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

Saturday, November 3, 2007

Knee pain? Maybe It Your Feet

There are several painful conditions of the knee that may be caused by problems with your feet. The knee joint is one of the most complex joints in the body. It is a hinge joint, a sliding joint and a rotating joint all at the same time. The proper and pain-free functioning of the knee requires near perfect alignment of the bones, ligaments and tendons that make up the knee joint. Pain in the knee is usually an early warning sign that something is wrong with the alignment. It is important to address these problems early to avoid serious, long term problems such as severe arthritis.

The improper alignment that causes knee pain is often the result of improper alignment of the joints of the foot and ankle. Let me give some examples.

Pain on the inside part of the knee may be caused by bursitis at the location where three of the tendons from the thigh muscles (sartorius, gracilis and semitendinosus) come together and insert into the upper/inner part of the tibia (bone of the lower leg). This condition is known as Pes Anserine bursitis. Pes Anserine is Latin for “goose foot”. I suppose it is called goose foot because these three tendons coming together look somewhat like a goose’s foot. The pain is caused by inflammation of the bursa beneath these three tendons. A bursa is a fluid-filled sac that is found where tendons and ligaments rub against bone. The bursa is designed to prevent the bone from irritating and damaging these tendons and ligaments as the rub back and forth over the bone. When these bursa become inflamed this is known as bursitis. Pes anserine bursitis is inflammation of the bursa beneath the three tendons that form the goose foot. Pes Anserine bursitis can be caused by excessive pronation of the foot. The excessive pronation (see article on normal foot motion) causes excessive stretching of these tendons which over time results in inflammation. The treatment and prevention of this condition involves an arch support to prevent excessive foot pronation.

Pain on the outside of the knee is sometimes caused by a condition known as iliotibial band syndrome. The iliotibial band runs from the pelvis down the outside of the leg and attaches to the outside part of the knee. Problems with the foot together with overuse (such as running or bicycling) can lead to inflammation where the iliotibial band inserts into the outer knee. There are several different foot problems that can cause this inflammation. If the person is flat-footed (over-pronatnor) this causes the tibia (lower leg bone) to excessively internally rotate. This increases the stretch on the iliotibial band and causes inflammation. On the other hand if someone has a high-arched foot, the foot is in a supinated position (see normal foot motion) and this too can cause excessive stretch on the iliotibial band and inflammation. These two very different types of foot problems result in the same painful condition (iliotibial band syndrome). However the two problems require very different treatments. In order to correct the problem it is essential to determine what exactly is causing the problem.

Knee arthritis can be caused or exacerbated by problems with the foot. Someone that has arthritis pain on the part of knee closest to the midline (medial compartment) may have a supinated foot that contributes to a bow-legged type of stance. Someone with pain in the lateral compartment (the outer part of the knee furthest from the midline) may be flat-footed, a hyper-pronator, which leads to a knock-kneed type of stance. Through the proper use of a foot orthotic I believe that we can, over time, reduce the load on the painful knee compartment, reduce the pain and at least slow down the degeneration of the cartilage.

Pain in the center of the knee is often cause by chondromalacia patella, also known as retropatellar (behind the kneecap) pain syndrome. This is often seen in someone with excessive pronation (flat-feet). As the knee straightens and bends the kneecap is supposed to ride smoothly in a cartilage-lined groove on the lower end of the femur (thigh bone). Someone that is a hyper-pronator has excessive internal rotation of the tibia. This excessive internal rotation changes the angle that the kneecap rides up and down in this groove (known as the Q angle or Quadriceps angle). Over time this leads to irritation behind the kneecap and the retropatellar pain syndrome. An arch support or orthotic can be very helpful in treating this condition.

In conclusion I have discussed a few of the common causes of knee pain that can be relieved or at least improved through the use of a simple foot orthotic. The key to treatment however is knowing what is causing the problem in the first place. The techniques we use for diagnosing the problem will be discussed in an upcoming article.
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Friday, November 2, 2007

Normal Foot Motion

Before we can begin talking about abnormal foot motion and the problems caused by abnormal foot motion it is first necessary have an understanding of normal foot motion.
There are three main phases of each footstep. The first phase of the step is called heel-strike. Most people first land on the outside part of your heel. If you look at the wear pattern on the bottom of an old shoe you will usually see that the outside of the heel is worn down. That is heel strike. As you put more weight on your foot you enter the mid-stance phase of the step. Mid stance is a very important part of the walking process. As you begin to load the mid-foot the foot starts to pronate. During pronation the bottom of the foot turns toward the floor and the arch flattens out a bit. As the foot pronates it unlocks all these bones here in the mid foot. At this stage the foot becomes what is often referred to as a “bag of bones”. This allows the foot to adapt to any surface it happens to be walking on, for instance, rocky surface, beach, pavement up hill, down hill. This pronation and unlocking is also very important for shock absorption. Pronation is very important.
As your foot goes further along in the step and you begin to load your forefoot the foot goes thru a motion called supination which is the opposite of pronation in which the bottom to the foot turns away from the floor. This supination now relocks the bones of the mid-foot and makes the foot into a firm lever arm to get ready for an efficient push-off also known as the toe-off phase of the step.
This is the normal foot motion. In the next post I will begin discussing abnormal foot motion and the problems that abnormal motion may cause.

Thursday, November 1, 2007

Cape Cod Doctor Uses Engineering and New Technology to Treat Arthritis

Technorati Profile

South Dennis, Massachusetts - Osteoarthritis, also known as “wear and tear arthritis”, is often caused by unbalanced transfer of body weight across the joint. As a result, one area of the joint is required to take more of its share of the body weight. The uneven load distribution leads to breakdown of the cartilage in the over-loaded area of the joint. The cartilage breakdown is what causes the joint pain known as osteoarthritis.

“Osteoarthritis is a biomechanical problem and therefore requires a biomechanical solution”, says Dr Jeffrey P. Davies, physician and biomechanical engineer at St Luke’s Health Alliance in South Dennis. The 12 years Dr Davies spent conducting research at the Orthopedic Biomechanics Laboratory at Mass General Hospital and the five years he has spent as a family physician has inspired Dr Davies to research how the biomechanical imbalances in joints can be corrected before the cartilage is damaged.

Dr Davies explains, “The cartilage overload sets off the viscous cycle that over-time ultimately leads to joint destruction. It has always been my belief that if we can correct the biomechanical problems of the joint early on we can prevent the cartilage break-down that ultimately leads to joint destruction.”

Using the latest technology with a system that he refers to as the C.A.L.F. System (Computer Analysis of Leg Function), Dr Davies combines an in-shoe pressure measurement system and with frame-by-frame video gait analysis to identify the structural problems that are causing the lower extremity pain.

“What is fascinating to me is that by making slight changes to the loading patterns of the ankle joint through the use of relatively simple foot orthotics, I can significantly improve the loading patterns of the knee, hip and low back,” says Dr Davies. “By correcting these imbalances we are relieving pain and this, to me, is very, very exciting.”

Dr Davies does caution that the pain relief is often not immediate. Dr Davies explains, “The biomechanical problems have developed over a long period of time. The body adapts to these biomechanical imbalances by lengthening and shortening ligaments and tendons, and by reshaping the bone. Simply putting a foot orthotic into the shoe does not immediately correct the problem. However once the biomechanics are corrected, the body will, over time, re-adapt to the now corrected alignment. The goal is to provide more uniform load transfer across the joint, eliminate overloaded areas on the cartilage, reduce pain and ultimately preserved joint function. This technology gives us the opportunity to help many patients that, up to now, have thought that the only solution to their joint pain was to take acetaminophen and/or anti-inflammatory medication, limit their activity and wait until they were old enough for a total joint replacement.”

S.C is one such patient helped by this new technology. S.C. explains, “When I went to my primary care doctor with my knee pain he told me I had early osteoarthritis. He actually told me that arthritis was something that I would have to learn to live with; it was part of getting old. He suggested that I begin taking regular daily doses of pain medicine. I heard about the work Dr Davies was a doing through a friend. The analysis that Dr Davies performed was fascinating. After Dr. Davies reviewed the results of the analysis with me, I understood what was causing my pain. It made perfect sense. Dr Davies explained the treatment plan which consisted of foot orthotics, exercises and natural supplements. After just a few weeks I am now more active and almost pain free. I feel grateful that I have taken action to relieve my pain rather than becoming a victim to it.”

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The Foot Bone Connected To The Leg Bone

Foot problems can cause problems with the knee hip and low back. While many may be inclined at this point to say “DUH?” the connection between the foot and the rest of the body is not widely accepted in modern medicine. In medicine there is a disconnect between medical doctors, podiatrists, and for that matter, dentists. Dentists take care of the teeth, podiatrists take care of the feet, and medical doctors take care of everything else. Even when I worked as a research engineer at Mass General we spent all our time studying the biomechanics of the knee and hip. These were some of the most brilliant researchers in the world but never once did I hear anyone bring up the possibility that foot problems may be the cause of at least some of the causes of hip and knee osteoarthritis. When I finally opened my medical practice and began treating my own patients with joint pain I was able to finally appreciate that problems with the feet often cause problems with the joints further up.

This seemed obvious to me at the time and I felt a little stupid for not realizing it before. However I was quickly disappointed to find that the research that was done did not show conclusively that improving the foot biomechanics with foot orthotics improved the biomechanics of other joints. This did not make a lot of sense to me so I then set up equipment in my office to study this for myself. I set up video cameras and bought special equipment that allows pressure sensors to fit inside the shoe and I began doing gait analysis. I asked doctors to send me their patients with foot, knee, hip and low back pain so that I could do this analysis. When I discovered problems with the foot biomechanics I corrected the biomechanics with foot orthotics. To my delight, and I will admit surprise, these patients would come back reporting that not only was their foot pain relieved but if they had pain in other joints this was improved as well.

When I see my patients getting better but most of the research says they shouldn’t be getting better then this tells me more research needs to be done. I now focus my entire practice to studying the biomechanics of the foot and its influence on the biomechanics of the knee hip and low back. I am conducting my own studies and trying hard to educate both patients and physicians. This blog is one part of the education process.