Flat Feet and Ankle Pain

Flat Foot and Ankle Pain/Injuries

Flat foot is divided into two Categories:

1.Acquired flat foot which is a condition which develops after we have attained maturity.
2.A congenital flat foot is a common condition and often not of pathological significance.

Adult Flat Foot

The adult flat foot has many potential causes which include dislocation and fractures, foot abnormalities, arthritic changes and neurological conditions.

The commonest cause however of this foot problem is a dysfunction of one of the foot tendons, the posterior tibial muscle tendon. The methods by which the tibialis posterior tendon malfunctions are varied and ascribed to degeneration, inflammation or trauma.

Pathological changes in the tendon of the posterior tibial muscle have been shown to occur more commonly in patients who take steroids, have high blood pressure, are overweight or diabetic and have had injuries or operation to their midfoot.

In the group of joint conditions known as spondyloarthropathies the incidence of tendon dysfunction is higher, patients usually having a family history of joint problems.

Older people without particular medical conditions can also suffer this condition. In 10% of patients with rheumatoid arthritis, this tendon pathology may occur.

Underneath the medial malleolus of the ankle and for a short distance forwards exists a region of limited blood supply which impacts on the tendon running through this area, contributing to an explanation of why degenerative change might occur more readily here.

The tibialis posterior tendon contributes to the stability of the medial foot arch which has both passive and active supports. The static, passive supports for the arch include the spring ligament (calcaneonavicular ligament), the long and short plantar ligaments and the plantar fascia. The spring ligament is support for the talus or ankle bone and stops it migrating inwards or downwards.

The most significant active or dynamic supporter of the medial arch is the tendon of the tibialis posterior muscle.

As the muscle contracts, it lifts the inside of the medial foot arch and turns the foot in if it not on the ground.
If this muscle function is lost due to damage or rupture of this tendon, then the foot loses its principal arch support and inward turning action, allowing the outward turning muscles to act without opposition.

This results in the foot suffering three main changes to its postural balance:

1.The medial arch flattens

2.The front of the foot turn out

3. The rear of the foot turns out also.

Because the ability to stabilize the rear part of the foot and make the forefoot into a stable and rigid platform has been lost, the patient’s gait pattern is altered and less efficient.

Due to the loss of the powerful function of the tibialis posterior muscle, this makes the main calf muscles, the gastrocnemius and soleus act further back in the foot rather than at the forefoot. The ankle bone is forced downwards and inwards which stretches the spring ligament, gradually leading to the inside of the ankle collapsing down as the joints assume new positions about each other.

Initial patient report on presenting with problems secondary to acquired flat feet is that of a painful and swollen inner border of the ankle region and foot, particularly when on their feet.

Patients may mention they have noticed a steady lowering of the foot arch and that they are taking weight on the inner part of the foot now.

A reduction in strength and the pain may cause a patient to limp and reduce the effectiveness of push off in gait, with examination of the soles of the shoes indicating the abnormalities in patterns of walking. Foot assessment by a physiotherapist starts with the evaluation of the feet and arches in standing position.

Observation by the physiotherapist of the heel from behind will allow the visualization of the two outer toes if more show then the forefoot laterally deviates. The physio will assess the angle between the lower leg and the heel to determine the valgus angle of the hindfoot, an important determining factor in foot health. To rise on tiptoe the calf muscle power must be engaged, in a normal foot causing an inversion of the heel.

Sports And Foot Injury.

Rugby is a highly high impact sport which can take its toll on the body throughout the course of a match. The physical nature of the game means that injuries are somewhat more likely compared to other games, with the severity of an injury typically determined by the force of the impact from the opposing player.

Some wounds, however, are more common than others, with joints complaints covering the ankle and knee something all professional sportspeople will experience at some stage. This article will focus on some of the more severe ankle injuries a player can encounter in ligament damage.

What Are Ankle Ligaments?

Ligaments are the tough bands of tissue which connect the bones within a joint and are responsible for the overall stabilization of the joint, without stabilization, a player cannot expect to walk, run or jump. Any damage to the ligament can affect your overall ability to keep active and move freely.

If you suspect that you have suffered ligament damage, then it is advisable to seek a professional diagnosis where a course of treatment will be prescribed depending on the severity of the condition.

How Can I Injure My Ligaments?

Ligament damage is one of the worst ankle injuries a player may encounter as it can be very painful and will ultimately put them on the sidelines for an extended period. Overuse can result in ligament damage where a player continues to remain active on a sprain, with the instability leading to further injury. When playing on an uneven surface slip, trip or catching your foot in a divot can equally cause damage.

Ultimately, any forceful, sudden and unnatural movement of the ankle joint can lead to ligament damage.

How Long Is The Recovery?

There is no simple answer to this as it depends on the severity of your injury, how fast your body heals and the treatment program you adopt. Mild damage to the ligaments may result in a couple of weeks on the sidelines with physiotherapy being used to help strengthen the joint before getting back into action. Where a tear or rupture has occurred then you could be looking at months on the sidelines while the injury heals before getting back into light training.

What Are The Available Treatment Options?

Following any injury, it is important to adopt the RICE principles of rest, ice, compression and elevation. Should the injury fail to show signs of improvement following a few days of rest then you should seek a professional diagnosis as the damage may require further treatment.

Mild Damage.

For slight damage to the ligaments, physiotherapy can help with offering stretching and strengthening exercises to rebuild strength in the joint. You may also be advised to wear an ankle support during this time to provide additional stability and minimize the risk of you rolling your ankle and causing further damage.

Serious Or Complex Damage.

Where serious damage has been sustained surgery may be used to repair or even replace the ligament.
A player can expect to miss the majority of the season following surgery, with an intensive treatment program to follow to get you back on the pitch.
A rigid ankle support may be employed to offer stability in the aftermath of surgery, moving to a material based support to be worn when undertaking light training.

This post was built with the support from Dave Regis and Jonathan Blood Smith.

Dave Regis discusses the use of orthotics for the management of ankle injuries, reviewing injury rehabilitation through exercise and the use of bracing and supports. He writes articles focus on the utilization of an ankle support and other methods of recovery.

Jonathan Blood Smyth, an editor of the Physiotherapy Site, writes articles about physiotherapy and physiotherapists in Cambridge, back pain, orthopedic conditions, neck pain and injury management. Jonathan is a superintendent physiotherapist at an NHS hospital in the South-West of the UK




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