|
FOOT AND ANKLE
Taking Care Of Your Foot And Ankle
"My feet are killing me!" is one of the most
enduring phrases in the English language. Like most
clichés, this one is grounded in day-to-day experience:
the foot and ankle region is subject to constant stresses
and hazards, from the effects of ill-fitting shoes to
traumatic sports injuries. The results can be painful
or worse. While our feet may not literally be "killing"
us, foot and ankle problems can have a significant impact
on our general health and well-being.
In this article you will learn about:
The basic anatomy of the foot and ankle;
Common ailments of the foot and ankle;
Ways to reduce the risk of injury;
Exercises to do at home; and
Physical therapy treatments.
In addition, we will discuss some important information
that will be of special interest to people living with
diabetes and other diseases. But whatever the nature
of your foot/ankle problem, physical therapy can often
help you recover function and keep you on the move.
Foot and Ankle Anatomy
The foot contains three main sections or functional
units: the rear foot, mid foot, and fore foot. These
three units work together to allow the foot to be flexible
(such as accommodating an uneven surface) or to be fairly
rigid (such as keeping the body upright as we go through
the normal walking cycle).
Each foot contains 26 bones: 7 tarsals (ankle bones),
5 metatarsals (instep bones), and 14 phalanges (toe
bones). The main arch of the foot is called the plantar
arch. It runs lengthwise and touches the ground only
at the heel bone and at the ball of the foot. The plantar
arch is thickly padded at both ends. There is also a
thick pad of fat under the heel of the foot to absorb
shock. In addition to the plantar arch, the foot has
two other arches: the metatarsal arch, which runs crosswise
under the instep, and the lateral arch, which runs lengthwise
along the outside of the foot.
The bones and joints of the foot and ankle are held
together by a strong network of muscles and ligaments.
The foot is connected to the ankle where one of the
tarsal bones, called the talus ,meets the lower leg
bones, called the tibia and the fibula.
The ankle joint is called upon to provide both great
stability (keeping us standing up) and great mobility
(walking, running, jumping). These two functions need
to be kept in balance if we're to keep our feet healthy
and functioning.
The Way We Walk
Physical therapists refer to the motion of the foot
during walking as a key part of the gait cycle. An individual's
gait cycle consists of two phases: the stance phase
and the swing phase.
In the stance phase, the foot is in contact with the
ground. During the first part of the stance phase, in
which the heel strikes the ground, the foot undergoes
pronation; during the second part of the stance phase,
in which the foot rotates forward onto the ball of the
foot and the toes and recovers stability, the foot undergoes
supination. The swing phase is the period during which
the foot is completely off the ground.
While most of us pay little attention to this "automatic"
process, problems can develop if the pronation and supination
phases are not in harmony. If, for example, a person
relies too heavily on the "wrong" muscles
and other soft tissue to recover stability, those muscles
and tissues may become stretched beyond their normal
range and become inflamed.
Every person's gait cycle is somewhat different. (If
you've ever noticed that the heels on your shoes wear
down quickly at a particular angle, this is an indicator
of your own particular style of walking.) Physical therapists
sometimes videotape a patient's gait cycle to help pinpoint
the source of a foot or ankle problem, particularly
if the problem is not the result of injury or disease.
Once the physical therapist can see exactly how a patient
is walking, it's easier to design an effective therapeutic
program that will improve the patient's "form."
In addition, the physical therapist will usually prescribe
exercises tailored to the particular needs of the patient.
What Causes Foot And Ankle Problems?
Because we are two-footed creatures, our feet and ankles
are called upon to perform a remarkable achievement
of biomechanics -they keep our bodies upright and stable
while permitting us to run and walk. This unique capability
puts great pressure on our feet and ankles. It can also
turn what were initially minor problems into major ones.
Shoes are often the culprits. The legions of women who
have forsaken "heels" for athletic shoes on
their daily commutes to the workplace are a vivid reminder
of the effect that shoes have on our daily lives. And
it's not just women who suffer from the dictates of
fashion: many men also feel compelled to squeeze their
feet into fashionable European-style loafers or tight
"executive" shoes at the expense of comfort
and, ultimately, health.
It's important for all of us to know what waiters and
waitresses have known for years: that if you're going
to stay on your feet and keep going, your shoes have
to fit right, be comfortable, and provide support -and
support means maximum coverage of the surface area under
the plantar arch. It's also necessary that your shoes
be able to absorb shock while you walk, and that they
provide stability to the heel area.
Fortunately, it's no longer necessary to sacrifice
style for comfort and health- several shoe companies
now specialize in making "healthy" shoes in
styles that are virtually indistinguishable from "regular"
shoes. When buying new shoes, remember that lace-up
shoes are generally preferable. They tend to provide
a snugger fit than slip-ons and more stability to the
heel; lace-ups also give you more control over the fit.
If you're not ready to invest in new shoes, the inexpensive
shoe inserts available in drugstores can provide a degree
of softness and shock absorption.
Foot And Ankle Injuries
The most commonly reported injuries in the foot/ankle
region are ankle sprains. A sprained ankle simply means
that the ligaments (the strong bands of tissue that
connect the bones of the foot) are stretched beyond
their normal limits, resulting in inflammation, tearing,
or rupture of the tissue.
Sprained ankles run the gamut from minor to serious.
If you're in pain for more than a day or two, or if
the pain is intense, you should see a physical therapist
or physician. If physical therapy is required, the sprained
ankle will be immobilized for a short period to prevent
further damage and to give the tissue a chance to heal.
After that, therapy progresses quickly with exercises
designed to restore stability and strength to the muscles.
It is also crucial that the patient's sense of balance
be restored or enhanced through exercise.
"Shin splints" is a catch-all phrase for
a number of foot and ankle problems, including overuse
of the muscles and tendons of the foot and ankle. Tendons
are the strong fibrous cords that attach muscles to
bones. The Achilles tendon, which takes its name from
ancient mythology, is easily felt at the back of the
ankle. Achilles tendinitis is an inflammation of this
tendon, often resulting from sports (such as basketball
or aerobic dancing) that require a great deal of jumping.
Plantar fasciitis is an irritation of the plantar fascia-
the tough tissue on the very bottom of the foot that
begins at the heel and is attached to the toes. It can
result in pain and lead to a heel spur, a bony growth
on the underside, forepart of the heel bone. This kind
of pain is usually at its worst in the morning, then
gradually diminishes during the day. Heel spurs are
caused by straining the foot muscles, stretching the
long band of tissue connecting the heel and the ball
of the foot, and by repeated tearing of the lining of
the membrane that covers the heel bone.
Metatarsalgia is pain in the forefoot, usually caused
by the over-prominence of one of the metatarsal heads,
i.e., the heads of the bones in the ball of the foot.
All of these overuse conditions can be aggravated by
excessive pronation.
Most people associate repetitive motion injuries with
the hand and wrist- but did you know that your feet
and ankles are also vulnerable? People who are on their
feet all day- salespeople, trial lawyers, teachers,
nurses, athletes - are at risk for a variety of foot
and ankle disorders, including tarsal tunnel syndrome.
While not as well-known as its "cousin" carpal
tunnel syndrome (in the wrist), tarsal tunnel syndrome
can be just as painful. As with many foot problems,
tarsal tunnel syndrome can often be blamed on shoes
that do not provide enough arch support and heel stability.
Ill-fitting shoes cause the foot to pronate excessively;
when this happens, one of the thick ligaments running
from the ankle to the bottom of the foot can become
stretched and inflamed. This in turn can irritate a
major nerve running just behind the ligament, resulting
in tingling and numbness. If the standard treatments
for heel pain are ineffective, a physician should be
consulted about the possibility of other treatment options.
Flat feet, also called "pancake feet," is
a condition in which the arch is judged to be lower
than normal. There are many degrees of "flat feet,"
and some physical therapists will point out that curve
of a "normal" arch is a subjective judgment.
Nevertheless, flat feet can cause discomfort, and sometimes
can lead to plantar fasciitis or other problems.
High arches, as opposed to flat feet, is a condition
in which the arches are higher than normal. The main
concern here is to make sure that the shoes have enough
surface contact and support for the arches; otherwise,
the stresses put on the foot and ankle can move "up
the chain" through the legs and spinal column.
In some cases, high arches may require custom orthopedic
shoe inserts to prevent more serious problems.
Disease-Related Foot Problems
Physical therapists commonly treat foot problems associated
with diseases such as diabetes or arthritis. Diabetes
can lead to peripheral neuropathy, a condition in which
feeling is reduced in the foot. This numbness is a serious
condition that can lead to injuries and ulcers on the
foot- and, in the most extreme cases, amputation. Because
the patient can't feel pain or pressure, a simple blister
can turn into an ulcer, infection can set in, and, in
severe cases, this can be followed by gangrene and amputation
of the foot or leg.
There is now a simple screening procedure that can
tell you instantly if you are at high risk for peripheral
neuropathy and its complications. Physical therapists
and physicians use a simple device that resembles a
toothbrush with a single long bristle. As the various
areas of the foot are touched by the "bristle,"
the patient indicates if he or she can feel it. In addition,
physical therapists and physicians can measure the amount
of feeling in a particular area by the degree to which
the bristle bends. If there are parts of your foot that
are numb and at risk for injury, you'll know exactly
where they are, giving you a head start in protecting
the area.
Physical therapy cannot reverse peripheral neuropathy,
but it can lessen its impact and ultimately help prevent
amputations. While physical therapy can help improve
blood flow to the feet, it is most important that the
patient learn to use his or her other senses (particularly
sight and touch) to detect trouble spots, and to protect
the feet with the right shoes.
You should also use your mirror and ask for assistance
from family members to help you detect injuries you
may have overlooked. In addition to using your eyes,
feel your feet with your hands-if one foot seems colder
than the other, it may be getting less blood circulation
and require more attention. Using this combination of
professional and home care, it is now estimated that
as many as 50% of foot amputations due to peripheral
neuropathy can be avoided.
Charcot's arthropathy is a very serious (and fairly
rare) condition that involves a disruption or disintegration
of some of the joints of the foot and ankle. Redness,
swelling, and deformity of the foot may follow. The
cause of Charcot's arthropathy is not well understood,
though (like peripheral neuropathy) it is often linked
with diabetes.
Your physician must be involved in the treatment of
Charcot's arthropathy, which will include immobilization
of the foot in a cast to prevent further trauma to the
foot. A physical therapist will often be called upon
to help the patient maintain mobility of the joints
through exercise.
Arthritis is the inflammation and swelling of the cartilage
and the lining of the joints. The foot and ankle region
is especially susceptible to arthritis because of the
large numbers of joints at risk (33 in each foot) coupled
with the tremendous weight-bearing load on the feet.
It's difficult to generalize about the causes of arthritis.
Heredity plays a role in some cases, traumatic injury
or infections in others. People over 50 are most at
risk. It's important that you seek professional care
if you suspect that you have arthritis; left untreated,
arthritis can be a debilitating or even crippling disorder.
The most common form of arthritis, osteoarthritis, is
a degenerative "wear-and- tear" disease associated
with aging, injury, or overuse. A more serious form
of the disease is rheumatoid arthritis, an autoimmune
disorder that is thought to be hereditary.
Arthritis can't be cured (although rheumatoid arthritis
sometimes goes through periods of remission). Your physician
may suggest taking medication to reduce inflammation.
And your physical therapist has many options to help
you maintain function and mobility. With the right professional
care, you can minimize the effects of arthritis.
If you are at risk for disease-related foot problems,
try to find a multidisciplinary foot clinic for treatment.
Such clinics have physicians, physical therapists, orthotists,
and pedorthists (to make customized shoe inserts) on
staff. Regrettably, these clinics are not yet found
in all parts of the country; they are, however, an ideal
setting for someone facing serious foot complications.
How Physical Therapy Can Help
While physical therapy is by definition tailored to
the individual's problems and needs, certain procedures
are common in dealing with foot and ankle disorders.
Typically, your physical therapist will begin your rehabilitation
by taking a detailed history and evaluation of your
foot and ankle problem. Related problems such as diabetes,
arthritis, and vascular disease are assessed during
this initial phase.
The second part of your therapy is often gait analysis,
in which the physical therapist observes you as you
walk or, in some cases, run. The physical therapist
will take detailed notes, sometimes using video cameras
as a diagnostic tool.
At this point the physical therapist may assess your
range of motion- how far and in what directions you
can move your foot and ankle, with and without the assistance
of the physical therapist. The physical therapist may
also perform tests to assess the strength, sensation,
and blood circulation in your foot and ankle.
Special tests may be performed as needed, including
assessments of individual joints and ligaments. A biomechanical
assessment can determine how the foot and ankle align
with the lower extremities.
Physical therapists may choose from an array of options
in treating you, including exercises for flexibility,
stability, balance, strength, coordination, and restoration
of range of motion, as well as massage, electrical stimulation,
ultrasound, traction or mobilization, or heat or cold.
These tools allow the physical therapist to create a
program of rehabilitation that is custom-designed for
your particular problem. In addition, the physical therapist
may consult with other health care practitioners to
provide special bandages, braces, supports, casts, or
shoe inserts.
To avoid or overcome a foot or ankle problem you may
need to learn some new habits or modify your current
level of physical activity, whether it involves work,
recreation, or both. Once your physical therapy goals
are met, your physical therapist will help you continue
therapy on your own with a home program designed to
fit your needs. The goal of physical therapy is to return
you to normal activity as quickly as possible, with
the knowledge you need to prevent reinjury or disability.
|
