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Heel Pain

Plantar Fasciitis: Pain directly beneath or in front of the heel; chronic
inflammation of the fascia as a result of excessive pronation.

The most common cause of heel or arch pain is actually caused by a painful stretching or micro-tearing of the plantar fascia. The plantar fascia is a fibrous or tendon-like structure that courses along the bottom of the foot connecting the toes and calcaneus or heel bone. During normal conditions, the fascia is flexible and strong. However due to factors such as abnormal stress, excessive weight, age, or improper foot support, the fascia can become weakened, irritated or inflamed. If the foot flattens excessively or becomes unstable at critical times during the gait cycle, the attachment of the plantar fascia onto the calcaneus may begin to stretch and pull away from the calcaneus. This painful condition is called plantar fasciitis. In addition to plantar fasciitis, after many years, a heel spur may develop on the bottom of the calcaneus.

heal-painHeel spurs are visible on a lateral view x-ray of the foot. X-rays sometimes reveal very large heel spurs that do not produce pain. It is not the bone, but rather the inflammation of the fascia attaching to the heel which causes discomfort.

The heel pain or plantar fasciitis is especially noticeable to the patient during the toe-off phase of gait.

The onset is gradual, yet most patients report the pain during the first steps on the floor in the morning, or after extended resting periods during the day.

The most frequent cause is an abnormal or excessive internal motion of the foot.

During resting or non-weight bearing periods, the plantar fascia shortens. When body weight is rapidly applied to the foot, the fascia must stretch and quickly lengthen, causing micro-tears in the fascia.

Hypermobility, (excessive internal motion) of the foot can induce future or coexisting problems involving the knee, hip, sacroiliac joint or the low back region.

Plantar Fasciitis and calcaneal heel spurs, when treated early, are usually controlled with conservative
or non-surgical treatment.

Although soft heel materials appear to cushion the heel, they do not address the problem of foot support, which initially caused the problem. Therefore, with soft heel cushions, the painful heel tends to return.

An orthotic should be used to stabilize the foot.

The role of the orthotic in these conditions is to prevent excess pronation and rapid excessive lengthening of the plantar fascia. The orthotic control limits the micro-tearing of the plantar fascia, thereby decreasing the pain.

In addition to the use of foot orthotics, steroid (cortisone) injections, changing shoes, foot taping, and mild stretching exercises are also helpful.

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Calluses are thickened, dead tissue involving the outer layer of the skin (epidermis). They are similar to corns, with the difference being their location. Calluses are located on the soles of the feet, particularly the ‘balls,’ while corns are located on the toes.

The primary cause of callus formation, as with corns, is excessive pressure due to the underlying bone. The metatarsal bones, which are the long bones forming the ‘balls’ of the feet, are the most frequent cause of calluses. These metatarsal bones can be long, rotated, enlarged or lowered in relationship to the other metatarsal bones, causing excessive pressure.

Abnormal weight distribution can also cause calluses. This ‘thickened’ tissue is built up out of the natural defense of the body to protect these areas of abnormal pressure. Footwear can aggravate the condition, however, hereditary is the major cause of the bony abnormalities.

Shoes with a thicker cushion sole may be beneficial in absorbing the abnormal pressure. If abnormal weight distribution is the cause of the callus formation, an orthotic can control the pressure across the balls of the feet.

To provide relief from callus pain, the abnormal weight the callused area is carrying must be reduced and re-directed to the rest of the foot. The easiest way to accomplish this goal is with the use of Custom-Made Orthotics. Custom orthotics can both control any abnormal foot motion which is occurring and relieve weight bearing from the painful callus. If you do not have custom orthotics then at least attempt to use an “off the shelf” type of insole for added cushioning. It is often helpful to make a cut-out in the insole directly under the painful callus. Addition of a metatarsal pad placed just proximal to the callus is sometimes helpful. If the calluses are severe enough and very thick you may need to see a podiatrist to trim them down.

Wear shoes with a low heel (about 3/4 to 1 inch high). Wear shoes with thick, well padded innersoles and outer soles, such as walking shoes. Even bedroom slippers should be well padded. Do not walk bare foot. Protect the bottoms of your feet with good shoes. Do not cut or trim them. If you are a diabetic or have poor circulation, check with your family doctor before treating your calluses. Don’t let calluses get too big; they can crack and become infected. To reduce friction when you run, wear thicker socks, such as Thor-Los, which have extra padding in high-friction areas. Watch for blisters that may occur next to thick calluses and treat them appropriately.

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Shin Splints

Shin Splints is the inflammation of the tendons and muscles in the front or on the medial side of the lower leg. Excessive pronation and overuse syndrome creates pulling of the Tibialis anterior or posterior muscles and damages these muscles at their tendinous insertion on the tibia.

Specifically, the pain associated with shin splints is a result of fatigue and trauma to the muscle’s tendons where they attach themselves to the tibia. In an effort to keep the foot, ankle and lower leg stable, the muscles exert a great force on the tibia. This excessive force can result in the tendons being partially torn away from the bone.

What Causes Shin Splints?
While there are many causes of shin splints, they can all be categorized into two main groups. Overload (or training errors), and Biomechanical Inefficiencies.

Overload (or training errors): Shin splints are commonly associated with sports that require a lot of running or weight bearing activity. However, it is not necessarily the added weight or force applied to the muscles and tendons of the lower leg, but rather the impact force associated with running and weight bearing activities.

In other words, it’s not the running itself, but the sudden shock force of repeated landings and change of direction that causes the problem. When the muscles and tendons become fatigued and overloaded, they lose their ability to adequately absorb the damaging shock force.
Other overload causes include:

Exercising on hard surfaces, like concrete;
Exercising on uneven ground;
Beginning an exercise program after a long lay-off period;
Increasing exercise intensity or duration too quickly;
Exercising in worn out or ill fitting shoes; and
Excessive uphill or downhill running.

Biomechanical Inefficiencies: The major biomechanical inefficiency contributing to shin splints is that of flat feet. Flat feet lead to a second biomechanical inefficiency called over-pronation. Pronation occurs just after the heal strikes the ground. The foot flattens out, and then continues to roll inward.
Over-pronation occurs when the foot and ankle continue to roll excessively inward. This excessive inward rolling causes the tibia to twist, which in-turn, over stretches the muscles of the lower leg.
Other biomechanical causes include:

Poor running mechanics;
Tight, stiff muscles in the lower leg;
Running with excessive forward lean;
Running with excessive backwards lean;
Landing on the balls of your foot; and
Running with your toes pointed outwards.

Since about half of all lower leg problems are caused by biomechanics inefficiencies, it makes sense to get the right advice on footwear. Your feet are the one area you should not “skimp” on.
Custom Foot Orthotics can help accomodate foot overpronation and provide extra cushioning
to the plantar surface of the foot.

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Neuroma is the inter-metatarsal forefoot pain located at the ball of the foot and/or toe numbness. Generally located between the 3rd and 4th metatarsal bones (third inner space).Morton’s neuroma is an enlarged nerve that usually occurs in the third interspace, which is between the third and fourth toes. It is caused by pressure on the cross-over lateral-medial plantar nerve, and associated with a number of flexible foot types.

neuromaThe reason the nerve enlarges has not been determined. Flatfeet can cause the nerve to be pulled toward the middle (medially) more than normal, which can cause irritation and possibly enlargement of the nerve. The syndrome is more common in women than men, possibly because women wear confining shoes more often. High heels cause more weight to be transferred to the front of the foot and tight toe boxes create lateral compression. As a result, there is more force being applied in the area and the nerve compartment is squeezed on all sides. Under such conditions, even a minimal enlargement in the nerve can elicit pain.

Custom Foot Orthotics with a metatarsal pad redistribute the pressures on the transverse metatarsal arch and cause the metatarsal heads to splay and release the entrapped nerve.

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Hallux Valgus (Bunions): a (sometimes painful) bump at the medial base of the great toe. Excessive pronation and hypermobility of first metatarsal ray causes toe-off to come off the medial (inside) side instead of the plantar surface of the great toe. This force stretches and distorts the joint.

bunionA bunion is a bone deformity involving the first metatarsophalangeal joint, or the joint attached to the great toe. Less commonly, a tailor’s bunion or bunionette involves the fifth metatarsophalangeal joint, or the joint next to the baby or fifth toe. The problem may involve one or both feet, but commonly one foot is more painful than the other.

Bunions are progressive throughout life. Certain factors, such as the type of shoe, amount of activity, surface of ambulation, and heredity may affect the type and rate of development of bunions. Bunion pain can be present from early teen years through any age. Commonly bunions will be visibly present for many years before they become painful.

A change of shoes, activity, or body weight can cause previously non-painful bunions to become painful.

Simplistically, a bunion is present when there is an enlargement of the “bump” just behind the great toe, and the great toe become rotated or deviated and presses against the adjacent second toe. In more advanced bunion cases, the great toe can overlap or underlap the adjacent second toe. Pain is present due to the rubbing of the enlarged bunion against the inner side of a shoe. There is also pain, when the great toe presses painful against the second toe. The second toe can become a hammertoe due to the presence of a bunion. The important issue is that a bunion is a bone problem, and not a problem of skin or a cyst.

In more progressive or severe bunions, there may also be the presence of arthritis within the bunion joint or the first metatarsophalangeal joint. When arthritis is present within the joint, both the arthritis and the bunion deformity must be individually addressed and treated. Typically when arthritis is present within the bunion joint, the joint becomes stiff and the pain is sensed as being deeper and more aching in character.

Although orthotic devices do not cure bunions, in some cases they can be utilized to slow the progression of the bunion and perhaps make the foot more comfortable while wearing certain types of shoes. Orthotics are more effective for treating bunions in men than in women, mostly due to the size and styles of shoes that women usually wear.

The exact cause of bunions is unclear. Some of the causative factors include heredity, flat foot structure, ligamentous instability or laxity, muscular imbalance within the foot and birth defects. Improper shoes during childhood may contribute to the formation of bunions, but this not common. Inappropriate shoes during adolescence and early adulthood may aggravate an existing bunion formation, but shoes generally do not cause bunions to develop.

Conservative methods of treating bunions include wearing wider shoes and perhaps foot soaks to decrease the soreness associated with an acute problem. However, considering the fact that bunions are a bony structural problem, the most effective treatment is a surgical one.

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Achilles Tendonitis

Inflammation of the sheath surrounding the Achilles tendon; pain behind the heel, ankle and lower calf.

Counter-rotation of the tibia against the femur as a result of excessive pronation causes two heads of the tendon to torque against each other and stretch the tendon.

The Achilles tendon is used to plantar flex the foot, or point the foot downward. This allows a person the run, jump and stand on one’s toes.

The Achilles tendon is the strongest tendon of the body, and able to withstand a 1000 pound force without tearing. Despite this, the Achilles ruptures more frequently than any other tendon because of the tremendous pressures placed on it during competitive sports.

There are two main types of injuries that affect the Achilles tendon; Achillis Tendonitis and Achilles Tendon Rupture.

Achilles Tendonitis is simply an inflammation of the tendon, and in most cases is caused by excessive training over an extended period of time.

Achilles Tendon Rupture, on the other hand, is a tear (or complete snapping) of the tendon, and usually occurs as the result of a sudden or unexpected force. In the case of a complete rupture, the only treatment available is to place the lower leg in a plaster cast for 6 to 8 weeks, or surgery.

Causes and Risk Factors
There are a number of causes and risk factors associated with Achilles Tendonitis. One of the most common causes is simply a lack of conditioning. If the tendon, and muscles that connect to the tendon, have not been trained or conditioned, this can lead to a weakness that may result in an Achilles injury.

Overtraining is also associated with Achilles Tendonitis. Doing too much, too soon places excessive strain on the Achilles tendon and doesn’t allow the tendon enough time to recovery properly. Over time small tears and general degeneration result in a weakening of the tendon, which leads to inflammation and pain.

Other causes of Achilles injury include a lack of warming up and stretching. Wearing inadequate footwear, running or training on uneven ground, and simply standing on, or in something you’re not meant to. Biomechanical problems such as high arched feet or flat feet can also lead to Achilles injuries.

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One or more of the metatarsal heads become painful and/or inflamed, usually due to excessive pressure over a long period of time. It is common to experience acute, recurrent, or chronic pain with metatarsalgia. Ball-of-foot pain is often caused from improper fitting footwear, most frequently by women’s dress shoes and other restrictive footwear. Footwear with a narrow toe box (toe area) forces the ball-of-foot area to be forced into a minimal amount of space. This can inhibit the walking process and lead to extreme discomfort in the forefoot.

metatarsalgiaOther factors can cause excessive pressure in the ball-of-foot area that can result in metatarsalgia. These include shoes with heels that are too high or participating in high impact activities without proper footwear and/or orthotics. Also as we get older, the fat pad in our foot tends to thin out, making us much more susceptible to pain in the ball-of-the-foot.

The first step in treating metatarsalgia is to determine the cause of the pain. If improper fitting footwear is the cause of the pain, the footwear must be changed. Footwear designed with a high, wide toe box (toe area) and a rocker sole is ideal for treating metatarsalgia. The high, wide toe box allows the foot to spread out while the rocker sole reduces stress on the

Unloading pressure to the ball-of-the-foot can be accomplished with a variety of footcare products. Custom Orthotics designed to relieve ball-of-foot pain usually feature a metatarsal pad. The orthotic is constructed with the pad placed behind the ball-of-the-foot to relieve pressure and redistribute weight from the painful area to more tolerant areas. When orthotics are used with proper footwear, you should experience significant relief.

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Hammertoes are painful bone contractures of the toes, usually with an associated area of hyperkeratosis or callous. They may be individual, or there may be hammertoes present on all eight lesser toes. The great toe can also develop a hammertoe.

hammertoeThe contractures may exist at either or both of the joints within the toes, in which there may also be arthritis. In addition to a downward contracture of a hammertoe, there may also be a side contracture, where one toe may be rotated beneath another adjacent toe.

A second hammertoe may be commonly associated with a bunion deformity. In some instances, there may be an infection beneath the callous of a hammertoe.

The causes of hammertoes are similar to those of bunions.

The pain associated with hammertoes can vary, depending upon the location, duration, shoe style, amount of activity and pain tolerance. The pain is frequently associated with a “corn”. Although the corn is painful, it is really not the underlying cause of the problem. If the corn is trimmed, the pain will commonly decrease or stop temporarily.

However due to the underlying bony problem associated with the corn, the corn will continue to develop until the bony hammertoe problem is treated. Probably the most common misunderstanding, is the belief that trimming a corn will cure a hammertoe. Although trimming a corn will help the pain, it does nothing to address the internal

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Knee Pain

Patellar Tendonitis
As with all cases of tendonitis, patellar tendonitis is simply the inflammation, degeneration or rupture of the patellar ligament and the tissue that surround it, leading to pain and discomfort in the area just below the knee cap.

What causes Patellar Tendonitis?
Overuse is the major cause of patellar tendonitis. Activities that involve a lot of jumping or rapid change of direction are particularly stressful to the patellar ligament. Participants of basketball, volleyball, soccer, and other running related sports are particularly vulnerable to patellar tendonitis.

Patellar tendonitis can also be caused by a sudden, unexpected injury like a fall. Landing heavily on your knees can damage the patellar ligament, which can lead to patellar tendonitis.

What are the Signs & Symptoms of Patellar Tendonitis?
The major symptom of patellar tendonitis is pain in the area just below the kneecap. Activities like walking, running and especially squatting, kneeling or jumping will cause increased pain and discomfort. Swelling is also commonly associated with patellar tendonitis.

Be aware of the importance of good footwear. A good pair of shoes will help to keep your knees stable, provide adequate cushioning, and support your knees and lower leg during the running or walking motion
For more information on Knee pain or ITB opain, see the ITB section under Foot Conditions

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Iliotibial Pain

This outside or lateral knee pain is caused by the ITB pulling up on it’s insertion on the outside of the knee. Underneath the ITB near it’s insertion at the knee is a bursa. Bursae are fluid filled sacs that lubricate areas where rubbing and friction occur. When that ITB is pulled tight it put too much pressure on the bursa and that bursa reacted by becoming inflamed and swollen, giving you pain.

iloibial-bandThe ITB is being pulled tight by one of two muscles – the TFL or the Gluteus Maximus. Running up hills, for example, uses more of the glutes than running on flat ground, therefore it will often trigger a bout of ITB pain. That also explains why the pain is often aggravated by hill repeats. The ITB can also be aggravated by running on uneven roads or on tight indoor tracks, running in poor running shoes or if your foot pronates (arch collapses).

There are two main causes of knee pain associated with iliotibial band syndrome. The first is “overload” and the second is “biomechanical errors.”

Overload is common with sports that require a lot of running or weight bearing activity. This is why ITB is commonly a runner’s injury. When the tensor fasciae latae muscle and iliotibial band become fatigued and overloaded, they lose their ability to adequately stabilize the entire leg. This in-turn places stress on the knee joint, which results in pain and damage to the structures that make up the knee joint.

Overload on the ITB can be caused by a number of things. They include:
Exercising on hard surfaces, like concrete;
Exercising on uneven ground;
Beginning an exercise program after a long lay-off period;
Increasing exercise intensity or duration too quickly;
Exercising in worn out or ill fitting shoes; and
Excessive uphill or downhill running.
Biomechanical errors include:

Leg length differences;
Tight, stiff muscles in the leg;
Muscle imbalances;
Foot structure problems such as flat feet; and
Gait, or running style problems such as pronation.
Custom made foot orthotics can help accomodate pronated feet and reduce the abnormal amounts of rotational forces placed on the knee joint and it’s surrounding structures. Talk to our Pedorthists, Athletic Therapists and Personal Fitness Trainers about stretches or braces that can help provide relief from ITB pain.

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