Importance of understanding and healing foot pain: Foot pain is often not given the same attention as other health issues. Instead, it is perceived as a natural part of aging that is to be expected. It is important to realize that foot pain is never normal. In fact, it is an indication of the abnormality of biomechanical function which, if left untreated, can lead to the development of problems in other parts of the body. Many feel that they do not have the time to address the issue of foot pain. It is important to know that a little time spent on the health of one’s feet will go a long way. Measures taken to prevent or ease foot pain can be the most time and cost-effective path to maintaining an active and healthy lifestyle. Finally, it is important to be properly educated about foot pain, including its causes, which will, in turn, assist in finding the right kind of treatment. This book was written with one of the most important causes of foot pain in mind—the effect of abnormal foot biomechanics on the rest of the body.

Foot and ankle pain contributes to one of the most common issues in the world. The feet provide an individual’s fundamental support for the entire body. This includes the ability to stand, walk, and run. Because of this, the feet may be subjected to significant impact. As a result, it is estimated that the average person will walk enough miles in their life to have traveled around the entire globe four times! This is an immense amount of wear and tear on one’s feet, and it can eventually lead to pain and problems. Furthermore, about 24% of adults are currently experiencing significant pain, limited mobility, or the inability to participate in leisure activities and exercise, with this percentage increasing significantly with age. Obviously, this is a major issue as it impedes one’s ability to participate in activities that are key to maintaining a healthy lifestyle. Even further, severe foot pain may limit an individual’s mobility, making daily routine activities challenging to impossible to perform. This often results in a less active and healthy lifestyle, placing these people at higher risk for developing other health-related problems. Early attention to foot and ankle pain is vitally important as it can decrease pain, prevent loss of mobility, and increase an individual’s chance for leading a healthy and active life.

Understanding Foot and Ankle Pain

Under normal circumstances, the foot and ankle can handle quite a lot of stress. Twenty-six bones, thirty-three joints, and over one hundred different muscles, tendons, and ligaments work together in the foot to absorb the impact of the body’s weight and to act as a lever to propel the leg forward. The ankle, at the upper end of the foot, acts as a hinge which provides the foot with a great deal of flexibility to adapt to the many different uneven surfaces that it may encounter. These combined factors make the foot and ankle particularly susceptible to injury and, as such, to pain. Unfortunately, if the pain is persistent, it can also become a source of injury to other parts of the body, most notably to the knee (which has to adapt to changes in walking or running caused by foot pain) and the lower back.

Importance of Addressing Foot and Ankle Pain

Foot and ankle pain, especially if prolonged, can go beyond physical discomfort. It can limit activity and movement and, thus, inhibit participation in social, work, and recreational activities. Prolonged pain may be a precursor to avoidable disability, and seeking diagnosis and treatment from a foot and ankle specialist can halt this progression. Addressing foot and ankle pain can also prevent the development of compensatory patterns of movement which may lead to stress on other joints (knees, hips, back) and, thus, further injury. Often times, people will accommodate an injury resulting in a different injury and pain in another part of the body. Those who experience foot and ankle pain are often impaired in their ability to perform activities of daily living. It has been reported that 15% of those over 60 have stated that they have been unable to perform tasks such as shopping, housework, taking medications, or self-care activities. In today’s society where independence is a key factor in self-worth, these people feel discouraged and hopeless. This may further lead to feelings of depression. A 2005 study in the Journal of the American Podiatric Medical Association found that 83% of 100 patients suffering from foot pain had significantly higher scores on the revised Beck Depression Inventory. In addition, the cognitive impact of foot problems has been measured with a Health-Related Quality of Life (HRQL) instrument. This helps to measure how medical conditions affect a person’s life quality. It has been found that foot and ankle problems have significantly more impact on the physical aspect of daily living. All these factors, including physical deformity, have a significant social impact on the individual and often lead to an overall decrease in life satisfaction and well-being. Just as foot and ankle pain can impact systemic health, systemic conditions can affect the health of the foot and ankle. It is for this reason that we should not understate the importance of foot and ankle health to overall well-being. In summary, foot and ankle pain can be a very disabling condition that affects many people. By addressing the pain early on, it will prevent further impairment and disability, improve overall quality of life, and prevent systemic conditions from further affecting foot and ankle health.

Success Stories

Diane was determined to avoid another surgery and resume all of her previous activities. She heard about a research study that was being done at Boston University on the effectiveness of orthotics on foot stress fractures. The study was being done by kinesiology students, supervised by Dr. McLaine. Diane was enrolled in the study, and the orthotics were found to be effective in offloading the injured arch. During the study, Diane learned about the option of physical therapy in the orthopedic world and the idea of getting her foot and posture back to normal rather than focusing on the injury. With the guidance of Dr. McLaine and his professional connection in the physical therapy world, Diane was referred to a therapist who was experienced with orthotics and postural restoration.

Diane had been a marathon runner and was no stranger to overuse injuries. She had been experiencing pain in her right foot for 3 years and was at the point that she could no longer run. Upon examination, it was found that she had a rigid flat foot that had also developed a bunion. Due to her highly arched foot, the flat foot had gone undetected and caused an imbalance in her foot leading to the bunion, pain in the great toe joint, and a plantar fascial tear. Surgery was recommended to correct the bunion and great toe joint pain, which involved fusing the great toe joint. Diane had the surgery, which was a success in regards to correcting the bunion and toe joint pain. However, her foot was now so stiff that it had essentially become a normal foot with a very high arch. She was fitted for custom orthotics to accommodate the changes in her foot and shoe wear. The pain in her arch and heel continued, and later tests revealed that the pain was due to the fact that she had developed an accommodative stress fracture to the very arch that was previously too flat. Her foot was overcorrecting… it was time to focus on healing the stress fracture.

Case Study 1: From Chronic Foot Pain to Active Lifestyle

At this stage she tried to reduce her orthotic wear due to the improvement in her symptoms, however it became evident that the orthoses were preventing reoccurrence of pes planus. Radiological reassessment of her feet revealed a notable increase in both talar and navicular height with an arch formed that was considerably nearer to the norm. The patient continues maintenance orthotic therapy on a biennial basis and has had no reoccurrence of symptoms to date.

Biomechanical assessment revealed extreme pronation and a subsequent referral for a weight bearing CT scan confirmed an accessory navicular. Custom foot orthotic therapy was prescribed in EVA with a deep heel cup and medial skive, combined with a rehabilitation programme to help increase the patient’s arch height and promote foot and lower limb mechanical realignment. After 3 months of orthotic therapy, the patient was able to temporarily increase her activity levels without significant discomfort and 4 months later was virtually pain free. She was now able to take part in regular gym sessions and fitness classes and proved the success of orthotic therapy by completing a 5k mud run, something she had never before considered possible.

A 38-year-old female patient experienced chronic foot pain due to undiagnosed pes planus for many years. This condition had affected her quality of life substantially, preventing her from standing or walking for prolonged periods and ruling out involvement in any impact sports or aerobic activity. In addition, she was severely restricted in her shoe wear and often required her to resort to ‘comfort’ shoes to avoid pain. This had a significant psychological impact and she attended the podiatrist feeling quite low and disabled due to her condition.

Case Study 2: Overcoming Ankle Injury and Regaining Mobility

The patient is a 73-year-old woman whose right ankle, for the past 5 years, had arthritis pain rated as 8 out of 10, and swelling and stiffness that severely limited her ability to walk. She had failed other treatments including medications, injections, a brace and a boot. Her past medical history included a total hip replacement, and she had significant deformity and limitation of ambulation due to pain and stiffness from post-traumatic arthritis in her ankle. Her activity was severely limited. She was able only to walk short distances using a cane for support. She was no longer able to swim, bicycle, or hike, activities she enjoyed and which helped her to control her weight. She felt she was too high a risk for an ankle fusion or replacement, and sought an alternative solution. An analysis of her gait showed that she walked with very little push off the right foot and increased load on the left hip and knee. She was treated with a combination of injections of platelet-rich-plasma and later bone marrow aspirate concentrate to the ankle, and a series of injections of bone marrow aspirate concentrate to the joints of her right foot. At 3 months she reported 50% improvement, and at 9 months 70%. There was a gradual decrease in pain and swelling, and increase in push-off on the right foot. At one year she reported feeling the improvement in her ankle and foot was now plateauing, and she was encouraged to undergo a second series of injections to the ankle which she felt brought her close to 80% improvement. She reported a remarkable increase in ability to walk and improvement in her activity including weight control measures. She said she was now able to climb stairs normally instead of one step at a time with both legs on each step. She was overjoyed at what she termed a life transformation due to the improvement in her ankle and foot. Her gait analysis showed improved propulsion from the right foot. She has continued periodic injections to maintain her improvement, and now can occasionally use hiking as a continued method of weight control and enjoyment. She is very active and has demonstrated a significant delay in the progression of her ankle arthritis to date. She no longer considers herself a candidate for an ankle fusion.

Case Study 3: How Proper Foot Care Transformed a Life

The patient expressed regret at putting up with the pain for so long, saying the only consolation was the inspiration it provided for his music. He described his plans for composing a piece with footstep sound effects as a part of the narrative. Dr. McCulloch agrees that sometimes inspiration for artistic expression can come from pain, but stresses that there are better ways of being creative.

Discussing a musician in his late 50s, with ankle pain and foot ache for virtually a decade had impacted on his ability to tour, Dr. McCulloch describes how a simple pair of customized shoe inserts turned the patient’s life around. The interview considers the durability and result of the inserts, with the musician maintaining he has not experienced pain once since putting them in his shoes. His relief is palpable as he describes playing a full tour for the first time in 10 years, lamenting the fact that he would have sought treatment sooner had he known of the effectiveness of the inserts.

Inspirational Journeys

May is a 46-year-old female librarian from Portland, Oregon who suffered with foot pain for over 10 years. She is not exactly sure how it all began, but she suspects it may have been working in her garden. Over the years, her foot pain steadily increased to the point where she found it difficult to walk. May was diagnosed with plantar fasciitis and met with a foot specialist who recommended custom orthotics for her shoes. This treatment seemed to help initially, but the relief was short-lived and May’s feet continued to worsen. She then became more aggressive with various treatments – more custom orthotics, physical therapy, cortisone injections, and even a walking cast. May’s symptoms did not improve and eventually she was told that surgery may be the only option to relieve her chronic pain. Fearing a complex surgery with a difficult rehabilitation, May sought a second opinion from a foot and ankle specialist who diagnosed her with tibialis posterior tendon dysfunction and a flatfoot deformity. This condition is a common cause of adult acquired flatfoot and is usually the result of an untreated sprained ankle. Over time, the condition causes the tendon to no longer support the arch, resulting in the progressive flattening of the foot. May’s new doctor was optimistic that this condition was the primary cause of her pain and that addressing it surgically could significantly improve her symptoms. After discussing the various treatment options, May elected to proceed with a tibialis posterior tendon reconstruction and a Kidner procedure, which is an osteotomy of the hindfoot with an in situ tendon transfer. This complex surgery would involve a strict no-weight bearing period and several months in a walking boot so May arranged an extended leave from work. Despite feeling somewhat anxious about the long recovery ahead, May was hopeful that this surgery would finally fix the problem in her feet and allow her to return to her normal activities without pain. The first few weeks after surgery were difficult for May because she was unprepared for the effects of staying off her feet and felt somewhat isolated being at home. However, she gradually made the adjustment and found ways to occupy herself at home. After 10 weeks of strictly staying off her left foot, May transitioned to a boot and was able to start limited weight bearing. Over the next several months, May’s foot gradually improved and she was elated to find that the pain she had suffered for so many years was completely gone! She has now made a full recovery and returned to all her previous activities including hikes in the outdoors. May is certainly a “success story” for adult acquired flatfoot and is proof that complex reconstructions can be very beneficial for patients willing to endure a long rehabilitation.

Journey 1: From Hopelessness to Triumph – Overcoming Foot Pain

Her problems began in her early 30s when she developed a large bunion on her left foot. A podiatrist assured Jane that it was “only a little bump” and that she should only worry about it for “aesthetic reasons” since it was not a painful bunion. Sadly, this misguided advice led Jane to spend several years in orthotics trying to control the bunion’s effects on making her big toe crooked and eventually leading to hallux limitus (a degenerative arthritis of the big toe joint). This greatly hindered Jane’s athletic lifestyle and led to a cascading spiral of foot pain on both feet. She had custom orthotics made for her shoes, had multiple cortisone injections, and even underwent a highly publicized (but very unrewarding) autologous blood injection procedure for her hallux limitus.

At first glance, you might mistake Jane as the depiction of good health. She is an energetic working mother of three, an avid runner, and an overall fun-loving person. Despite Jane’s foray into her 40s, anybody would describe her as the “life of the party”. A closer look, however, would reveal the constant pain and discomfort Jane has silently endured for the past several years.

Overcoming foot pain is one of the most rewarding types of success because it frequently has transformative effects on a person’s life. It’s our hope that after reading Jane’s story you will feel the same way.

Journey 2: Rebuilding Confidence After Ankle Surgery

During the years following her last operation, Jennie reported feeling abnormal sensations in her ankle when she attempted to walk. She eventually began to develop an altered gait in attempts to protect the injured joint, which was leading to musculoskeletal strains and pain. After encouragement from family and friends, Jennie decided to consult an athletic trainer who then referred her to the nearest physical therapy facility. Her physical therapist examined her walk on a treadmill and analyzed the movement of her lower extremities with a video camera. The footage was startling to Jennie as she realized how awkward her walk had become. It was at that moment that she truly understood the extent of her disabilities and decided that she needed to take corrective action.

Jennie’s chances of excelling in a professional tennis career were much higher than many other girls her age. By 19, she was competing in the professional circuit and appeared destined for greatness on the court. That is until a serious ankle injury made it impossible for her to continue playing the sport she loved. Over the years, she underwent three surgeries to repair damaged cartilage and tendons. Despite giving her ankle ample time to heal after each operation, it seemed that the joint would never function the same way again.