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soft tissue disorders
Despite the fact that there are 26 bones in each foot
and over 20 joints, the vast majority of foot pain stems from soft tissue
inflammation and injury - caused mostly by overuse. When people have
swelling, pain and disability in their feet they often think an x-ray
should be taken. In fact, an x-ray is rarely useful. The most common
foot pain that is x-rayed is heel pain. Even when an x-ray shows a "heel
spur" it is a misleading diagnosis, since heel pain is almost always
caused by soft tissue inflammation of the soft tissue structure known
as the plantar fascia, where it inserts into the heel. The x-ray finding
is usually irrelevant. My favourite soft tissue disorders are listed
below.
Metatarsalgia
Defined as pain in the ball of the foot. There are an infinite number
of causes. Generally speaking, pain in the ball of the foot is caused
by soft tissue inflammation. It usually affects the 2nd or 3rd ball
of the foot joints (MPJ's) or can be felt on the outside of the foot.
People mistakenly think the pain is caused by a dropped metatarsal head.
This is almost never true. Metatarsal heads cannot "drop"
because they are all connected via ligaments and joint capsule - the
2nd, 3rd and 4th MPJ's work together as a unit. Unless you have systemic
arthritis, metatarsal heads do not and cannot "drop". This
is why the use of metatarsal pads (which are designed to "lift"
a dropped metatarsal head) is generally unsuccessful and often counterproductive.
Occasionally, pain in the metatarsal head area can be a stress fracture.
This condition can be diagnosed easily because of the characteristic
swelling and warmth it causes in a localized and specific area of the
foot. An x-ray can confirm the diagnosis 10 days after the crack in
the surface of the bone occurs.
Back to the usual cause of metatarsalgia - soft tissue strain. The most
common causes are over-exertion, poor footwear, high arched feet, high
impact activities, excess pronation. The classic scenario involves someone
who has just returned from a walking holiday in Europe where they wore
thin soled flimsy shoes for miles and miles of walking on cobblestone
streets.
Treatment usually includes rest, massage, improved footwear,
some type of insole or orthotic and time.
Sesamoiditis
This condition is extremely painful and difficult to treat. Under the
big toe joint there are 2 small bones called sesamoids. They act for
the foot in a similar way that the patella acts for the knee. They guide
tendons to the big toe joint and are responsible for maintaining stability
of the joint. If they become inflamed they result in considerable pain
with walking and standing. They burn, ache and make one's life downright
miserable. This condition is common in dancers.
The treatment involves unweighting the sesamoids (using
padding techniques to lift weightbearing pressure off the bones). Sometimes
this can be done with simple padding and other times it has to be done
in conjunction with a custom orthotic.
Tendonitis
There are a number of tendons that can become inflamed - the 3 most
common are the peroneal tendon (on the outside of the leg and foot),
the posterior tibial tendon (on the inside of the leg and foot) and
the achilles tendon. All of these tendons are responsible for control
of foot motion. They become inflamed when faulty biomechanics of the
foot or lower extremity changes the function of these tendons. Generally
speaking, people with overly pronated feet are more likely to have problems
with the posterior tibial tendon or the achilles tendon, while people
with overly supinated feet tend to develop problems with the peroneal
tendon. Peroneal tendonitis is also commonly associated with chronic
foot pain. The tendons can be tender, warm, swollen or may simply ache
and interfere with regular activities and walking.
Achilles tendonitis is quite common, especially in runners
and athletes. Eliminating or modifying one's running activities is the
most effective but least desirable treatment option. There may be underlying
factors that predispose someone to developing achilles tendonitis. These
would include a tight achilles tendon, excess pronation, improper footwear
and improper training techniques. Many a sports medicine specialist
sees achilles tendonitis en masse. Physiotherapy is a good place to
start. The podiatric approach focuses on proper pronation control and
dealing with the faulty biomechanics.
Ligamentous Strains
Suffered by most of us on an ongoing basis because we simply are on
our feet too much. The odd ache and pain in the foot is usually a ligamentous
strain. It hurts intensely in a localized area - usually for less than
a week. Often the problem is related to a specific incident - dancing
barefoot for an evening. twisting the foot while walking on a railroad
track, wearing heels higher than one is used to - there are many scenarios.
Rest and ice and good shoes are the standard treatment suggestions.
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