you first get up and walk after sitting a while?" These are the classic symptoms for a condition known as plantar fasciitis. The bottom of the foot is called the plantar surface of the foot. Fascia refers to a strong fibrous band of tissue, similar to a ligament. The term "itis" refers to inflammation. For instance, appendicitis is inflammation of the appendix, fasciitis is inflammation of the fascia.
The plantar fascia is a fibrous band of tissue that connects the heel to the base of all five toes. The plantar fascia acts like a spring and is responsible for maintaining the height of the arch of your foot. As you take a step, the plantar fascia permits the arch to pronate (rotate toward the floor) and flatten out a bit to allow the foot to adapt to what ever terrain it happens to be walking. At the end of the step the plantar fascia helps the foot to supinate (rotate away from the floor) and become rigid again so that a forceful push-off can be achieved.
The plantar fascia becomes inflamed if the foot pronates or rolls over too much and stretches out the plantar fascia too much. This causes inflammation where the plantar fascia is attached to the heel. The plantar fascia actually starts to pulls away from the bone and this is what causes the pain. One way that the body protects itself against this pulling away from the bone is to build up more bone in that area. The resulting build-up of bone is called a bone spur. A bone spur in-and-of-itself sounds painful but usually it is not what is causing the pain. If you have ever seen a bone spur on an x-ray it looks like a horn of bone growing out from the bottom of the heel. When you see this on an x-ray you wonder how anybody can walk with a heel spur. However many people have heel spurs on x-ray but have no heel pain. The heel pain associated with plantar fasciitis comes from the tearing away of the fascia from the bone and not the bone spur itself.
Why is the pain worse first thing in the morning or when you start walking after sitting for a while? I mentioned previously that the heel pain is due to the plantar fascia tearing away from the bone. The human body is a rapid healer. When you go to bed or even if you just sit down for a while the attachment between the bone and the plantar fascia begins to heal. However, when you get up and start walking again ...ouch! You just tore away the newly repaired attachment.
The treatment for heel pain due to plantar fasciitis is a two fold process. You have to heal the inflamed tissue where the plantar fascia attaches to the heel. As the inflamed tissue is healing it is important to also correct the problem that initially caused the plantar fasciitis and the heel pain.
The healing of the inflamed plantar fascia is accomplished by healing the inflamed tissue and correcting the cause. First of all you should start some type of anti-inflammatory medication such as Motrin® or Aleve®. Tylenol® may reduce pain but does not have anti-inflammatory properties. Applying ice to the heel will also reduce some of the inflammation. In addition some doctors prescribe what is called a dorsal night splint to heal the plantar fascia. The dorsal night splint is worn on the lower leg at night. The idea is to use the splint to hold the foot slightly flexed up toward your head as you sleep. This allows the plantar fascia to heal in a stretched out position so that the first steps in the morning do not break away the newly healed tissue.
As the plantar fascia begins healing it is essential that the problem which caused the heel pain is corrected. Most heel pain is the result of a biomechanical problem that causes excessive pronation (excessive flattening of the arch) and thus excessive stretching of the plantar fascia. The excessive pronation can be corrected with an arch support. The over the counter cushioning devices are helpful to reduce the pain, help calm things down a bit and allow the healing to start but in order to prevent the heel pain from returning you have to correct the faulty biomechanics. This usually requires a custom arch support. Custom arch supports will be made to match the exact contour of your foot. The custom arch support will limit the pronation, reduce stretch on the plantar fascia, reduce the heel pain and allow the heel to heal.

For more information please visit Heel Spurs

Thursday, September 18, 2008

Calluses Indicate Foot Problems

If you have calluses on the bottom of your feet this indicates that you have a problem with your foot biomechanics. A biomechanical problem means that there is a problem in the way in which the many joints, muscles, ligaments and tendons of the foot and ankle are functioning. As you walk and run your foot is subjected to tremendously high loads. When all the muscles, ligaments, tendons and muscles are working as they should the load is distributed appropriately and calluses do not develop. If the is a problem with the biomechanics, the load is not properly distributed and calluses develop in the areas that take the higher loads.

Your body adapts to the physical demands that are placed upon it. Calluses form where there is too much pressure or friction on your foot. Your body responds to excess pressure on the bottom of the foot by thickening the skin (callus) in the high pressure area. The callus develops to protect that area.

Although the body develops the calluses for protection, if untreated the calluses can do harm. Calluses that are not treated will become painful. The excess thickness of skin may itself cause pressure and pain in the area. The body will start viewing the callus as a foreign body and mount an inflammatory reaction. Calluses will often cause a tear in the skin where it interfaces with the surrounding softer skin. These cuts can lead to infection. This is a particular problem for diabetics. People with diabetes often have a difficult time healing cuts in the skin and fighting infections. If a diabetic develops an infection in their foot this puts them a great risk for amputation. It is essential that diabetics protect their feet to prevent calluses from forming and if a callus develops they must seek attention immediately.

If the calluses are large and at risk for causing a skin tear they should be removed by a podiatrist. You should avoid using over-the counter products to remove the callus. These products often contain acids that can damage the healthy skin. While waiting for your appointment with a medical professional you can reduce the callus by soaking your foot in warm water and carefully using a pumice stone to gently smooth the callus.

To prevent calluses from reforming once removed you need to correct the cause. If the cause was ill-fitting shoes you should be fitted by a professional shoe fitter. If caused by a biomechanical problem such as flat feet, overloaded joints, poorly functioning ligaments and tendons, a custom foot orthotic may be necessary to correct the problem.

For more information please visit Archatomics

Thursday, September 11, 2008

Relieve Foot Pain With Simple Exercises

Did you know that pain in the ball of the foot may be due to an inability to fully bend your ankle joint? Did you also know that the type of shoes that you wear (i.e. high heels) may be at the root of the cause of the pain? Don’t despair. There are some simple exercises that may help to relieve the pain in the ball of the foot.

Pain-free walking requires the precise integration of numerous joints, muscles, tendons and ligaments. One of the most critical and complex joints involved this process is the ankle joint. The ankle joint is required to bend the foot downward, toward the floor, (plantar flexion), upward toward your head (dorsiflexion), rotate inward (inversion) and outward (eversion). For this discussion we are going to focus on problems caused by the limitation of ankle joint dorsiflexion during walking.

Inability to fully dorsiflex the foot results in a condition referred to as ankle equinus. It is called equinus from the term equine which refers to a horse. I am not implying that a person with ankle joint equinus has a hoof. However if you notice a horse’s hoof, the front of the foot points in a downward direction; it appears to be plantar flexed (pointed down toward the floor). The person with ankle joint equinus may appear to have a plantar flexed foot and may have a tendency to walk more on their toes.

Rarely, ankle equine is caused by a piece of bone from an old fracture blocking the proper motion of the ankle or by a congenitally short Achilles tendon that prevents full dorsiflexion of the ankle. Ankle joint equinus may also be caused by arthritis that results in deformity of the bones of the joint that interferes with the full dorsiflexion of the joint. Most commonly ankle joint equinus is caused by tight calf muscles. If the calf muscles are too tight the ankle is not able to fully dorsiflex the ankle.

Spending too much of your day in high heels can result in tight calf muscles and subsequently ankle joint equinus. The body adapts to the demands that are placed upon it. If you wear high heels the distance between the heel and knee is decreased and the calf muscles will contract in order to compensate for this shorter distance. Then when you put on your flatter shoes and try to walk the tight calf muscles interferes with the ability of the ankle joint to function as it should to provide pain-free walking.

The person with ankle equinus has a tendency to walk on the ball off the foot. They have difficulty keeping the heel on the ground as they walk and raise the heel off the ground early in the step cycle. Ankle joint equinus causes the normal biomechanics of walking to get all screwed-up. When humans have biomechanical problems that interfere with the normal biomechanics of walking they compensate. People with equinus compensate by walking on their toes. They may lift up their heel early in the step that makes them appear as if they are bouncing along as they walk. They may compensate by flattening out their arch in order to take some of the load off the front of the foot. Sometimes they turn their feet to the outside as they walk and contact the ground with the inside part of the heel. All of these compensations disrupt the normal biomechanics of walking. When the biomechanics is disrupted the joints are not loaded as they should, the muscles, tendons and ligaments are strained. Strained muscles, tendons and ligaments cause pain.

People with equinus deformity may experience pain in the ball of the foot because they tend to toe walk and overload the front of the foot. They may develop pain in the mid foot from compensating by flattening out the foot and overstretching the plantar fascia, the may develop heel pain by the tight Achilles pulling the at its insertion point on the heel.

In order to properly treat the pain associated with equinus it is first necessary to determine the cause. Obviously if the problem is due to a piece of fractured bone blocking motion at the ankle joint or a congenitally short Achilles tendon, this would require an evaluation by an orthopedist for possible surgery. However if the ankle equinus is caused by tightness of the calf muscles, which is often the case, this can usually be treated conservatively.

The goal of treatment for someone with tight calf muscles is to first reduce the strain in the calf muscles and bring the floor up to meet the heel. This is usually accomplished with a heel lift inside the shoe that is used temporarily as the calf muscles are slowly being stretched thru exercises. The patient may also require a custom orthotic to support the arch. The orthotic may incorporate what is called a metatarsal pad that fits just behind the heads of metatarsal bones (long bones of the foot) to take the load off of the ball of the foot. The long term treatment however involves stretching exercises and making sure the patient is placed into appropriate footwear. In addition your doctor may prescribe what is called a dorsal night splint which holds the foot in a dorsiflexed position as you sleep to facilitate stretching of the calf muscles. Let me describe some simple techniques that are used to stretch the two main calf muscles, the soleus (sole-ee-us) and the gastrocnemius (gas-trock-knee-me-us).

To stretch the gastrocnemius muscle you stand facing the wall with your feet about 12 inches from the wall. Step back about 6 inches with one leg. Then while keeping your rear knee straight, your forward knee slightly bent, your back straight and both heels on the floor, lean into the wall. When you feel the muscle start to stretch hold the position for 10 seconds. Do this stretch ten times in a row for each foot and repeat 3 times per day.

To stretch the soleus muscle stand facing the wall as described above for stretching the gastrocnemius with one foot further back. However this time squat down as if in a seated position while keeping your hands on the wall for balance. When you start to feel the muscle stretch as you lean toward the wall, hold the position for 10 seconds. Do this stretch ten times in a row for each foot and repeat 3 times per day.

These stretching exercises together with a temporary heel lift and possibly a dorsal night splint will reduce the pain in the ball of the foot as our biomechanics improve. If however these measures do not improve your symptoms you may want to consider a custom foot orthotic.

For more information please visit Archatomics

Monday, May 5, 2008

For Serious Cyclers, The Feet Are Key To Power Production

The problems associated with the feet of cyclists are much different from walking. Common injuries associated with cycling include pain in the Achilles tendon, plantar fasciitis , patellar tendonitis causing kneecap pain, iliotibial band syndrome causing hip pain and pain on the outside of the knee. There are biomechanical problems of the foot that can cause or at least significantly contribute to these condition. However before correcting problems with the foot it is essential to first be sure that the bicycle is properly fit to the rider. This usually requires a specialist with knowledge on the proper biomechanical alignment of the rider to the bike. In addition if the rider is using shoes with cleats and it is critical that the cleats and shoes be properly matched to the rider. Leg length differences, even slight leg length differences, can cause significant biomechanical imbalances for the cyclist and lead to injury. The leg length difference can be difficult to measure accurately but should become evident when being properly fit for the bicycle.

Misalignment of the foot during cycling can result in misalignment of the entire leg leaving the cyclist prone to injury as well as an inefficient power production. In terms of foot orthotics, a rigid orthotic is best suited for the cyclist to prevent pronation and to provide the most efficient force transfer to the pedal. In addition the orthotic should be full length with cushioning for the toes. Forefoot wedging is particularly important for the cyclist to ensure optimal biomechanical alignment of the leg to prevent the common injuries discussed above. If there is a leg length difference this can easily be incorporated into the orthotic.
For More Information Visit

Thursday, May 1, 2008

Preventing Tennis Injury

The advance of technology in tennis rackets have led to an increase in the number of injuries. The ball is hit with much more power and at greater a speed which means that the response time of the players has to be all that much faster. Tennis players are required to start, stop, change direction and contort their bodies in unnatural ways constantly throughout the game. This combined with the increased power in which the ball is hit leads the tennis player more prone to injury. Tennis players also spend a lot of time with their body weight concentrated on the ball of their foot. In addition, it is difficult to get the tennis player to stop playing when injured so it is all that much more critical to avoid injury in the first place.

The most common injuries of the tennis player are subungual hematomas, (broken blood vessels under the toe nails), ankle sprains, plantar fasciitis, foot and calf cramps, Achilles tendonitis, muscle strains.

Proper foot orthotics can play a significant role in preventing some of these injuries. In particular the foot orthotic should be able to provide shock absorption and arch support to prevent excessive pronation and strain on the plantar fascia. The orthotics should distribute the body weight evenly across the foot the prevent the pain in injury associated with overloading the forefoot. The shoes must fit properly (and accommodate the orthotic) to prevent excessive motion in the shoe which may lead to toenail injury. In addition some players may benefit from orthotics which promote mobility of the great toe.

Today there are orthotics that are specially designed to prevent tennis injuries and keep the tennis player on the court.
For More Information Visit

Saturday, November 10, 2007

Pain in the Ball of the Foot

If you have pain in the ball of your foot you are not alone. Pain in the ball of the foot is a common complaint. When someone is referring to the ball of the foot they are usually referring to the location of the metatarsal heads. The long bones of the foot are called metatarsals. The metatarsal heads are the knobby ends of the metatarsals that form a joint with the toes. Thus the ball of the foot is the area where the toes form a joint with the long bones of the foot, the metatarsals.

Pain in the ball of the foot can come from a problem with the nerves as seen in conditions such as neuropathy or a neuroma, which will be discussed shortly. Often, pain in the ball of the foot can is the result of one or more of the metatarsals taking more than their share of the load. Metatarsalgia is a general term which simply means pain in the metatarsal bones. For this discussion I am going to be talking specifically about pain in the metatarsal heads.

There are several reasons why one or more of the metatarsal heads can become overloaded.
• Some people gradually lose the fat pad that cushions the area under the metatarsal heads as they age. If there is less cushion the bones feel more of the load and this causes pain.

• Some people were born with a deformity known as Morton’s toe in which the first metatarsal bone (long bone of the big toe) is short. As a result the second metatarsal or second toe is longer than the big toe. This causes most of the body weight to be put onto the second metatarsal head. This overloads this bone and causes pain.

• Some people with high arches have pain in the ball of the foot. In the person with the high arch we often see that they load the foot primarily at the heel and then again in the ball of the foot. The mid-foot does not take its share of the load. This again overloads the metatarsal heads at the ball of the foot.

• Another painful condition felt in the ball of the foot is Morton’s neuroma. This is usually felt between the 3rd and 4th toes. One quick way to tell if you may have this condition is to grab your foot around the metatarsal heads and squeeze your whole foot. If you have a neuroma this squeezing will causes pain at the site of the Morton’ Neuroma.

Although the cause of pain in the ball of the foot is varied, the treatment, at least the initial treatment, is the usually the same. We try to reduce load and if necessary movement of the metatarsal heads. This is accomplished by adding a metatarsal pad to an orthotic or arch support. The metatarsal pad fits in the ball of the foot just behind the metatarsal heads. This allows more of the weight to be taken up by the long shafts of the metatarsals and less on the metatarsal heads. The metatarsal pads can be added to a custom arch support. They can also be purchased over-the-counter from a pharmacy or specialty shoe store. The correct placement of the metatarsal pad is critical so follow directions or ask your physician or podiatrist for help.

For more information please visit Archatomics

Monday, November 5, 2007

Flat Feet, Foot Pain and a Simple Solution

I love to see patients with flat-feet. In fact sometimes I feel that I should dedicate my medical career to educating people about flat-feet. Flat feet causes so much trouble for people and they just don’t realize that in most case it can be easily corrected with a good arch support. As a family doctor I spend a lot of time treating patients with chronic conditions they will have for the rest of their lives. Therefore I love it when patients come in with problems associated with flat-feet. This is one of the few problems I can actually fix and best of all it doesn’t require a medication to fix it.

Flat-feet in medical terms is known as hyperpronation, meaning over pronation. Pronation is the motion of flattening out of the arch as the foot rotates counter-clockwise (externally rotates). Pronation is important because it allows the foot to absorb shock. In addition, Pronation also allows all the bones of the mid-foot to unlock and become like a “bag of bones”. Being a loose “bag of bones” enables the foot to adapt to uneven surfaces (uphill, downhill, rocky surface, etc.). In moderation, pronation is a good thing. Hyperpronation is a bad thing.

The problem with flat feet or hyperpronation is that the foot remains pronated throughout the step. The foot does not supinate (soup-in-ate) as the foot moves into the later stages of the step. Supination is the opposite of pronation. In supination the foot internally rotates (rotates clock-wise). Supination re-locks the bones of the mid-foot and transforms the foot into a rigid lever arm to provide an efficient push-off and propel the body forward. If the foot cannot supinate it remains essentially a loose “bag of bones” and you are unable to use the foot as an efficient, firm lever arm for push off.

If the foot does not supinate it cannot form an efficient lever arm. As a result, the calf muscles have to work all that much harder in order to propel the body forward. This causes fatigue and ache in the muscles of the lower legs at the end of the day. In addition if the calf muscles are working harder they become very strong and bulky. This sometimes leads to a condition known as shin splints. The term "shin splints" usually refers to pain along the inside-front part of the lower leg. Shin splints is usually caused by an imbalance between the calf muscles on the back of the lower leg (posterior muscles) and the anterior muscles or muscles on the front part of the lower leg. The more powerful posterior muscles overwork the less powerful anterior muscles as the anterior muscles try to decelerate the body at heel strike. This causes excess strain, inflammation and pain where the anterior muscles attach to the shin bone.

Hyperpronation can cause the heel pain known as plantar fasciitis. The typical symptom of plantar fasciitis is severe heel pain when taking the first few steps in the morning or during the first few steps after sitting for a few minutes. Hyperpronation causes excessive flattening of the arch. This causes the ligament called the plantar fascia on the bottom of the foot to stretch out too much. The excessive pulling on the plantar fascia causes inflammation where the plantar fascia inserts into the heel.

In conclusion, someone with flat feet has very inefficient foot function and this can lead to heel pain, muscle fatigue and shin splints. By adding an arch support the foot is prevented from hyper-pronating and this improves the over-all efficiency of the foot function. Occasionally you can buy an arch support off-the-shelf that provides support. In most cases, however, the off-the-shelf insoles only provide cushioning and do not correct the hyper-pronation. Life is too short to suffer in pain, especially when the problem can be easily corrected. If someone is having pain as the result of flat-feet it makes sense to spend the extra money to purchase a custom arch support that will correct the problem once and for all.

For more information please visit Archatomics