Metatarsalgia

Metatarsalgia is a general term for pain in the ball of the foot. It may feel like an aching, burning, or sharp pain that worsens with walking, running, standing, and going barefoot. It may feel like you have a pebble under the ball of your foot when you stand or walk.

Metatarsalgia is often caused by an increase in standing, running or sporting activities. Improper footwear is also a cause, especially if they are too tight, too worn, or don’t have enough padding. High heeled shoes transfer your weight to the ball of the foot and can contribute to metatarsalgia. Other contributing factors that can create pain in the ball of the foot are altered foot mechanics (fallen metatarsal heads), having high arches, or a second toe that is longer that your great toe.

Physiotherapy treatment involves addressing the cause of the pain. Switching to proper footwear, modifying your activity, and using a metatarsal pad can all help to reduce the pain in the ball of your foot. Metatarsal pads can be purchased over the counter, but there are a couple of different kinds. The gel pads can help if your pain is from wearing high-heeled shoes. However, if your pain is from altered foot mechanics, you will benefit from using the metatarsal pads that help to lift the middle metatarsal bones to disperse the pressure under those metatarsal heads. Using anti-inflammatory ointments as recommended and applying an ice pack around the ball of your foot for 15 minutes a few times a day can help to reduce the pain and swelling. Manual therapy mobilizations and soft tissue release of the foot and lower leg can improve tightness contributing to metatarsalgia. Low impact exercise like biking or swimming can keep you exercising while the foot is healing. Taping techniques to improve the foot and toe mechanics can also help reduce stress under the metatarsals.

Plantar Fasciitis

Plantar fasciitis is a common condition that produces pain in the bottom of your heel. The plantar fascia is a thick band of ligament that connects your heel bone to your toes thereby providing support for your arch.

Plantar fasciitis is often caused by overuse or improper footwear. You may be predisposed to plantar fasciitis due to your foot mechanics (flat foot, high arch, or altered walking mechanics).

Physiotherapy treatment focuses on improving the flexibility of the calf and Achilles tendon and reducing the stress on the plantar fascia. Specific calf stretching and plantar fascia release exercises are performed to loosen the area. Manual therapy mobilizations and soft tissue release of the foot and lower leg can improve tightness contributing to plantar fasciitis. Self-massage, rolling a ball under the arch and heel, and foam rolling the calf muscle can help to improve blood flow and make the tissue more supple.

Proper footwear with good arch support or over-the-counter or custom orthotics can help to improve foot mechanics and take the stress off the plantar fascia which gets over-stretched when the foot pronates excessively. Once the pain in the heel has reduced and if the foot biomechanics have improved with proper retraining, the orthotics can be discontinued.

It is also important to make sure your shoes bend in the right area – the toe box, NOT the mid-foot. Flip flops, ballet flats, and some dress shoes bend in the middle of the shoe which places extra stress through the plantar fascia.

Arch strengthening exercises are important to re-educate the foot to adopt a neutral position in standing.

Icing the bottom of the foot can improve heel pain by reducing the inflammation. Icing can be done for 15 minutes several times a day during the acute period. Some people find it beneficial to roll a frozen water bottle under the foot and heel for 5 minutes at a time, several times a day.

Applying kinesiotape, leukotape, or sports tape to the bottom of the foot can help take the pressure off of the plantar fascia and provide significant relief while the plantar fascia is healing.

If ongoing calf tightness is contributing to your plantar fasciitis, you may benefit from using a night splint that holds your foot in a stretched position while you sleep. As your calf and plantar fascia are not being allowed to shorten as you sleep, those first few steps in the morning will be more tolerable.

How to tape for plantar fasciitis with Kinesiotape/KT tape

For severe cases, your doctor may prescribe anti-inflammatory medications or perform a steroid injection into the heel to reduce the pain and swelling.

In a small percentage of case, the plantar fasciitis may become chronic. In these cases, there are many medical procedures that can assist in activating the healing process. If your plantar fasciitis becomes chronic, it is important to see a Podiatrist, Sports Medicine Doctor or Orthopaedic Foot Specialist to discuss treatment options such as Botox injections, Platelet Rich Plasma Therapy (PRP), Shockwave Therapy, Amniotic Stem Cell Therapy, Ultrasonic Tissue Repair, Topax Technology, Relef, TenJet and Tenex procedure, or surgery.

Ankle Sprains

Ankle sprains happen when you roll or twist your ankle while walking, running, jumping, or sometimes even standing. The injury stretches or tears ligaments that attach the ankle bone to the foot bone.

Ligaments help to prevent too much movement of a joint. When the joint moves beyond its normal range, the ligaments will stretch or tear.  This makes the joint less stable. A pop is often heard  at the moment of injury. The ligaments on the outer ankle are the most commonly injured.

Depending on the severity of the sprain, you may or may not be able to weight bear on the foot. The ankle will often swell up immediately and bruising will appear later.  The ankle movement will be limited and a feeling of instability may be noted.

If the pain is severe and you are unable to weight-bear, please contact your doctor for an x-ray to rule out a broken bone.  If the bruising and swelling are severe, you may have torn a number of ligaments.  This would also require a check-in with your sports doctor for proper instruction on the immobilization period and weight-bearing recommendations during the healing process.

Ankle Sprain Prevention Tips

• A good warm-up is important to prepare your muscles before you exercise or play sports.
• Be cautious when exercising on uneven surfaces.
• Wear well-fitting footwear specific to your sport.
• Play sports at your level of fitness.
• Practice balance activities outside of your sport to challenge your stability.

Physiotherapy treatment of ankle sprains involves initial protection of the ligaments while they are healing.Modalities such as low level laser, ultrasound, and electrical stimulation can be performed to reduce pain and improve healing. Range of motion exercises are progressed according to the phase of healing. Manual therapy mobilizations and soft tissue release of the foot and lower leg can improve ankle mobility and prevent scar tissue from forming as you heal from an ankle sprain. Strengthening and muscle re-education exercises are important to regain full function. The last phase of healing will focus on retraining balance and proprioception in order to create new neural pathways for the remaining ligament. In order to prevent a subsequent sprain, balance and proprioception retraining must be performed.

Chronic Ankle Instability

The ankle can become chronically unstable when acute ankle sprains do not fully heal.

An individual with chronic ankle instability will often roll their ankle for no reason, for example, just standing. Multiple ankle sprains can cause chronic pain that flares up with increased activity or exercise.

Ligaments that are chronically over-stretched or torn will become longer and less able to resist forces to protect the ankle. This will produce the viscous cycle of re-injury and further weakening of the ligaments causing more instability.

If conservative physiotherapy treatment consisting of stretching, strengthening, taping/bracing, and most importantly proprioceptive and balance re-training do not improve the condition, a referral to a sports medicine specialist or surgeon would be indicated.

Peripheral Neuropathy

An individual with peripheral neuropathy will describes feelings of numbness, tingling, burning, achiness, and sometimes sharp pain in their feet. They may also have the sensation that they are wearing a stocking when they are actually barefoot.

The cause of peripheral neuropathy is a degeneration of the peripheral nerves that go to the feet.  It often involves the sensory nerves that give your brain information on pain, temperature and pressure. Less commonly, it could also involve the motor nerves that cause muscles to contract, or autonomic nerves that communicate your body’s temperature and function of the heart, lung, and viscera to the brain.

It is important to work with your doctor to determine the cause of your neuropathy.  Significant improvement can be gained by addressing the cause. It may be related to diabetes, autoimmune disease, infection, vitamin deficiency, a side-effect of medication or alcoholism.

Physiotherapy treatments can help with managing the symptoms and improving your function. It is important to promote circulation to stimulate healing and nerve regeneration. Although nerve regeneration may be minimal, stopping the progression of symptoms is very important. Manual therapy mobilizations and soft tissue release of the foot and lower leg can improve foot and ankle mobility, improve muscle tone and circulation, and reduce pain caused by peripheral neuropathy. Proper footwear is paramount when treating peripheral neuropathy. The footwear must provide adequate support as well as cushioning.

When numbness is present, the individual is recommended to wear the shoes anytime they are walking or standing in order to prevent stepping on a sharp object that may be unnoticed due to the numbness.

Gentle exercise to improve circulation, strengthen the muscles, and improve balance can be helpful.

1. Calf stretch with strap (easier with the shoe on)
2. Active range of motion of ankle and toes with leg elevated
3. Straight leg raises
4. Side-lying hip abduction
5. Toe raises in standing with shoes on (only if pain-free)
6. Tandem balance or single leg balance
7. Ball rolling under bottom of foot

Electrical nerve stimulation machines can help to stimulate the nerves of the feet and reduce pain. Low level laser therapy can assist with reducing pain and healing nerve fibres, and self-massage and mobilization of the foot can to improve circulation, desensitize the feet and improve mobility.

Achilles Tendonitis

The Achilles tendon is a thick white tendon that attaches the calf muscle to the back of the heel. It is a very powerful tendon as it is responsible for propelling us forward as we walk or run. It can be injured with overuse, usually when running or hiking or playing sports like tennis, basketball, and soccer.

It is important to catch pain in the Achilles tendon early and modify or reduce your activity to allow healing. This tendon is susceptible to chronic injury or rupture if not treated early.

Symptoms usually begin with an ache at the midpoint or lower part of the Achilles tendon after running or doing sports. An individual with Achilles tendonitis may also have morning stiffness in the back of the ankle and tightness in the calves. Possible predisposing factors for Achilles tendonitis are flat feet and tight calf muscles.

Also, as you age, your tendons have less water in them and are more susceptible to tears. Running on uneven terrain, increasing your mileage significantly, adding hill training, and wearing old worn-out running shoes can also predispose you to Achilles tendonitis.

There are some great ways to reduce your chances of getting Achilles tendonitis.

1. A proper warm up is essential to prepare your muscles for high intense activities like tennis, basketball, and soccer. Start by jogging for 5 minutes and doing some dynamic movements that are specific to your sport before you go full out.
2. When starting to increase your mileage or a new sport, increase your mileage or your time spent doing the sport gradually. The 10% increase rule is a great way to prevent injury. For example, if you are used to running 5km, and want to work up to 10km, add 10% every run as long as things are going well. That would be 5.5km for your 2nd run, 6.05km your third run, 6.65km your fourth run, and so on.
3. Wearing the proper footwear is key. The running shoes should be the right ones for your feet, and chosen with the help of a sales representative that has been trained to generally assess your feet. Buying shoes from a running store from someone who can tell you if your feet are flat, neutral, or high-arched is a good idea. Sometimes an arch support is needed in your running shoe if you are flat footed. Also very important is replacing your running shoes once you’ve put over 500-800km on your shoes. Remember that any walking, not just running, counts. Also, minimalist shoes will need to be replaced sooner than regular shoes, and a heavier individual’s shoes will need replacing sooner than a light individual’s shoes for obvious reasons.
4. Daily stretching of the 2 calf muscles (gastrocneium and soleus join to form the Achilles tendon) will help to maintain good flexibility. If your calves are feeling tight, stretching every morning as well as another 2 times throughout the day will help to improve the flexibility. Once flexible, make sure to stretch after your run to undo the tension that builds in the muscle while running.
5. Strengthening your calf muscles is helpful to prevent an injury.  The stronger the muscles are, the more they can handle. Eccentric heel raises have long been known to help strengthen the calf and bulk up the Achilles tendon. Remember to stretch after you strengthen so you don’t tighten up.
6. One of the best ways to avoid an overuse injury like Achilles tendonitis is to cross-train. Instead of running 5 days a week, try running 3 days a week, and do biking, swimming or yoga on alternate days. This gives your body (and Achille’s tendons) a chance to recover from the previous day’s activities.

Physiotherapy treatment for Achilles tendonitis focuses on correcting muscle imbalances that exist within the lower extremity. There may also be mal-alignment issues that need to be addressed because of these muscles imbalances. Soft tissue release to the lower leg and Achilles tendon can improve circulation and reduce tightness of the Achilles. There may be foot or ankle joint limitations also contributing to the injury that can be improved with joint manipulation and mobilization.

Muscle re-education and strengthening, as well functional exercises, plyometrics, and balance and proprioceptive training help to return the individual to their sport. Kinesiotaping or leukotaping of the foot/ankle/calf can help reduce pain during the healing process. Low level laser therapy has also shown good results with tendon healing.

Achilles Rupture

You will hear a loud pop if you rupture your Achilles tendon. You will have immediate pain at the back of your ankle and be unable to bear weight. You will require immediate medical attention, and possibly surgery.

To reduce the change of rupturing your Achilles tendon, it is important to warm up well prior to playing sports, especially if you are above 40 years old.

Bunion (Hallux Valgus)

Hallux Valgus occurs when your big toe starts to migrate laterally toward the 2nd toe. It creates a larger angle of the great toe. This may cause a bunion or bump at the inner aspect of your 1st toe joint. This can sometimes get red, swollen, and be quite painful. You may have reduced toe movement as well as corns and calluses from altered pressure on the feet.

Bunions are fairly common as foot types are passed down from parents and grandparents. Typically, flat feet with loose ligaments are more likely to get bunions. A short big toe can also predispose you to a bunion. As well, tight footwear, especially in the toe box can place extra stress on the toes, encouraging them to change their alignment.

When the bunion is severe and causing pain and reduced daily function, you may consider having surgery to correct it. When a mild or moderate bunion is painful, it is important to slow the progression of deformity by removing the pressure on the inside of the big toe. This can be done by wearing shoes with a wider toe box and using silicone padding and/or spacers when wearing shoes. You may also benefit from wearing custom or over-the-counter orthotics to improve the alignment of the mid and hind foot and subsequently prevent more stress and further progression of the great toe.

Contrast baths, application of cold pack, or rubbing topical anti-inflammatory cream can help reduce the pain and swelling. As well, specific toe and foot stretching and strengthening exercises can help to balance the muscles and tendons that pull on the toe. Stationary bicycling, swimming, and rowing, and weightlifting (while sitting) are good forms of exercises that won’t aggravate a bunion.

Bunion splints can be helpful to wear at night for some people who want to give a prolonged stretch to the big toe joint. It may help realign the toe by a few degrees and help to prevent progression of further angulation. You will want to be doing some of the other recommended treatments as well if you want to reap the benefits of a bunion splint.

Physiotherapy treatment involves great toe mobilization and soft tissue release, re-education of foot and toe muscles, modalities such as low level laser therapy, ultrasound or electrical stimulation to reduce pain and swelling, and taping techniques to improve the toe alignment. Education on footwear, pain management, and activity modification would be given.

Hammertoes

Hammertoes are a fairly common occurrence. A hammertoe occurs when the base of the toe joint extends, the middle toe joint bends, and the last toe joint hyper-extends. This usually happens to the 2nd, 3rd, or 4th toes. A hammertoe can be painful as it becomes difficult for the toes to fit properly into shoes. Corns and calluses may develop as the toe is unable to fully straighten in a shoe, and the toe may become painful to bend and straighten.

Hammertoes are the result of an imbalance between the tendons, muscles and ligaments affecting the toes. Commonly, one group of toe flexor muscles (lumbricals) stops working as well as they should when the foot is flat or over-pronated. The other toe flexor muscles (flexor digitorum longus and brevis) now work extra hard and pull on the toes in way that causes the middle knuckle of the toe to raise. Tightness of the extensor muscles on top of the foot and base of the toes ensues which further contributes to the mal-alignment of the toe. As the condition progresses, the toe joints can fuse in a bent or extended position.

Another possible cause of hammertoe is wearing ill-fitting footwear that compresses the toes for long periods of time. As well, past trauma to the toes, such as breaking or stubbing a toe, can lead to hammertoes. Lastly, if your second toe is longer than your great toe, you are more likely to develop a hammertoe.

Physiotherapy treatment of mild to moderate hammertoes can help to relieve pain and pressure on the toes involved.

1. Padding the the hammertoe to remove pressure
2. Taping the toe to re-align it
3. Wearing over-the-counter or custom foot orthotics to improve foot mechanics
4. Ice or contracts baths to reduce inflammation
5. Mobilizations, soft tissue release, self-massage and stretching to the toes and foot to improve circulation and range of motion
6. Toe strengthening exercises to improve the muscle balance of the toes
7. Modalities such as low level laser therapy, ultrasound, and electrical stimulation to reduce pain and improve healing
8. Wearing proper footwear with adequate room in the toe box.

Severe hammertoes can be corrected with surgery.

Post-Surgical Foot and Ankle Physiotherapy

When physiotherapy is required post surgery for bunionectomy, Lapidus, hammertoe correction, neuroma resection, tarsal tunnel release, ankle fusion, ankle stabilization repair, etc, your surgeon will dictate the length of time your foot or ankle needs to be immobilized, when you can bear weight, and when you can begin movement and strengthening in the post operative period. The Physiotherapist will take over the rehab once you have been given the green light to commence physiotherapy.

Post-operative physiotherapy focuses on reducing scar tissue and regaining range of motion of the foot and ankle. Joint mobilizations and soft tissue release performed by your Physiotherapist can improve accessory joint mobility to help regain your ankle/foot movement. Stretching and strengthening exercises will be given to regain flexibility and strength and improve your physical function. In the final phase of rehab, the focus will be on improving functional movements, balance and proprioception to get you back to your pre-surgical status.