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Cause of Common Foot Problems





Many common foot complaints, like heel pain, arch pain and ball of foot pain, are caused by faulty foot mechanics. The combination of tight calf muscles and overpronation contributes to the development of plantar fasciitis, Achilles tendonitis, posterior tibial tendonitis, midfoot arthritis, metatarsalgia and bunions. This page offers a detailed discussion of these common foot problems.

Anatomy of Achilles tendon plantarflexing the ankleThe calf muscle originates in the back of the leg. The Achilles tendon links the calf muscle to the back of the heel. The tendon inserts on a bone called the calcaneus. When the calf muscle contracts, the foot moves down at the ankle. This motion is called plantar flexion. The drawing to the right demonstrates the motion of plantarflexion. When the calf muscle contracts at the end of the gait cycle (walking cycle), it helps propel the body forward. The motion is the same as plantarflexion, except the foot is on the ground, thus the motion pushes the foot off the ground and propels the body forward. Mouse over the image to the right to see the motion of plantarflexion.    

Normal Gait Cycle

 During the normal gait cycle (normal walkling) the heel hits down first as seen in the first picture below and this is called heel strike. The forefoot then hits the ground and stabilizes the foot. The leg then moves forward. As the leg is straight over the foot, this is called midstance. The leg continues to move forward with the foot remaining on the ground. The heel then lifts off the ground and the body is propeled forward, called propulsion.

Images of the Gait Cycle  

Tight Calf Muscles

Ankle dorsiflexion during midstance of the gait cycleMany individuals have tight calf muscles. When the calf muscle is tight, it causes an abnormal motion when walking. In the illustration to the left, the leg moves forward during the normal gait cycle, before the heel comes off the ground. But, if the calf muscle is tight, this prevents the motion seen in this picture and the heel must come off the ground early to compensate for the tight calf muscles. Mouse over the image to see this exact same image seen above rotated 30 degrees. It shows the motion the foot during this phase of walking, right before "push off". In this picture here it is easy to visualize how much the foot has moved up, in relationship to the ankle. It is also easier to imagine the pull on the Achilles tendon in this position.

Midfoot Collapse: When the calf muscle is tight, many people refer to the Achilles tendon as being tight. Regardless of the title, the muscle and tendon will exert an abnormal force during walking.

Seen here is a picture of the foot in a normal position. The ankle bone, known as the talus, is connected to the navicular bone. The two bones come together at the talar-navicular joint, abbreviated the T-N joint. (mouse over image to see collapse)  Midfoot diagram with anatomy labeled before midfoot collapse
When the Achilles tendon is tight, it is essentially pulling the heel bone up, earlier than during the normal phase of walking. In response to this, the talus starts to tilt down, as seen in this picture to the right. 

Midfoot collaspe as the talus is starting to tilt down

As the Achilles tendon and calf muscle continue to exert their force, the heel starts to rise and the talus continues to tilt downward. This results in the talar-navicular joint collapsing, which contributes to the midfoot collapsing. As the heel continues to elevate off the ground, a tremendous amount of pressure is transfered to the forefoot.    

Midfoot collapse diagramwith bones labeled

In the normal walking cycle, the foot is a rigid lever (supinated) at this point and is able to propulse (push off) in a normal fashion. In this case, the foot is pronated (the heel out and the talus down) and the force moves to the forefoot, pushing the first metatarsal upward. The force is then transferred to the lesser metatarsals, especially the 2nd metatarsal head. 

Diagram of midfoot collapse with elevated first ray and weight transfer to the lesser metatarsals

 

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The X-ray below shows what has been demonstrated in the drawings above. The heel bone sits elevated in comparison to the front of the foot, the talus is tilted down, contributing to collapse of the midfoot. The response of the 1st metatarsal is to elevate, which transfers weight to the lessers metatarsals. Mouse over the image to see an outline of the bony structures.

X-ray of a flatfoot showing the midfoot collapse      

 

Picture of a flatfoot with midfoot and arch collapseThe forces described in the drawings above are evident here in this image of a flatfoot. The talus has tilted down and rotated in, forcing the midfoot to collapse. The talar-navicular joint does not normally rest on the ground as seen in this image.   

Illustration of the area of pain in metatarsalgiaWeight is transferred from the big toe joint to the lesser metatarsal phalangeal joints (MPJs). The big toe joint is designed to carry the weight of the body, but the smaller joints are not. This results in localized pain at the 2nd MPJ, or at all the lesser MPJs, which many people will describe as "ball of foot pain" and is known as metatarsalgia.

Pronation

The drawings and explanations above are an oversimplification of what is really happening in the foot. The excess pronation which occurs during the walking cycle in individuals with tight calves is not well demonstrated. For a better understanding of pronation, look at the images below. On the left, the foot is moving up at the ankle (dorsiflexion), the forefoot is moving away from the midline of the body (abduction) and the heel is tilting out, away from the midline of the body (eversion). The combination of these three movements creates pronation. The drawing on the bottom right shows a description of the pronated foot in stance.

Pronation motion non-weight bearing drawing

Pronated foot labeled

Forefoot abduction diagram

 

The drawing to the left demonstrates the amount of movement of the forefoot, away from the centerline of the body when the foot is pronating. The foot can be forced into this position when the calf muscles are tight because there is not enough flexibility in the ankle to allow the leg to move forward over the foot. Mouse over the image to the left and notice that the ankle bone (talus) is rotating toward the midline of the body and the navicular, outlined in black, is rotating away from the midline of the body. This motion is called abduction. If the calf muscles are tight and do not allow movement at the ankle, the foot must flex instead of the ankle. The result is flexion (and collapse) of the midfoot, and movement of the front of the foot out (away from the midline of the body) to allow the leg to move over the foot and then propel the body forward.

Common Foot Problems

The majority of foot problems are a result of tight calves and overpronation. The most common foot complaints are heel pain, arch pain and pain in the ball of the foot.Areas of foot pain labeled on a foot

  • Heel Pain: Achilles tendonitis, plantar fasciitis
  • Arch pain: plantar fasciitis, posterior tibial tendonitis, flatfeet, arthritis
  • Ball of foot pain: metatarsalgia, 2nd metatarsal overload syndrome, neuromas, stiff big toe joint, bunions


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Heel Pain

There are many causes of heel pain and many types of heel pain, but two common causes of heel pain are plantar fasciitis and Achilles tendonitis. Tight calf muscles generate excess stress and pull on the Achilles tendon resulting in pain at the insertion of the tendon on the heel bone, or a few inches above this area. More on Achilles tendonitis.

Tight calves contributing to heel pain and plantar fasciitisAs the Achilles tendon pulls up on the heel bone and the midfoot collapses, there is a tremendous amount of stress placed on the plantar fascia which originates on the heel bone. This can result in tearing, inflammation and pain. Although the diagram above demonstrates the development of plantar fasciitis in individuals with tight calves, overpronation and flatfeet, all types of feet (high arch, normal arch and low arch feet) can develop plantar fasciitis. More on plantar fasciitis.Posterior tibial tendon anatomy labeled

 Arch Pain and Tendonitis

 

When the midfoot collapses, excess stress is placed on the arch. This places stress on the plantar fascia, (as seen above) the posterior tibial tendon and on the midfoot joints, which, over time, can result in midfoot arthritis. Normally, the posterior tibial tendon travels from the leg, behind the ankle bone and attaches on the navicular and other adjacent bones. The posterior tibial tendon helps to support the arch and prevent collapse. When the foot has excess stress through the midfoot, the tendon becomes overstressed. This can result in tearing, inflammation, pain and eventual degeneration of the tendon. More on posterior tibial tendonitis.

Midfoot Arthritis

The X-ray to the right shows a more severe midfoot collapse on an X-ray with the resultant arthritis that can develop in the midfoot from years of abnormal motion in this area.

Severe midfoot collapse and arthritis shown on X-ray   

 

Ball of Foot Pain

Different types of ball of foot painPain in the ball of the foot is a common result of tight calf muscles and overpronation. The most causes of ball of foot pain are:


  • Metatarsalgia: a catch-all term for pain in the ball of the foot, metatarsalgia is generally used to describe pain and inflammation at the joints in the ball of the foot.
  • 2nd metatarsal overload syndrome: pain and inflammation specifically at the 2nd metatarsal phalangeal joint.
  • Neuroma: an inflamed nerve in the foot, typically causing burning pain at the ball of the foot which can shoot to the 3rd and 4th toes, and sometimes the 2nd and 3rd toes.
  • Sesamoiditis: pain under the big toe joint is a common cause of forefoot pain but is not as common in those with tight calves, hypermobile feet and midfoot collapse.

 
Treatments For Common Foot Problems

All of the foot conditions listed above have separate and specific treatments. But, they all have some common treatments, which are listed below. Most of these foot problems will benefit with wearing the appropriate shoe (rigid with a heel wedge) and calf stretching. A motion control orthotic to decrease pronation is essential for those with overpronation. Many can use a prefabricated orthotic (off the shelf) but some may need a custom made orthotic by a podiatrist.

ShoesShoe bend comparison

It is important to wear a rigid, supportive shoe. Many of the foot problems listed above are worsened with soft, flexible shoes. The shoe should only bend at the toe, not in the middle of the shoe. More on shoes.

Heel Lift

To take stress off the Achilles tendon and decrease the stress through the midfoot, use a heel lift or wedged heel shoe. A Dansko style shoe has a wedged heel, a rigid sole and a rocker at the toe. This decreases the tension on the Achilles tendon, distributes pressure more evenly between the forefoot and the heel, prevents further midfoot collapse and decreases the load on the forefoot. A heel lift placed in a rigid shoe will help accomplish the same goals. Although it may seem counterintuitive, the heel lifts and wedged heeled shoes help forefoot problems like metatarsalgia.

Stretching

 One of the most important parts of treating these common foot problems is stretching the calf. Stretching the calf will help to decrease abnormal pronation, decrease the midfoot collapse and relieve the excess pressure on the ball of the foot. Perform each of these stretches by holding each stretch for 60 seconds and repeating 3 times. Go through this sequence twice a day.

Illustration showing a stretch of both calves Runner's Stretch image Calf stretch using a band while seated Calf and arch stretch against the wall


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Night Splints

Strasburg Sock soft night splint for plantar fasciitis

Langer Comfort Night Spint for Achilles tendonitis and plantar fasciitis

Strassburg Sock Comfort Night Splint

Nights splints assist with general calf stretching, but are essential in the treatment of plantar fasciitis and Achilles tendonitis. When asleep, the foot falls into a plantar flexed position. This causes the Achilles tendon, calf muscle and plantar fascia to be placed in a relaxed position.  

 To keep the calf muscle and plantar fascia stretched out during the night, the night splints hold the foot at 90 degrees and pull the toes back to keep both the fascia and calf stretched throughout the night. This helps to prevent pain with the first step in the morning. 

Plantar fascia relaxing compared to tension with a night splint


 

 

 

 

 

 

Prefabricated Orthotics

 To help control pronation, support the midfoot and distribute forefoot pressure, try a rigid prefabricated orthotics.

Superfeet-Green-tn.jpg Prolab posted orthotics to control abnormal motion Prolab unposted orthotic semi-rigid designed to control motion
Superfeet Green Insoles Prolab P3 Posted Orthotics Prolab Unposted Orthotics


Orthotics help decrease pronation by controlling the motion at the rearfoot. When the heel rotates in, as in pronation, it causes the arch to collapse. The more pronation and arch collapse, the more rigid the orthotic should be. Severe flatfoot should be treated with custom made orthotics.    

Overpronation view of foot from rear with structures labeled Pronation corrected with posted Prolab Orthotics


Metatarsal pads

HaPad Metatarsal Pad Placement

Neuroma Pad Placement Illustration

HaPad Metatarsal Pad Neuroma Pad

 Metatarsal pads help distribute pressure in the ball of the foot and help forefoot problems like metatarsalgia and neuromas. Placement of the pads is essential. The pads need to be placed behind the ball of the foot, behind the area of pain. NOT under the area of pain. The purpose of the pad is to transfer pressure away from the sore area of your foot.

There is no "magic bullet" treatment for any of these problems. Although rest, ice and anti-inflammatory medications may decrease the pain and inflammation associated with some of the foot problems mentioned above, they are not addressing the cause of the problem and should be used in addition to the therapies mentioned above. Finding the cause of the problem by identifying the aggravating activity, poor quality shoes and/or faulty foot mechanics and then addressing these problems, will give better long term results for most common foot problems.

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last updated 6/24/10

Disclaimer: The advice on this website is not intended to substitute for a visit to your health care provider. We will not be held liable for any diagnosis made or treatment recommended. Consult your doctor if you feel you have a medical problem.