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CHAPTER 14:
The Foot

The foot is the most complex structure in the lower body. It is made up of many bones that interact, unlike the rest of the structures of the lower body, in which only two or three bones interact.

      The main function of the foot is to absorb the shock of the body's weight landing on it. The foot supports up to four times your body weight when you are running fast, and it must bear at least 1,800 foot strikes for every mile you walk or run. It also must lock itself into a rigid position when you come up on your toes to push off so that it can act as a lever for propulsion. And the foot must roll from outside to inside as your body weight comes forward from the heel to the front of the foot. It's really a physiological wonder.

FOOT ABNORMALITIES

A structural abnormality of the foot can cause stress all the way up the leg into the back. The lower extremity can be viewed as a set of building blocks placed one on top of the other: the foot, ankle, calf, leg, knee, thigh, hip, and lower back. When one building block does not function as it should, the blocks above it also do not function properly because they have an insecure base. Imagine if the Eiffel Tower had been built with one of the lower segments unevenly balanced. Any segment above it would be unstable.

      Nearly all overuse injuries of the lower extremities are due to an abnormality in the way the foot hits the ground. To correct a foot problem, you may need to put something in your shoe to change the way the foot functions.

Common Types of Foot Abnormalities Pronating Foot

The pronating foot has loose ligaments and, because it doesn't have the proper support, rolls to the inside. The foot appears to be flat because the arch becomes compressed when the foot rolls over. But when the weight is taken off the foot, the arch reappears. A person with true flat feet has no arch at all.

      When a person with a pronating foot stands, it looks as if he or she is learning how to ice skate. The inward roll of the foot causes the entire leg to rotate to the inside. The kneecaps point toward each other. Everything in the person's leg and hip is pulled out of line.

      A pronating foot can be propped up with an arch support under the inside of the foot. This keeps the foot in line when it strikes the ground and prevents the leg from rolling inward.

Supinating Foot

The supinating, or cavus, foot, which rolls to the outside, is the mirror image of the pronating foot. The ligaments are tight, and the foot is rigid with a high arch, which causes the person to walk on the far outer portion of the foot. Because the arch is too tight, it cannot collapse when the foot hits the ground. With no arch to absorb the shock of each step, the shock is sent straight up the outside of the leg.

      The supinating foot requires soft padding under the outside of the foot. If you have this problem, I suggest you take a $4 Dr. Scholl's Flexo Arch® and glue a quarter-inch of soft foam padding along the outside edge of the arch. This will cause your foot to roll back slightly toward the middle and will provide some padding to reduce the pounding on your leg, or you may need an orthotic device to take some of the weight off of the outer side of your foot.

Morton's Foot

Morton's foot is characterized by the second toe being longer than the big toe. The problem is that the bone behind the big toe (first metatarsal) is too short. This inherited trait occurs in about 25 percent of the population and causes problems in more people than the other two foot abnormalities combined.

      When you walk or run, you create forward momentum by pushing off with the big toe, which is called toeing off. Just before toeing off, you place all of your weight on the head of the first metatarsal. In people with Morton's foot, the first metatarsal is too short to provide the leverage needed to shift the weight to the bottom of the big toe. Instead, the foot buckles to the inside, and the weight rolls along the inner side of the big toe. This is similar to what happens with the pronating foot, but a Morton's foot doesn't pronate until weight is placed on the toes.

      People with Morton's foot first strike the ground with the far outer part of the foot. This is probably an unconscious attempt to correct the inward roll of the foot, but it doesn't help prevent the pronation on toeing off. Instead, the person ends up walking across the foot, landing on the outside of the heel and then toeing off on the inside of the big toe, instead of walking with a straight-footed, heel-to-toe gait.

      Walking on the inner side of the big toe of a Morton's foot usually forms a large callus there. The big toe will also be pushed toward the second toe, and the pressure on the inside of the big toe may cause bunions on the inside of the foot.

      If you have Morton's foot, you may get by with a commercial arch support along with a foam pad under the big toe. More likely, you will need an orthotic that has an arch support and is built up under the big toe joint. When your foot starts to buckle, the built-up area will force you to push straight off your foot.

Flat Feet

Bones, muscles, and tendons under the foot create an arch in most people. Some people, however, are born with "fallen arches," or flat feet. Contrary to popular belief, flat feet are not a problem for athletes. In fact, flat feet usually are more flexible, have greater range of motion, and are better able to absorb the shock of running and jumping.

      It is the athletes with high arches who are more injury-prone. An unusually high-arched foot is more rigid and has less range of motion during quick, agile movements. Also, a foot that's precariously balanced on the heel and ball has poor shock-absorbing ability.

      Many children start off with flat feet, but the vast majority develop normal arches as they grow. Until recently, flat-footed children were frequently treated with orthotics and perhaps surgery to create a higher arch. But few studies have shown that wearing a particular shoe or arch support can make a significant difference in the development of an arch. Most doctors now feel that flat-footed people should not limit their activities and do not need special treatment. Seek medical care only if your feet hurt.

Telltale Signs of Foot Abnormalities

One of the best ways to diagnose foot problems is to look at the wear pattern in a pair of athletic shoes. A pronating foot wears out the inside of the heel and toe, and the shoe breaks over to the inside. If the shoe is placed flat on a table top, it will lean to the inside, particularly the heel counter. A supinating foot wears out the outside of the shoe, from the heel all the way down to the toes. This shoe will lean to the outside. A Morton's foot wears out the shoe on the outside of the heel and midsole, and then straight across the sole to the inside of the big toe (see the figure below).

      I ask people who are having foot problems to bring their running or tennis shoes with them to my office. Often, they bring in a new pair of shoes because they are ashamed to show me how badly ruined their old shoes are. Of course, a brand new pair of shoes tells me absolutely nothing about their foot problems.

Orthotics

Orthopedists have begun to question the safety, expense, and usefulness of the rigid, custommade inserts that have become trendy among athletes. Orthotic devices contain carefully placed divots and bumps designed to shift your weight in a way that forces you to walk or run more naturally. They are made from a variety of materials, from layered foam to leather-covered cork to hard plastic.

      Orthotics are not the answer to all foot problems. In fact, about 80 percent of the people who spend hundreds of dollars for custom-made devices would do just as well with a soft arch support. Many commercial arch supports are available for $15 to $40 at drug or sporting goods stores.

      I usually don't send anyone to be fitted for an orthotic until he or she has failed to improve with a stock arch support. If the foot problem is so complex that a simple stock arch will be ineffective, then I order an orthotic right away.

      If you have persistent foot pain that you can't trace to an episode of trauma, put some type of arch in your athletic shoe. If nothing changes, then your pain is not due to an overuse injury, and you need to see a doctor to find out what's wrong. If the pain diminishes or even gets worse, then you probably have an overuse injury. Any change in pain is a sign that the arch support has had some effect. If the pain goes away, continue using the arch support. If the pain gets worse, see a sports podiatrist for a properly fitting orthotic.

      In looking for a podiatrist to make an orthotic, it's important to find someone who deals with athletes. A running orthotic is very different from a walking orthotic. If you choose someone who doesn't understand the mechanics and stresses of running, you may end up spending a lot of money for little or no pain relief. Also, wearing an orthotic insert should never be painful. If it is, take it back and have it adjusted.

FOOT PAIN

Pain in the front of the foot just behind the toes (metatarsalgia) can be due to the stress of placing weight on the toes when you run. Usually, you will feel the pain in your second or third toe. The heads of the metatarsal bones in these toes may drop slightly, and the excessive weight placed on them as you come up on your toes causes pain. A pad behind the heads of these toes will lift them and take the weight off, and this usually relieves the pain.

BRUISED FOOT

A batter who fouls a ball off the foot, a soccer player who continually kicks the ball, or a person whose foot is stepped on can develop a nastylooking bruise. If you bruise your foot, ice it for four or five days and rest it until you can walk normally.

BROKEN FOOT

Any bone in the foot, from the toes to the heel, can be broken. Broken bones in the foot other than the toes require immediate medical attention and casting. The length of time you will have to spend in a cast depends on the bone involved. Four to six weeks is customary. Each break is different your time to recovery may be a great deal longer.

BROKEN TOE

A broken toe usually only needs to be buddytaped to the next toe. Put gauze between the two toes before taping them together; otherwise, sweat will cause the skin to soften and flake away.

BLACK TOENAILS

I frequently see long-distance runners whose toenails turn black and fall off. This is due to the toenail banging into the toe box of the runner's shoe. The constant banging causes bleeding under the toenail, which makes it turn black.

      The problem is an undersized shoe. As you run, your foot spreads out and swells up slightly, so your running shoes should be one size larger than your dress shoes. Sizes vary from brand to brand, so always carefully try on a new shoe. Regardless of a shoe's stated size, if your toenail turns black after running, the shoe is too small.

      People with Morton's foot have an additional problem. The toe boxes of running shoes are all designed with the assumption that the big toe is the largest toe. In the person with Morton's foot, the second toe is largest, so most athletic shoes do not fit properly. If you have Morton's foot, try on a lot of styles and see which one is the most comfortable.

TURF TOE

"Turf toe" is the vernacular term for a sprained joint at the base of the big toe. This injury has always been around, but it became more common with the replacement of natural grass playing fields with artificial turf.

      The injury is due to the unforgiving interface between the athletic shoe and a hard surface. When you run on natural grass with cleats on, the grass gives. If you look at the ground, you will see dirt packed down by cleat holes. This means that some of the stress of toeing off has been absorbed by the ground. The hard surface of artificial turf doesn't give, and the entire stress of toeing off is transferred to the toe joint.

      The aggressive push-off with the big toe places an overwhelming force on the toe ligament, and the joint can sprain. This injury is very painful and slow to heal. You need to rest your toe until the pain is gone. When it begins to heal, you can tape the toe down so that it can't extend upward. A sports podiatrist can provide a strapping technique and a special appliance to hold the toe down and speed your return to action.

PLANTAR FASCIITIS

The plantar fascia is the elastic covering on the sole of the foot that holds up the arch. It runs the length of the foot, from just behind the toe bones to the heel bone. This shock-absorbing pad can become inflamed, a condition called plantar fasciitis, causing a dull ache along the length of the arch.

      The ache is due to overstretching or partial tearing of the plantar fascia. This injury usually happens to people with rigid, high arches. They feel the pain when putting weight on the foot or when pushing off for the next stride. When the arch starts to come down, it stretches the plantar fascia and pulls on its fibers. The torn fibers may go into spasm and shrink. With every step, the plantar fascia tears a little more and causes intense pain.

      If you suffer from this injury, you will feel the pain particularly upon arising or after sitting for a long while. With the weight off your feet, the plantar fascia will start to heal. But each time you again put weight on your foot, the torn fibers will be pulled apart as the arch collapses.

      The treatment is to put an arch support under the foot immediately to prevent the arch from collapsing and the plantar fascia from stretching. Also, put an arch support in your slippers and wear them as soon as you get out of bed. Even a few steps without support can stretch the plantar fascia. By using arch supports, you will likely feel relief within two to three days.

      Plantar fasciitis is particularly common among middle-aged people who have been sedentary and who suddenly increase their level of physical activity. Running and jogging lead to most of the injuries. Inappropriately fitting shoes or a weight gain of 10 to 20 pounds can also contribute to the condition.

"HEEL SPUR"

One of the most common complaints I hear is about heel pain. The patient will say, "My doctor told me I have a heel spur, and he wants to operate. What should I do?"

      The first thing you should do is not have surgery. The pain under the surface of the heel may or may not stem from a heel spur. A heel spur is a hook of bone that irritates the heel. More likely, however, the pain is from an irritated, overstretched plantar fascia.

      The pain originates under the surface of the heel where the plantar fascia hooks into the heel bone. Constant pulling on the plantar fascia where it attaches to the heel can cause the heel bone to overgrow and form a spur. This can be seen on an x-ray. For most people, however, the pain is simply due to overstretching the plantar fascia when the arch comes down, not to the growth of a spur. An arch support can hold up the plantar fascia and keep it from overstretching. Even if an x-ray shows an actual heel spur, you may not need surgery.

      Some doctors recommend a heel cup, which holds and cushions the heel within the shoe. But a heel cup may make things worse. Many heel cups are rounded on the bottom, which causes increased pronation in the heel and stretches the plantar fascia even farther.

      If your heel is very painful, you may need a cortisone injection to reduce the inflammation in the plantar fascia. This, however, is a last resort. You will still need to use an arch support to prevent the pain from recurring.

HEEL BURSITIS

Pain in the back of the heel where the Achilles tendon attaches to the heel bone can be due to bursitis. Under the Achilles tendon is a small bursal sac, about the size of a bean, that protects the tendon from rubbing on the heel bone. When the Achilles tendon goes out of alignment, a situation usually due to pronation, it puts undue stress on the bursa, and the sac becomes inflamed and painful.

      This bursitis sometimes responds to an arch support, which brings the Achilles tendon back into alignment. More often, however, it requires a small injection of cortisone, like any other bursitis.

HEEL STRESS SYNDROME

Stress syndrome is another cause of pain in the heel. It occurs on both the inside and outside of the heel bone, but more severely on the inside. You will feel pain when your heel hits the ground, and the pain will worsen from running. This pain is due to excessive pronation of the foot. The heel rolls to the inside, and the force of your weight is delivered at an angle rather than straight down.

      I often see this problem in young children in the spring and fall because the pronation problem is aggravated by cleats. If a child has a pronating foot, the broad base of a shoe or sneaker tends to stabilize the foot. When the child wears cleats, however, there is minimal contact between the surface of the shoe and the ground, and the foot is allowed to slide much further toward the inside. Children with pronating feet who go out for football, soccer, or baseball pound on their heels and feel the pain.

      This heel stress in children is often misdiagnosed as an inflammation of the growth center in the heel, called Sever's disease. This is a rare disorder. The heel pain is much more likely to be due to the stress of running.

      Again, the answer is to put an arch under the foot to correct the pronation. Some children who can barely walk will be free of pain after two to three days of using the arch. I also recommend that children with heel pain practice in sneakers and wear cleats only during games.

STRESS FRACTURE OF THE FOOT

If you have felt mild pain in your foot for days or even weeks while running, and you then feel a sudden, severe pain in the front part of your foot during a run, you probably have a stress fracture of the foot.

      When excessive force is transmitted to the second, third, or fourth metatarsal bone, the bone can crack from overfatigue. When you come up to toe off, most of your weight is on the first metatarsal, behind the big toe. This bone is very thick and heavy to provide support. If the bone is too short, as in the Morton's foot, your weight will be transmitted to the other toe bones, which are not as heavy, and they can crack.

      If you suffer a stress fracture, both the upper and the lower surfaces of your foot will be tender, and you may have some swelling. You will need to get an x-ray of the foot, and sometimes even a bone scan, to confirm the diagnosis.

      A stress fracture needs rest for four to six weeks to allow the fracture to heal. Crutches are necessary only if you feel severe pain when you walk. Casting is usually not necessary. However, you will need an orthotic to redistribute your weight so that the bone doesn't crack again when you return to activity. Early use of an orthotic will give you relief while the fracture heals.

      A stress fracture of the fifth metatarsal, behind the little toe, is a more serious injury. This results from an excessive load on the outside of the foot, such as with the supinating foot. These fractures heal poorly and require early medical attention. Simple rest is not the answer. You may be in a cast and on crutches for anywhere from six weeks to several months. Many of these fractures are treated surgically, with a screw used to hold the fragments together.

TOE TENDINITIS

Tenderness and swelling along the top of the foot only is usually due to tendinitis, an inflammation of the tendons that raise the toes. It will hurt if you hold your toes down with your fingers and try to pull them back up against resistance.

      The cause may simply be that you are lacing your shoes too tightly. Or you may have poor padding under the tongues of your shoes.

      The treatment is to ice the tendons intermittently until the pain and swelling subside and to take anti-inflammatory agents. I also suggest that you go to an upholstery store and get a wad of foam to put under the tongues of your shoes.


Choosing an Athletic Shoe

I remember when sneakers or "tennies" were the shoe of choice for athletes. Made of thin rubber soles and thin canvas tops with white laces, they were worn for every sport. They were the original cross-trainers.

      When I first took up jogging, the Nike Waffle Trainer® had just come out and I, along with everyone else, thought it was the greatest advance in comfort yet. Today, however, no one would consider using this shoe, or a canvas tennis shoe, because of its flimsy construction and lack of padding.

      Athletic shoe design has become a high-tech specialty. There are now new air soles, gel soles, fluid soles, and gimmicks such as the Pump®. There are so many different makes and models and shoes for so many different sports that we now have a hybrid called the cross-trainer, which is good for a lot of sports but not great for any one. I still can't see the need for separate shoes for walking and jogging.

      And the cost of shoes has gone out of sight. When I was young, the only children who wore sneakers to school were those who were too poor to afford real shoes. Today, everyone wears sneakers to school. It's not uncommon for a hightop basketball shoe worn only to school to cost more than $100, and adult athletic shoes can cost more than $150--quite a difference from the $9.99 Converse® tennies I used to wear.

      By wearing proper athletic shoes, you can reduce the risk of all the injuries that stem from a poor foot strike and lead to pain all the way up the leg to the back. Here are some necessary features for sports-specific shoes:

  • In running shoes, look primarily for good cushioning and good stability. The soles should curve up in the front and back, with a slightly elevated heel; heel counters should be firm; and the edges should be sharp for stability. The shoes should be lightweight with soft, breathable, and flexible uppers. They should have good midsole cushioning and soles that are grooved or studded.

          If your foot tends to pronate, choose a shoe with a straighter last and extra firmness along the inner edge for more stability. If your foot tends to supinate, choose a shoe with a curved last that forces your foot inward and with a soft midsole and heel counter.

  • Walking shoes should be made to suit the heel-to-toe gait of walking. They should have adequate flexibility in the forefoot and adequate room between your toes and the top of the shoe. The shoes should be lightweight and have strong heel counters, good midsole cushioning, slightly elevated heels, and flexible soles that curve up at the heel and toe. The upper should be made of breathable materials with a hard, reinforced area to protect the toe.

  • Tennis shoes should provide good lateral support and good shock absorption. They should be heavy and strong with flat soles and a hard, squared-off edge. Also look for a reinforced front, a cushioned midsole, a firm heel counter, and a sole with circles to facilitate turning.

  • Racquetball shoes should have lightweight uppers, good midsole cushioning, and tacky, round-edged soles that are thinner and more flexible than those of tennis shoes.

  • Volleyball shoes should be lightweight and flexible with reinforced toes, well-cushioned midsoles, and soles made of ridged gum or rubber with rounded edges for good lateral support.

  • Aerobics shoes are a lightweight combination of tennis and running shoes. They should have good shock absorption, and stabilizing straps may be good for the side-to-side action of low-impact aerobics. Good aerobics shoes will have slightly elevated heels; firm heel counters for stability; lots of midsole cushioning; and wrapped, soft rubber soles for lateral support.

  • Basketball shoes should be heavier than tennis shoes, with good shock absorption, ankle support, traction, and stability. This means good lateral support, hard rubber cup-ridged soles, and sturdy midsoles.

  • Football shoes should have thick, rigid, leather uppers with sturdy heel counters and spiked rubber soles.

  • Baseball shoes should have uppers made of leather or nylon and leather, soles with sharp edges for good traction, a long tongue flap that folds back over the laces to keep dirt out, and soles with cleats of molded plastic or hard rubber.

  • Cycling shoes should have stiff soles for efficient pedaling. Racing shoes should have a very stiff sole and touring shoes a little more flexibility. The snug-fitting, stiff uppers should be made of leather or leather and nylon with no cushioning. Shoes for mountain biking may use more durable materials. Many cycling shoes have Velcro snaps for a snug fit. The shoe should also fit snugly into the toehold on the pedal, and the soles should have grooves to help grip the pedals.

  • Weight-training shoes need a wide base for stability and a firm midsole for support. Stabilizing straps can lock in the heel to provide a firm footing.

  • Cross-trainers pack flexibility, stability, and cushioning into one pair of shoes. Choose shoes with restraining straps for good lateral support and with reinforced toes. You need a shoe that provides adequate cushioning, especially in the heel and ball of the foot.




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