Bridgett Kleinknecht

The reason I talk to myself is that I'm the only one whose answers I accept.

Arch Pain Exercises A Comprehensive View

Overview


Pain across the bottom of the foot at any point between the heel and the ball of the foot is often referred to as "arch pain." Although this description is non-specific, most arch pain is due to strain or inflammation of the plantar fascia (a long ligament on the bottom of the foot). This condition is known as plantar fasciitis and is sometimes associated with a heel spur. In most cases, arch pain develops from overuse, unsupportive shoes, weight gain, or acute injury. If arch pain persists beyond a few days, see a foot and ankle surgeon for treatment to prevent this condition from becoming worse.


Foot Arch Pain


Causes


Also known as pes planus, this is when the arch of the foot collapses completely dropping the whole sole of the foot down to the ground. Flat feet are a common cause of foot arch pain. Babies are born with flat feet and as they grow, the foot arches should gradually form, but in approximately 30% of the population, they never do. They can also develop later in life, due to illness, pregnancy, injury, excessive stress on the feet or as part of the aging process. Many people who have flat feet don?t complain of any accompanying symptoms, but some develop foot arch pain, or problems further up the leg such as knee pain or back pain. They may find their feet tire quickly when they are standing or walking, and that it is difficult to rise up onto their tiptoes. Someone who is experiencing pain on the bottom of the foot or elsewhere due to their flat feet can benefit from exercises and orthotics (specially designed insoles to correct the foot position) as well as walking barefoot rather than in shoes. A quick test to see if you have flat feet is to put your foot in a tray of water and then place it on a smooth level surface e.g. thick paper. Have a look at your footprint, the more of the sole of the foot that you can see, the flatter your foot.


Symptoms


Go to a podiatrist at the first sign of symptoms. Besides pain on the bottom of the foot, additional symptoms may include burning sensation in arch, difficulty standing on tiptoes, inflammation, more pain after sleeping or resting, redness, heat, localized pain in the ball of the foot, sharp or shooting pain in the toes, pain that increases when toes are flexed, tingling or numbness in the toes, aching, pain that increases when walking barefoot, pain that increases when walking on hard surfaces, pain the increases when standing (putting weight on your feet) or moving around and decreases when immobile, skin Lesions, it?s important to get a proper diagnosis and treatment plan. Let?s go over the possible causes of the pain.


Diagnosis


Magnetic Resonance Imaging (MRI) can show tendon injury and inflammation but cannot be relied on with 100% accuracy and confidence. The technique and skill of the radiologist in properly positioning the foot with the MRI beam are critical in demonstrating the sometimes obscure findings of tendon injury around the ankle. Magnetic Resonance Imaging (MRI) is expensive and is not necessary in most cases to diagnose posterior tibial tendon injury. Ultrasound has also been used in some cases to diagnose tendon injury, but this test again is usually not required to make the initial diagnosis.


Non Surgical Treatment


Flat feet in a child do not need treatment if they are not causing pain or walking problems. Your child's feet will grow and develop the same, whether special shoes, shoe inserts, heel cups, or wedges are used. Your child may walk barefoot, run or jump, or do any other activity without making the flat feet worse. In older children and adults, flexible flat feet that do not cause pain or walking problems do not need further treatment. If you have pain due to flexible flat feet, the following may help. An arch-support (orthotic) that you put in your shoe. You can buy this at the store or have it custom-made. Special shoes. Rigid or painful flat feet need to be checked by a health care provider. The treatment depends on the cause of the flat feet. For tarsal coalition, treatment starts with rest and possibly a cast. Surgery may be needed if pain does not improve. In more severe cases, surgery may be needed to clean or repair the tendon, fuse joints in the foot into a corrected position. Flat feet in older adults can be treated with pain relievers, orthotics, and sometimes surgery.


Arch Pain


Surgical Treatment


There are two types of bone procedure for flat feet, those where bone cuts and bone grafts are used to alter the alignment by avoiding any joint structures, or joint invasive procedures (called fusions or arthrodeses) that remove a joint to reshape the foot. With joint fusion procedures, there are those procedures that involve non-essential joints of the foot versus those that involve essential joints. All bone procedures have their place in flat foot surgery, and Dr. Blitz carefully evaluates each foot to preserve as much motion and function while obtaining proper and adequate alignment. In many cases a flat foot reconstruction involves both soft tissue procedures and bone procedures to rebuild and restore the arch. There are several joints in the arch of the foot that can collapse - and these joints are non-essential joints of the foot. This does not mean that they do not have a purpose, but rather become inefficient is providing a stable platform for function. As such, locking these non-essential non-functioning joints into place is commonly recommended. These joints are fused together with screws and/or plates. A heel bone that is no longer in proper position and pushed outwards away from the foot can be corrected with a bone cut and realignment procedure, so long as the displacement is not too significant. A benefit of this surgery is that it keeps the back portion of the foot mobile, and helps the surrounding tendons work for efficiently in maintaining the arch. In certain flat feet, the foot is deviated outwards and away from the midline of the body. Sometimes, this is due to the outer portion of the foot being shorter than the inner portion. Here bone graft can be added to the outer edge of the foot to lengthen the foot to swing the foot over into a corrected position. This procedure is most commonly performed in children and young adults. A bone graft is inserted into the top part of the arch to realign a component of the flat foot, medically known as forefoot varus or medial column elevatus. The back part of the foot (called the rearfoot complex) can be the cause (or source) of the flat foot or the simply affected by the flat foot foot. In simple terms, the back part of the foot can be made to flatten out due to arch problems - and vica versa for that matter. Dr. Blitz specifically identifies the cause of the flat foot as this will determine the best treatment plan, as each flat foot needs to be evaluated individually. The rearfoot is made up of three joints, and depending on the extent and most importantly the rigidity of these joints, they may require fusion to restore alignment. When all three joints require fusion - this call is a triple arthrodesis. For completeness, isolated fusion of any of the three joints can be performed (such as subtalar joint arthrodesis, talonavicular arthrodesis, and calcaneaocuboid joint arthrodesis). The medical decision making for isolated fusions is beyond the scope this article, but Dr. Blitz tries to avoid any rearfoot fusion for flexible feet because these are joints are essential joints of the foot, especially in younger people. Those in severe cases, it may be advantageous to provide re-alignment.


Prevention


There are several things that you can do to prevent and treat arch pain. This includes Avoiding high heeled shoes, Stretching the calf muscles regularly, Wearing well fitted, comfortable shoes, Using customisedorthotic devices or shoe inserts, Elevating the feet and applying ice and taking over-the-counter anti-inflammatory medications. You can also care for your feet by paying attention to any changes in your feet as you get older. It is normal for feet to lose some of their fat pads as a person ages. Your feet may get bigger, both wider and longer as well. Make sure that you wear shoes that are sturdy, but comfortable, and have your feet measured before you buy shoes to make sure that you are still wearing the right size. Shoe sizes vary from one brand to the next, so it is a good idea to have your feet measured every time you purchase shoes. When choosing shoes, match the shoe to the activity for which it will be worn. Within the broader grouping of athletic shoes, there are different categories with different features. For example, a running shoe has different features than a walking shoe. You may develop some arthritic changes in your feet over time, too. If you notice that you are experiencing more pain in your feet, see your doctor for an evaluation. If the pain is arthritis-related, your doctor may recommend medication or other treatment to slow the progression of the arthritis.


Stretching Exercises


Try these simple stretches to assist with relieving pain in your arches. (Note: Stretch slowly and gently. You should feel a moderate pull on the muscle and tendon but no pain. If these stretches are painful, stop and seek further advice from a health professional). STRETCH ONE. Stand at arm?s length from a wall with one foot in front of the other, forward knee bent. Keeping your back leg straight and back heel on the floor, lean into the wall until you feel a stretch in your calf. STRETCH TWO. This time, bend your back leg slightly, and lean into the wall. You should feel a stretch in the lower part of your calf. Hold each stretch for 20 seconds and repeat on each leg, a few times daily.
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Which Are The Key Causes Of Adult Aquired FlatFeet ?


Overview
Posterior tibial tendon dysfunction is one of several terms to describe a painful, progressive flatfoot deformity in adults. Other terms include posterior tibial tendon insufficiency and adult acquired flatfoot. The term adult acquired flatfoot is more appropriate because it allows a broader recognition of causative factors, not only limited to the posterior tibial tendon, an event where the posterior tibial tendon looses strength and function. The adult acquired flatfoot is a progressive, symptomatic (painful) deformity resulting from gradual stretch (attenuation) of the tibialis posterior tendon as well as the ligaments that support the arch of the foot.
Flat Feet

Causes
Overuse of the posterior tibial tendon is often the cause of PTTD. In fact, the symptoms usually occur after activities that involve the tendon, such as running, walking, hiking, or climbing stairs.

Symptoms
Many patients with this condition have no pain or symptoms. When problems do arise, the good news is that acquired flatfoot treatment is often very effective. Initially, it will be important to rest and avoid activities that worsen the pain.

Diagnosis
Starting from the knee down, check for any bowing of the tibia. A tibial varum will cause increased medial stress on the foot and ankle. This is essential to consider in surgical planning. Check the gastrocnemius muscle and Achilles complex via a straight and bent knee check for equinus. If the range of motion improves to at least neutral with bent knee testing of the Achilles complex, one may consider a gastrocnemius recession. If the Achilles complex is still tight with bent knee testing, an Achilles lengthening may be necessary. Check the posterior tibial muscle along its entire course. Palpate the muscle and observe the tendon for strength with a plantarflexion and inversion stress test. Check the flexor muscles for strength in order to see if an adequate transfer tendon is available. Check the anterior tibial tendon for size and strength.

Non surgical Treatment
Non-surgical treatment consists of custom orthoses and or special bracing devices along with supportive measures aimed at reducing the symptoms. While non-surgical treatment helps the majority of patients with PTTD, progressive cases may require surgical treatment including soft tissue tendon transfers, osteotomies and lastly fusion.
Acquired Flat Foot

Surgical Treatment
For patients with a more severe deformity, or significant symptoms that do not respond to conservative treatment, surgery may be necessary. There are several procedures available depending on the nature of your condition. Ligament and muscle lengthening, removal of inflamed tendon lining, transferring of a nearby tendon to re-establish an arch, and bone realignment and fusion are examples of surgical options to help with a painful flatfoot condition. Surgery can be avoided when symptoms are addressed early. If you are feeling ankle pain or notice any warmth, redness or swelling in your foot, contact us immediately. We can create a tailored treatment plan to resolve your symptoms and prevent future problems.
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Flat Feet In Adults


Overview
Some people have always had flat feet from a young age. Unfortunately as people reach their fifties they will suddenly have one foot with a flatter arch than the other foot. This situation is termed adult acquired flatfoot. Adult acquired flatfoot is a painful condition occurring in one foot. The common patient profile is a female over the age of 50 with pre-existing flatfeet, high blood pressure, high cholesterol, diabetes and obesity. All of these underlying problems will lead to a weakening of the support structures of the arch. If you have adult acquired flat foot you will not be able to lift your heel off the ground while standing on one leg. Adult acquired flatfoot may develop due to trauma or degeneration of major tendons ankle & foot. Weakness or paralysis of leg muscles can also create a flatfoot deformity.
Adult Acquired Flat Feet

Causes
Several risk factors are associated with PTT dysfunction, including high blood pressure, obesity, diabetes, previous ankle surgery or trauma and exposure to steroids. A person who suspects that they are suffering from PTT dysfunction should seek medical attention earlier rather than later. It is much easier to treat early and avoid a collapsed arch than it is to repair one. When the pain first happens and there is no significant flatfoot deformity, initial treatments include rest, oral anti-inflammatory medications and, depending on the severity, a special boot or brace.

Symptoms
The types of symptoms that may indicate Adult-Acquired Flat Foot Deformity include foot pain that worsens over time, loss of the arch, abnormal shoe wear (excessive wearing on the inner side of shoe from walking on the inner side of the foot) and an awkward appearance of the foot and ankle (when viewed from behind, heel and toes appear to go out to the side). It is important that we help individuals recognize the early symptoms of this condition, as there are many treatment options, depending upon the severity, the age of the patient, and the desired activity levels.

Diagnosis
Clinicians need to recognize the early stage of this syndrome which includes pain, swelling, tendonitis and disability. The musculoskeletal portion of the clinical exam can help determine the stage of the disease. It is important to palpate the posterior tibial tendon and test its muscle strength. This is tested by asking patient to plantarflex and invert the foot. Joint range of motion is should be assessed as well. Stiffness of the joints may indicate longstanding disease causing a rigid deformity. A weightbearing examination should be performed as well. A complete absence of the medial longitudinal arch is often seen. In later stages the head of the talus bone projects outward to the point of a large "lump" in the arch. Observing the patient's feet from behind shows a significant valgus rotation of the heel. From behind, the "too many toes" sign may be seen as well. This is when there is abducution of the forefoot in the transverse plane allowing the toes to be seen from behind. Dysfunction of the posterior tibial tendon can be assessed by asking the patient to stand on his/her toes on the affected foot. If they are unable to, this indicates the disease is in a more advanced stage with the tendon possibly completely ruptured.

Non surgical Treatment
Because of the progressive nature of PTTD, early treatment is advised. If treated early enough, your symptoms may resolve without the need for surgery and progression of your condition can be arrested. In contrast, untreated PTTD could leave you with an extremely flat foot, painful arthritis in the foot and ankle, and increasing limitations on walking, running, or other activities. In many cases of PTTD, treatment can begin with non-surgical approaches that may include. Orthotic devices or bracing. To give your arch the support it needs, your foot and ankle surgeon may provide you with an ankle brace or a custom orthotic device that fits into the shoe. Immobilization. Sometimes a short-leg cast or boot is worn to immobilize the foot and allow the tendon to heal, or you may need to completely avoid all weight-bearing for a while. Physical therapy. Ultrasound therapy and exercises may help rehabilitate the tendon and muscle following immobilization. Medications. Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, help reduce the pain and inflammation. Shoe modifications. Your foot and ankle surgeon may advise changes to make with your shoes and may provide special inserts designed to improve arch support.
Flat Feet

Surgical Treatment
If conservative treatments don?t work, your doctor may recommend surgery. Several procedures can be used to treat posterior tibial tendon dysfunction; often more than one procedure is performed at the same time. Your doctor will recommend a specific course of treatment based on your individual case. Surgical options include. Tenosynovectomy. In this procedure, the surgeon will clean away (debride) and remove (excise) any inflamed tissue surrounding the tendon. Osteotomy. This procedure changes the alignment of the heel bone (calcaneus). The surgeon may sometimes have to remove a portion of the bone. Tendon transfer: This procedure uses some fibers from another tendon (the flexor digitorum longus, which helps bend the toes) to repair the damaged posterior tibial tendon. Lateral column lengthening, In this procedure, the surgeon places a small wedge-shaped piece of bone into the outside of the calcaneus. This helps realign the bones and recreates the arch. Arthrodesis. This procedure welds (fuses) one or more bones together, eliminating movement in the joint. This stabilizes the hindfoot and prevents the condition from progressing further.
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Sore Achilles Tendon Treatment

Overview


Achilles TendinitisAchilles tendinitis is a common condition that causes pain along the back of the leg near the heel. The Achilles tendon is the largest tendon in the body. It connects your calf muscles to your heel bone and is used when you walk, run, and jump. Although the Achilles tendon can withstand great stresses from running and jumping, it is also prone to tendinitis, a condition associated with overuse and degeneration. Simply defined, tendinitis is inflammation of a tendon. Inflammation is the body's natural response to injury or disease, and often causes swelling, pain, or irritation. There are two types of Achilles tendinitis, based upon which part of the tendon is inflamed. Noninsertional Achilles tendinitis, Noninsertional Achilles Tendinitis. In noninsertional In both noninsertional and insertional Achilles tendinitis, damaged tendon fibers may also calcify (harden). Tendinitis that affects the insertion of the tendon can occur at any time, even in patients who are not active.


Causes


There are hundreds of tendons scattered throughout our body, but it tends to be a small handful of specific tendons that cause problems. These tendons usually have an area of poor blood supply that leads to tissue damage and poor healing response. This area of a tendon that is prone to injury is called a "watershed zone," an area when the blood supply to the tendon is weakest. In these watershed zones, they body has a hard time delivering oxygen and nutrients necessary for tendon healing, that's why we see common tendon problems in the same parts of the body. Tendonitis is most often an overuse injury. Often people begin a new activity or exercise that causes the tendon to become irritated. Tendon problems are most common in the 40-60 year old age range. Tendons are not as elastic and forgiving as in younger individuals, yet bodies are still exerting with the same force. Occasionally, there is an anatomical cause for tendonitis. If the tendon does not have a smooth path to glide along, it will be more likely to become irritated and inflamed. In these unusual situations, surgical treatment may be necessary to realign the tendon.


Symptoms


Patients with an Achilles tendon rupture frequently present with complaints of a sudden snap in the lower calf associated with acute, severe pain. The patient reports feeling like he or she has been shot, kicked, or cut in the back of the leg, which may result in an inability to ambulate further. A patient with Achilles tendon rupture will be unable to stand on his or her toes on the affected side. Tendinosis is often pain free. Typically, the only sign of the condition may be a palpable intratendinous nodule that accompanies the tendon as the ankle is placed through its range of motion (ROM). Patients with paratenonitis typically present with warmth, swelling, and diffuse tenderness localized 2-6 cm proximal to the tendon's insertion. Paratenonitis with tendinosis. This is diagnosed in patients with activity-related pain, as well as swelling of the tendon sheath and tendon nodularity.


Diagnosis


On examination, an inflamed or partially torn Achilles tendon is tender when squeezed between the fingers. Complete tears are differentiated by sudden, severe pain and inability to walk on the extremity. A palpable defect along the course of the tendon. A positive Thompson test (while the patient lies prone on the examination table, the examiner squeezes the calf muscle; this maneuver by the examiner does not cause the normally expected plantar flexion of the foot).


Nonsurgical Treatment


Treatment depends on severity of pain. The most effective long-term treatment for Achilles tendinitis/tendinopathy is physical therapy, particularly therapy that focuses on eccentric muscle/tendon strengthening. Calf and Achilles stretching are also an important part of the treatment. In severe cases, treatment may begin with a period of rest and immobilization in order to calm down the tendon before physical therapy is initiated. Anti-inflammatories may be prescribed. Avoiding activities that aggravate the Achilles tendon will help the healing process. Improvement and resolution of symptoms can take months. Exercise might be the cause of Achilles tendonitis, but it can also help prevent it and aid in recovery. Healing will occur more quickly if there is no pressure on the injured tendon, and if the foot is at least partially immobilized.


Achilles Tendinitis


Surgical Treatment


Many people don't realize that Achilles tendon surgery can be very traumatic to your body. The type of trauma you experience after surgery can be compared to what you go through when you first injured your Achilles tendon. During the first 24 to 72 hours after the surgery your ankle will be tender, swollen and very painful. Your leg will be weak and unstable making it impossible for you to put weight on your leg without some kind of help. This is why your doctor or surgeon will have you outfitted for a cast, ankle brace and/or crutches before the procedure. When you are relying on a cast/brace and crutches your Achilles tendon is less likely to be as active as it once was. This is usually why atrophy (loss) of your lower leg muscles (specifically your calf muscle) happens. In general, more than 80%* of people who undergo surgery for an injured Achilles Tendon are able to return to their active lifestyle. In order to avoid re-injury, it is important to commit to a regular conservative therapy routine.


Prevention


Suggestions to reduce your risk of Achilles tendonitis include, icorporate stretching into your warm-up and cool-down routines. Maintaining an adequate level of fitness for your sport. Avoid dramatic increases in sports training. If you experience pain in your Achilles tendon, rest the area. Trying to ?work through? the pain will only make your injury worse. Wear good quality supportive shoes appropriate to your sport. If there is foot deformity or flattening, obtain orthoses. Avoid wearing high heels on a regular basis. Maintaining your foot in a ?tiptoe? position shortens your calf muscles and reduces the flexibility of your Achilles tendon. An inflexible Achilles tendon is more susceptible to injury. Maintain a normal healthy weight.
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Bridgett Kleinknecht

Author:Bridgett Kleinknecht
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