The Foot – Part Two

Some of the problems we have with our feet may be related to the fact that we keep them locked up in shoes all the time. Our feet are adapted for reacting to the surface of the ground and gripping and exercising the muscles as we cope with varying situations underfoot. Now we all wear shoes the foot has much less to do as it has an unvarying slab of leather or plastic underneath it and does not need to react greatly to the ground surface. If the small muscles of the feet are not exercised regularly by interacting with the surface and doing their job they will waste and become less effective.

The arches of the foot and the function of the toes alter as the intrinsic muscles of the foot weaken as the toes lose the ability to hold themselves straight when gripping the surface. Due to this they start to bend or claw, and as this progresses the muscles which extend the toes can shorten in sympathy, drawing the toes up in a flexed position. This takes the pads of the toes away from any possible contact with the ground, obliging them to take force on the tips perhaps. Overall the foot becomes less functional and the arches decrease in height.

As the inside and long ways arch loses height, perhaps connected to the tendency to roll the foot inwards excessively in walking, the tissues under the arch become strained as they are put under tension stretch. This can cause pain and aching with time on the feet such as standing or walking for a while. The smaller front arch across the foot can also give problems if it loses some of its strength and tension. This allows the underneath of the head of the second metatarsal to contact the ground and take body weight pressure, a job it is not designed to do.

Having less padding under it, the second metatarsal is less equipped to manage the weight in standing, and people often feel like they are standing on a pebble under the ball of the foot. Hard skin areas known as calluses can develop over this area and are an indication that weight is being taken under the head. High heeled shoes can worsen this condition as the toes are typically crowded together as they are unable to push off in this position and the raised heel area moves the body weight forward over the forefoot.

In the forefoot bunions are a common development with an enlarged and sometimes inflamed joint between the big toe and the first metatarsal. There is a tendency for this type of foot deformity to run in families so inheritance is important. The enlargement of the joint can be a source of pain and cause difficulties with shoes as the big toe moves towards the other toes. This process can be part of the transformation of the foot, with muscle weakness contributing, from an active and dynamic system to a static prop for the body.

The relationship between the big toe joint and the first metatarsal is not the whole determinant of a bunion problem, as the first metatarsal is typically angled towards the inside and this makes the abnormality worse. Orthopaedic surgeons can approach these problems with a number of operations with differing goals, the first metatarsal osteotomy being a common intervention to restore the natural alignment between it and the big toe. Day case surgery has taken over from overnight admission or longer in cases where the patient can learn to mobilise quickly either weight bearing on the heel or hopping and if the pain can be well controlled.

Physiotherapy assessment and treatment of foot pain due to flat feet and other abnormalities is normally performed by physiotherapists who have specialised in this field to some degree due to its complexity. There is a large range of off-the-shelf insoles, known collectively as orthotics, which can be used to correct the angular imbalance of the heel or to support the medial and transverse arches of the feet. These are typically prescribed along with exercises to work at restoring the normal muscular balance of the feet.

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

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