From The Foot To Lower Back (Part II)
In the fourth edition of Healthy Times, we covered bunion, tired aching leg and knee pain (patello-femoral syndrome), which can be a result of over-pronation. In this edition, you will read more about over-pronation related common conditions such as Metatarsalgia (Ball of foot pain), Achilles’ tendonitis, Ilio-tibial band syndrome (Outside knee & hip pain), Tibial Stress Syndrome (Shin Splints) and Lower Back Pain.
Metatarsalgia (Ball of foot pain)
Metatarsalgia is usually described as a "burning and sometimes sharp pain in the ball of the foot". This is usually aggravated when walking barefoot or on hard surfaces. Sometimes patients may describe the pain as a lump underneath the ball of the foot. Applying pressure to the plantar surface of the metatarsal heads may elicit pain.
Cause:
When a foot is pronated excessively, there is a progressive weakening of the soft tissue structures. In the forefoot, as this occurs the metatarsals plantarflex and rotate. This results in shearing forces on these foot structures. After a period of time the foot may experience nerve damage or callosities.
Treatment:
Custom orthotics can prevent plantar-flexion and shearing of the metatarsal shafts. Balancing the weight distribution over metatarsal bones helps remove excess weight and friction which commonly causes the callus and burning sensation. Treatments also include icing and appropriate footwear such as shoes with deep roomy toe box.
Achilles’ Tendonitis
It is an inflammation of Achilles’ tendon, commonly found in athletes. Symptoms included sharp, nagging pain above the heel. Limited ankle flexibility and inflammation over the affected area are often present.
Cause:
It commonly occurs from shearing and tractional forces placed on the Achilles tendon above the heel. When the foot accelerates into an excessively pronated position, the heel bone everts which causes an increase in medial Achilles’ tendon traction resulting in transverse shearing.
Treatment:
Custom orthotics can reduce medial Achilles’ tendon traction, therefore helping to alleviate the problem. Proper Achilles’ stretch, ice therapy (15 minutes, 3 times a day) and rest from exercise are also important.
Ilio-tibial band syndrome (Outside knee & hip pain)
It is a common overuse injury in athletes caused by abnormal friction & torsion of the ilio-tibial band over the knee and hip joints. It is a gradual but rather severe pain on the outside knee joint and less commonly on the outside hip section. Sometimes, simply walking up or down stairs may aggravate this condition. The pain usually subsides immediately upon rest but reoccurs with activity.
Cause:
Excess pronation causes excess internal tibial rotation which effectively causes the ilio-tibial band to shear over the lateral femoral condyle, resulting in friction, tightness and secondary inflammation.
Treatment:
Orthotics control the internal rotation of the tibia and furthermore the rotation on the knee and hip joint. Thereby, it can reduce tractional and frictional forces on the ilio-tibial band. Additional treatments include ice therapy, strengthening and stretching of the ilio-tibial band.
Tibial Stress Syndrome (Shin Splints)
It is an inflammation of soft tissues along the tibia. The patient will complain of tightness/tenderness and sometimes throbbing pain along the border of the tibia that comes on with a specific activity (especially running & walking long distances) and often settles upon resting. Often, it will start like a dull ache but quickly becomes sharper and more aggravated.
Cause:
There are two type of tibial stress: anterior and posterior. Anterior tibial stress is often experienced by new runners or walkers when pain occurs in the anterior muscles of the shin during exercise. Posterior shin splints (medial tibial pain) are a more chronic condition occurring along the inside edge of the tibia and generally occurs with over-use related sports.
Both conditions are related to excess stretching of soft tissue structures along the shin bones (tibia and fibula). Excessive pronation and internal tibial rotation increase the medial tractional forces upon the deep flexors and extensors of the leg. This is a common factor in muscular overuse conditions and commonly exhibits secondary periosteal swelling due to tractional forces placed upon the soft tissue structures on the tibia and fibula.
Other causes of shin splints include stress fracture of the tibia and tendonitis of the muscles that cross the ankle and compartment syndrome.
Treatment:
Custom orthotics assists reduction of internal tibial rotation and reduces medial tractional forces upon anterior tibialis and posterior tibialis muscles. Additional treatments include ice therapy (15 minutes, 3 times a day), rest from exercise, deep tissue massage, stretching and strengthening of tibial muscles.
Lumbo-Sacral Pain (Lower back pain)
It is a dull ache and stiffness in the lumbar region. Standing for long periods or sitting in the same position may worsen the pain.
Cause:
Bilateral excess pronation internally rotates the tibial and femoral shafts which can lead to anterior tilt of the pelvis and a forward shift of the body's center of gravity, resulting in increased lordotic curvature and compensatory muscular tightness of the lumbo-sacral region. The upper body (Thoracic Region) commonly develops a secondary kyphotic curvature. Unilateral excess subtalar joint pronation lowers the vertical distance of the foot to the ground, therefore creating a functional short leg, causing hip mal-alignment.
Treatment:
Custom orthotics control internal rotation of the tibial and femoral shafts, thereby limiting anterior pelvic tilt and secondary muscular tightness of the lumbo-sacral region. Proper exercises also play an important role of treatment.
1. Strengthening of the abdominal muscles - 'safe' sit-ups (lift head and shoulders off the ground whilst keeping the neck straight and eyes focused on ceiling)
2. Press-ups: like push-ups, however the legs and pelvis stay flat on the ground
3. Hamstring and lumbo-sacral stretches
The above treatment options serve as a general guideline only. Every case should have their individualized treatment plan. One should consult their foot and ankle specialists if further evaluation and/or management are needed.