Crooked foundation consequences

Conway McLean, DPM

Suppose some guy, let’s call him Joe, builds a cabin out in the woods. But Joe has no background in construction, and has not done his homework, so he doesn’t properly level the ground for his foundation. This means Joe’s house is going to be crooked, causing various problems for those residing within. Worst of all, this leaning structure is not going to stay up very long, and the tilt will lead to an eventual collapse.

Although slightly different, the same basic concepts apply to the human body. When the foundation for the human body, the foot and lower leg, do not support the rest of the body, problems will occur. What kind of problems? The list is staggering, and includes some conditions that are seemingly unrelated to foot-ankle function. From chronic back pain down to pain at the tips of the toes, various pathologies can often be traced to the improper alignment and mechanics of the body’s foundation.

Before we can talk about bad foot mechanics, we need to discuss what is normal, healthy function. This is a bit complicated, so I will attempt to provide a brief explanation. There are two primary motions of the foot, one whereby the arch raises up, and the second where the arch rolls down. Both occur in normal gait, with every step. The term used to describe the “falling” motion is pronation.

But this motion occurs in three distinct directions, as does its corollary, supination. The lowering arch does not simply fall straight down to the ground; the arch also goes through an inward rolling motion, in towards the middle of the body, as well as causing the front part of the foot to move away from the center of the body.

Have you heard of these terms before, pronation and supination? They’re hard to miss, and have become part of the lexicon of the 21st century. If you are a runner, you undoubtedly have, since running causes such stress to the human body. But you absolutely don’t have to be a runner to experience the consequences of pronation syndrome, which is the term for having too much of the falling motion of the arch. Roughly 25 percent of the population have healthy foot and leg mechanics. The rest supinate or pronate too much, with the latter being significantly more common. That’s a lot of bad feet!

This discussion gets interesting when you look at how foot function affects various structures of the human body. One of the most common problems I see in practice is heel pain, often developing because of this excessive falling-rolling motion of the arch. A lengthening of the arch is produced by hyper-pronation, predictably resulting in increased tension of the arch ligament, a structure called the plantar fascia.

This physical stress leads to inflammation and subsequently pain. In case you’ve not suffered from a case of plantar fasciitis (by far the most common cause for heel pain), this can be a seriously debilitating condition. How many activities don’t involve putting weight on your heel?

Another consequence of abnormal pronation is altered alignment of the structures running out to your toes. Some examples include tendons, muscles and ligaments. Early on, there is no structural change to the toes, but, with time and continued excessive pronation, permanent changes result, specifically some variation of mal-aligned toes, aka hammer toes. Although there are many reasons an individual may develop hammer toes, pronation syndrome is the most common.

What about the other end of the foot, the Achilles tendon? Tendonitis of this structure is common, and, again, there are many causes, but this rolling and falling of the arch is often responsible. Pronation syndrome consists of excessive motion of the arch, so, predictably, there will be extra movement of the heel bone. The Achilles tendon tends to be physically irritated by this, leading to the chemical changes of inflammation. Decrease abnormal pronation and you reduce the rubbing motion of the heel on the tendon.

Speaking of tendon problems, one of the most debilitating is that of an over-worked arch tendon. This is one term for the tendon which attaches to, and helps to support, the inside of the arch. When there is increased pronatory motion, this tendon, termed the posterior tibial, can become chronically stressed, leading to inflammation, swelling, pain. With time and continued excessive pronation, the posterior tibial tendon becomes weakened and can tear, either partially or completely. A sudden and dramatic collapse of the arch may result. This is a condition with dire consequences, generally requiring surgical intervention.

Unfortunately, these examples are only a small sampling of the complications associated with pronation syndrome.

At this juncture, a timely question is “how is pronation syndrome best treated?”. Options are many, some of which are fairly simple, yet quite beneficial. For example, a stretching exercise for the Achilles tendon can be helpful. Over time, excessive pronation will cause the Achilles to shorten, which eventually worsens the lowered position of the arch. Stretching out this structure, the largest tendon in the body, is not an easy task, and takes time. The research shows you need an hour of stretching a day.

A commonly utilized approach for this condition is an arch support. But what kind of support works best? What materials are most effective? This is an unbelievably complex topic, with thousands of options commercially available. Not everyone needs a custom, prescription arch support, but clearly, this will be the most specific type, and the most beneficial, for any one individual.

Foot orthotics, when properly prescribed and fit, have the ability to treat a host of problems. Unfortunately, many physicians dispense foot orthotics without the care and attention required to achieve optimal rewards. But when the exam and fitting process is executed correctly, (foot) orthotics can provide great comfort, as well as relief of pain, and with few complications.

A less utilized approach is the placement of a specialized metallic implant into the joint below the ankle. This particular joint, the sub-talar joint, is the one usually responsible for allowing excessive pronation. The design of this device has improved tremendously over the years, and no longer requires any sort of bone work. The recovery is quite easy, and can have an amazing effect on foot function and mechanics, and therefore on reducing or eliminating symptoms.

Many options are available for treating the inflamed, painful structures that can result from years of pronation syndrome. Various physical therapies are intended to achieve this goal. Steroid injections and oral anti-inflammatories both can reduce the pain of a chronically strained soft tissue structure. Yet, whichever structure is under duress will tend to become re-inflamed if the excess rolling collapse of the arch is not treated. Thus, although helpful in relieving pain, this approach tends to provide only temporary benefits.

These kinds of mechanical abnormalities of the musculoskeletal system are complex, and difficult to grasp by the average lay person. And much is unknown about kinesthesiology, the study of gait mechanics of the human body. But an effective treatment for these functional problems is best attained by a physician specializing in this area of medicine. When a correct diagnosis is made, a solution becomes that much more achievable. After all, standing and walking are critical quality-of-life issues. So find out how you can walk without pain. Then you can get active, and get happy!

Editor’s note: Dr. Conway McLean is a podiatric physician now practicing foot and ankle medicine in the Upper Peninsula, having assumed the practice of Dr. Ken Tabor. McLean has lectured internationally on surgery and wound care, and is board certified in both, with a sub-specialty in foot orthotic therapy. Dr. McLean welcomes questions, comments and suggestions at drcmclean@penmed.com.