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5 1/2 Tips to Beat Bad Ankle Pain

bad ankle

Source: Pixabay

Too many of us live with daily ankle pain. Usually the factors creating ankle pain are often quite controllable and manageable with the right sports medicine advice.

Both athletes and non-athletes are susceptible to sore ankles, ankle sprains and chronic ankle pain. Controlling the pain and maintaining healthy ankles, feet, toes and calves is not difficult. I’m often asked for tips and suggestions on these body parts by individuals both young and old. Let me share with you the same tips I use on NFL players to help you live a fun and active lifestyle.

1.  Strengthen your Base of Support

Strong arches and toes are key to stabilizing everything above the feet. Any base of support, be it a building or a human body is vital to both stability and function. Simple exercises such as picking up marbles with your toes, barefoot walking/running, toe towel curls and  barefoot balance drills should be done on a daily Basis.

2.  The Right Shoes for Sprained Ankle

Wearing the proper shoe and, more importantly, not wearing the wrong shoe is vital if you want happy “dogs”. Women’s shoes are the best things to happen to pediatrics (foot doctors) because they consistently create ankle, feet and toe pain for women. Spending a little more money on the right shoe is money well spent if an active lifestyle is a priority of you.

3.  Warm-up/Cool Down for Running Ankle Pain

If there’s one thing I’ve learned about my body since I’ve turned 40 is that warming up and cooling down is important. In saying this, I realize it doesn’t require a lot of time to do so. The use of a roller, flexibility exercises, compression sleeves and ice has help me do this quickly and consistently.  Too often ice is not considered an important option for chronic ankle injuries.  That’s a mistake…ice therapy rocks and it should be considered to be one of your best friends!

4.  Embrace your Downward Dog

This could be your most important stretch. Last week I was doing a downward dog stretch in my living room at 4:15 AM when I was startled by the sight of my dog Marshall right next to me also doing a downward dog with me!

My Loyal Dog Marshall

It’s a great stretch that addresses muscle, tendons, joints and fascia from your toes through your arches, over your heels, through your calves, into the back of your knees, throughout your hamstrings, behind your hips and all though your low back…..just to name some of the locations.

5.  Self Traction and Mobilizations

These require more skill or may require the assistance of a friend although they are priceless for maintaining normal ankle mechanics. With the sore ankle at approximately 90° or a “neutral position”, gently pulling on both the heel and the top of the foot together.  This will create a gaping of the ankle from the lower shin. This can be accomplished with the help of an assistant or by placing the foot under a bed or couch to stabilize the foot and ankle.

Another mobilization move which is helpful to maintain the mechanics of a sprained ankle is to gently move or mobilize the lateral ankle bone both directly forward and more importantly directly backwards. This lateral ankle bone or lateral malleolus is a common source of a sore ankle.  Increasing its mobility is one of my favorite tricks to decreasing pain in a chronically sore ankle.

Bonus Tip –  Aggressively Directed Massage

If you really want to loosen up chronically stiff ligaments and muscle, aggressive massage should be included. Once a sore ankle, shin and arch are warmed up, apply a moderately aggressive massage with your thumbs to the locations around your ankle locations noted below.

Focus on the areas on both sides of the Achilles tendon that forms the backside of the ankle joint, the entire edge surfaces of the lateral ankle bone and the front of the ankle joint.  Including the arch and the great toe is always an added bonus. After these areas have been loosened up, it’s important to get all those moving parts active and functional to both normalize range of motion and to re-program the entire leg how to move pain-free.

Foot Orthotics – Are They Worth the $?

I’m often asked about orthotics and the questions usually involve two basic issues:

     1.  Do orthotics really work?

     2. Why are orthotics so expensive?

I find it ironic that most people asking these questions own orthotics.  If they are wearing orthotics and they have to ask if they work, it must mean the orthotics are not doing their job.  No one seems to ask such questions about contact lenses or glasses.  If they’re wearing contacts and they question their effectiveness, the contacts probably aren’t the right lenses for that person.

Orthotics are no different.

As for the price, in many cases I think orthotics are grossly over-priced.  Sure there is tons of science and detail installed into a properly fitted pair of orthotics but there is little reason why someone needs to charged $600 for any shoe insert that isn’t covered in gold and diamonds!

I’m a fan of orthotics if fitted properly….for the right reasons and for the right price.  Approximately 40% of my athletes presently wear orthotics.  I owe a great deal of my knowledge about the lower kinetic chain and orthotics to David Tiberio, professor and friend from one of my alma maters, the University of Connecticut.  He’s a brilliant physical therapist and I appreciate him sharing his amazing insight with me over the past 25+ years.

What is an orthotic?

An orthotic is a specifically designed shoe insert which is custom-made to correct a biomechanical abnormality by correcting the poor alignment and enhancing the body’s ability to move.

How Do Orthotics Work?

As I tell my pro football players: “Orthotics bring the ground up to the foot.”  The foot is the base of support of the entire body and it starts the movement pattern when the foot is in contact with the ground during standing, walking or running.

If you were to put a smaller wheel on the front left side of your car, the car will still be driveable and get you to where you want to go.  It will be slower, it will be harder to drive, other parts of the car will be stressed more, the other tires will wear-out faster and the appearance of your car will change.  Poor foot alignment is no different.

To get that car alignment corrected without changing the tire, it can be done two ways.  1.  The car can be driven without the front left tire ever touching the road – not likely to happen or  2. The road can be brought up to the tire as if that tire was now riding on the curb.  This is a simple example of how an orthotic functions.

The Benefits of Orthotics

There are many reasons why orthotics are used.  Those reasons include leg length discrepancy, plantar fasciitis, heel pain, ankle sprains, tendonitis, arch pain, shin splints, foot pain, stress fractures, low back pain, muscle pain/injury, neuromas, bursitis, and sciatica. The influence of an orthotic, as with the base of support of any structure, can reach from the bottom to the top of that structure.

There is much discussion related to the best manner to create the orthotic and it goes well beyond the scope of this sports medicine blog posting.  Weight bearing status, casting, laser, standing, sitting, laying prone, hard orthotics, half-length, orthotic material, where to stabilize the arch,…etc. are just some of the factors related to orthotics.

The Truth About “Perfect Alignment”

The mechanics of the human body are amazing and a big reason why I love doing what I do as an athletic trainer and physical therapist in the NFL.  Every joint in the body has a three-dimensional movement pattern.  Unlike the hinges on your door that moves in only one plane of motion, the human body joints have what is called accessory movements.  These are subtle movements of a joint are necessary for full range of motions to occur.

I like to restore “proper alignment” because there is no such thing as “perfect alignment”.  This normal three-dimensional movement means that an orthotic must bring the ground up to the foot to allow for this normal movement pattern to happen naturally.  In other words, orthotics allow the body to do its job by moving naturally without pain.

I tell my players that the only time they will have bilateral symmetry on the football field is during the National Anthem.  It’s true.  Think about it: the field is never level and they are always changing direction throughout the game.

The A Factor

As for the athletes (A) themselves, one leg is usually longer than the other, injuries change joint motions over the years, flexibilities vary from side to side, the wear pattern of the shoe alters the mechanics of the foot, muscle weakness alters the running sequence and their joint laxity/arthritis changes how that athlete moves.

In other words, the athlete himself isn’t moving the same on both sides of the body.  With this being said, the theory of an orthotic is to help balance the manner in which an athlete moves on both sides of their body.

Back to Orthotics….

Now that we got all the kinesiology and body mechanics out-of-the-way, let’s get back to the orthotics themselves.  I emphasize to my athletes that a properly fitted pair of orthotics should fit like your favorite pair of blue jeans.  They “just fit right”.  No two pair of favorite jeans are the same.  The same is true for orthotics.  A well-fitted orthotic should have no hot spots, no pressure points, no uneasy feeling when they are worn and the athlete should almost forget that they are there.

Think about it this way:  if your orthotics are doing their job properly, the foot and the entire body above it is positioned to do its job.  Those previously noted movements can now happen with ease.  It’s like tucking that napkin under the leg of the wobbly table.  Now the table is both level and stable to do its job of being a table.

Getting the proper orthotic to meet your needs is the key.  The most important factor related to the orthotic is what YOU, the athlete, feel and think.  Speak up and give your medical team the necessary feedback to adjust your orthotics so they “just fit right”.  Don’t forget that it’s your feet and your money!

 

Metatarsalgia: Foot Pain’s Evil Brother

No One Can Ignore Metatarsalgia Foot Pain

Metatarsalgia is a general term relating to forefoot pain secondary to inflammation in the area of the distal foot and toes.  The swelling involves the joints that connect the metatarsal bones of the foot and the phalanges (toe) bones.  The 2nd, 3rd and 4th MTP joints are most often stricken with this disorder.  With the joints of the toes, Metatarsalgia is commonly found within the 2nd, 3rd and 4th interphalangeal joints.

Morton’s Neuroma is a similar condition that demonstrates with forefoot pain.  Unlike Metatarsalgia, Morton’s Neuroma pain is located between the distal metatarsal bones where Metatarsalgia is typically pain within the joints themselves of the forefoot and toes.

Morton’s Neuroma is caused by a pinching of the nerves between the 2nd, 3rd and 4th metatarsal bone creating an inflammation of the nerves.

Ball of the foot pain is not typically linked to either of these condition although it is not surprising to develop such symptoms by compensating for any lower extremity dysfunction.

Signs and Symptoms of Metatarsalgia

  • Forefoot and toe pain which increases with weight bearing activities.
  • Tight fitting shoes and high heels increase symptoms.
  • Point tenderness pain in the distal foot area and proximal toes.
  • Excessive blistering, callus and wear patterns are commonly found in the forefoot and toes.
  • Passive bending and rotating of the toe will increase pain.
  • Ball of foot pain can be present which tends to be more related to compensation mechanics with chronic foot pain symptoms.
  • Long-term abnormal toes alignment such as claw toes or bunions may be contribute to the condition.
  • There may be excessive skin or calluses under the foot due to excess pressure.

Sign and Symptoms of Morton’s Neuroma

  • Localized pain between the 3rd and 4th distal metataral bones and toes.
  • Complains of increased weight bearing symptoms as if they are “standing on a pebble”.
  • Pain increases with weight bearing activities.
  • Symptoms into the distal foot and toes can include sharp pain, burning, numbness and/or tingling.
  • Increased symptoms between the metatarsal bones with squeezing of the forefoot.
  • Excessive callus and wear patterns are commonly found under the distal forefoot and great toe.
  • Ball of foot pain can be present which tends to be more related to compensation mechanics with chronic foot pain symptoms.

Treatment for Metatarsalgia and Morton’s Neuroma

  • Aggressive icing of the arch, foot and toes with ice bags, ice massage or, ideally, an ice bucket for 10 to 15 minutes.
  • Wear the proper footwear for the activity you are performing
  • Minimize activities that include weight bearing.
  • Massage and soft tissue treatments to the arch, great toe, ankle joint and calf.
  • Biomechanical evaluation to assess contributing issues such as: a leg length discrepancy, hyper pronation/supination, tight ankles, restricted toe extensor tendons, hypomobile toes, knee, hip or low back factors.
  • Consistent calf stretching.
  • Orthotics with possible rigid steel insert of ball of foot pain is present.

Questions a Pro Athlete Would Ask

A smart professional athlete with Metatarsalgia who wants to safely return to his/her sport should ask his sports medicine specialist the following questions:

  1. Do you have any concern that I may have stress fracture in my foot or toes?
  2. Is there any chance that some of my foot symptoms are coming from nerves in my back or leg?
  3. Will orthotics help me and if so, where can I get them at a reasonable price?
  4. If you had this same problem, where would you go to do your therapy?

Sports Medicine Tips

If the Shoe Doesn’t Fit, Don’t Wear It – True fact:  woman’s shoes are the best invention for the foot doctor profession.  They look sexy and stylish but they are killing your feet.  Ladies or dudes:  You know that it’s true so get rid of any shoes that are creating foot problems.

Sole Searching – The shoes are typically the source of your problem.  Old shoes, improper shoes and worn shoe soles are common factors that lead to foot and arch pain.

#2 Pencil – Using the eraser end, use it to apply pressure between the metatarsal bones of the foot.  It’s a simple tool to help determine the location of the pain and the diagnosis.

Ice is Your Friend – It’s a reality check:  Ice hurts but it’s exactly what you need for this injury.  The Pros will tell you that ice is their best teammate.  Stop complaining and do what you know you need….ICE and lots of it.

Turf Toe Management

Turf Toe Caused By Hyperextension

Turf toe is an injury with a short name but a long history of pain in the NFL.  With large men rapidly changing directions on varying surfaces, the forces originating at the ground level are extremely high.  Simply stated, every football player move that you see on your plasma screen during Sunday’s game start at the foot and big toe.

Turf toe is the medical term related to a sprain of that 1st metatarsophalangeal (MTP) joint or, as it is commonly referred to as, the “big toe”. The name turf toe originated in the mid-1970’s when certified athletic trainers and physicians reported an increase in 1st MTP joint injuries with a large number of games being played on artificial turf.  The combination of harder playing surfaces, increased shoe traction and lighter less rigid shoes proved to be the main contributing factors to injuries related to the big toe.

Big toe pain originates at the 1st metatarsophalangeal (MTP) joint and usually includes surrounding soft tissue.  The most common mechanism of injury is joint compression with hyperextension of the 1st MTP joint.  In reality, turf toe can occur with any combination of compression with excessive extension, flexion, rotation, adduction (moving away from the 2nd toe) or abduction (moving towards from the 2nd toe) of the 1st MTP joint.

An example of this injury in football is when a player lands on the back of another player’s ankle while athlete’s big toe is planted in the ground and extended.  With the extra weight applying pressure into the arch and the player’s inability to unload the front of the foot, the 1st MTP joint is forcefully hyperextended and the joint surfaces are compressed.  It’s easy to see how this mechanism of injury can create considerable damage to the joint itself and all the structures on the plantar (undersurface) of the distal arch and big toe.

With the example noted above, the muscles that flex or bend the 1st MTP joint can be stretched or torn.  The capsule that surrounds the joint is vulnerable along with the ligaments and plantar plate complex, which is the stabilizing structure on the underside of the big toe.

Lastly, the two small sesamoid bones that rest under the 1st MTP joint, or “ball of the foot”, are potential sources of pain with turf toe and any injury that affect this area of the distal arch.  With direct trauma or hyperextension of the big toe, the sesamoids can become inflamed or fracture.

Signs & Symptoms of Big Toe Pain

  • A sudden or slow onset of pain anywhere encompassing the base of the big toe.
  • With an abnormal motion of the 1st MTP joint, a “pop” or a “shifting” sensation is noted.
  • Point tenderness and swelling at the base of the big toe.
  • Passive and active movements of the toe upward (extension) are painful and the amount of motion is significantly limited when compared to the other foot.
  • When moving the big toe into the direction of the injury, the symptoms increase and the strength in that position is significantly reduced.
  • Pressure while weight bearing, twisting and pushing off the front of the foot will increase symptoms in the big toe.

Treating Turf Toe Pain

  • Icing, elevate and rest the foot is the best start to controlling the swelling and pain.
  • Icing techniques include a 15 minute ice bag (good), a 10 minute ice massage (better) or the Granddaddy of them all, the 12 minute ice bucket (the best).
  • Walking boots are valuable tools in the NFL and a wonderful ways to protect the toes, forefoot and ankles while allowing an athlete to walk.
  • When you’re able to comfortably wear a shoe, utilizing a steel shoe insert or rigid orthotic in all of your shoes will stabilize the forefoot and minimize extension at the big toe.
  • Avoid barefoot walking or any activities in flimsy and unsupported shoes.
  • Massage of the arch, gentle painfree range of motion (ROM) of the toes, stretching of the ankles and calves will enable better blood flow to the injured tissue while maximizing the drainage from the areas with excess swelling.
  • When the warmth in the joint has subsided and at least 75% of your painfree motion had returned, picking up marbles/rocks/peanuts with your toes will increase the strength and mobility of your toes.
  • Towel curls, to be started with the same criteria as the marbles, will effectively strengthen your arches and intrinsic muscles of your forefoot.

Asking the Right Questions Like a Pro

Here’s what a smart pro athlete would ask his/her sports medicine specialists to ensure a fast and safe return to sports:

  1. Do I have turf toe and exactly what structures did I damage with my injury?
  2. Do I need an x-ray, MRI or CT Scan to determine the extent of my injury?
  3. Will orthotics help me and if so, where do you suggest that I purchase them at a reasonable price?
  4. Did my shoe wear contribute to my injury and if so, what changes do you suggest?
  5. Are my non-athletic shoes contributing to my problem?
  6. Do you think that I need surgery on this injury now or in the future?

Elite Sports Medicine Tips from Mike Ryan

  • Swelling Control – Your toes are located at the end of very long network of blood vessels, which are assisted by both contracting blood vessels and gravity.  Help control your swelling by minimizing your standing time, maximizing your elevation time, aggressive icing, wearing stiff shoes and being consistent with your physical therapy.
  • Gout? – I have pro football players fight me on this every year.  Sometimes Gout really is the source of the pain if the mechanism “just doesn’t fit”.  If your unsure, check with your doctor because Gout is more common than you think.  “If the Gout shoe fits, wear it.”
  • Joint Surface Status – Degenerative joint disease (DJD) in the big toe is common with high level “stop and go” athletes as are…(are you ready for this?)….women who commonly wear crowded, pointed-toed high heeled shoes. If your toe angles are changing and your toe ROM is decreasing, your joint surface is probably less then ideal.
  • Don’t Forget About Your Calves – Ankle ROM is an important factor related to toe pain.  Keeping your calves loose and limber will help.  Massage and stretching of the calves will immediately increase ankle ROM and decrease the need for excessive 1st MTP extension.  Flexible calves and loose ankle can reduce your turf toe pain by 25%!
  • Little Piggy’s #2, 3, 4 & 5 – Don’t forget about the little guys in the neighborhood.  Your other toes need to be stretched and cared for as well.  I see many bad looking toes and toenails in my business and I can tell you that your foot will function allot better with all five Little Piggy’s doing their part.

How To Eliminate Heel Pain

In order to eliminate heel pain, we have to know what causes heel pain? Although the term heel pain is somewhat general, if you suffer from the condition you can testify to the significance of the injury.  The source of the pain in the arch area on the underside of the foot can vary.

Heel pain can be due to a trauma such as forcefully striking the heel on a hard surface or it may be an overuse injury, such as plantar fasciitis.

The calcaneus bone, or heel bone, has a thick layer of fat and protective fascia on its underside to provide padding as it makes contact with the ground.  Excessive forces or repetitive pounding of the heel can cause the fat pad to move or become inflamed.  When the protective layer under the heel bone decreases in efficiency like this, heel pain and burning feet can result.

Common Sources of Heel Pain:

  • Plantar Fasciitis – A common source of arch pain, this inflammatory process involves the plantar fascia, which enters into the back of the arch.
  • Heel Bone Spur – This occurs when excessive bone forms under the calcaneus(heel).
  • Heel Contusion – Known as a bruising of the heel bone.
  • Calcaneal Stress Fracture – This is a preliminary or significant fracture of the calcaneus bone.
  • Tarsal tunnel syndrome – This happens when the nerves encroach the back of the foot and arch.
  • Calcaneal bursitis – Is inflammation of the sack of fluid which sits under the heel
  • An increased warmth and possible swelling of the underside of the heel bone.
  • Arch pain originating on the heel and possibly extending into the underside of the foot towards the toes.
  • Posterior heel pain with weight bearing on the foot, which may worsen with active toe flexion.

Signs & Symptoms

  • Tenderness anywhere associated with the surface of the heel bone.
  • An increased warmth and possible swelling of the underside of the heel bone.
  • Arch pain originating on the heel and possibly extending into the underside of the foot towards the toes.
  • Posterior heel pain with weight bearing on the foot, which may worsen with active toe flexion.

Professional Treatment for Heel Pain

  • Icing the entire heel bone with an ice bag, ice massage or, ideally, with an ice bucket.
  • Rest the area to minimize the pressure on the calcaneus.
  • Easy massage of the arch and toes.
  • Modify the shoes to increase the padding encompassing the heel bone to provide greater shock absorption.
  • Increased calf stretching to allow greater pain-free movement of the ankle joint.
  • Consider utilizing orthotics or arch supports, depending upon your lower extremity anatomical alignment and biomechanics.
  • Heel bone spur symptoms can be improved with treatment noted above and it may require surgery.

 

Receive The Best Care By Asking The Best Questions

To ensure you receive the best possible care for your injured foot, ask questions like a smart professional athlete who wants to safely return to his/her sport as quickly as possible.  Here’s what a pro athlete would ask his sports medicine specialist:

  1. Are you certain of the diagnosis?
  2. Do I need an x-ray to determine the extent of this injury?
  3. What are my options with treating this injury?
  4. What can I expect with this injury for the next 2, 4 and 6 weeks?
  5. Who do you consider to be the expert heel pain rehab specialist in this area?
  6. Will I be given a detailed rehabilitation protocol to direct my rehab for both my therapist and me?

Tips to Quickly Recover from Heel Pain

  • Start Treatment Fast – Arch pain and heel pain are not injuries to ignore.  Start the treatment fast and this injury can usually be resolved quickly with minimal downtime.
  • Sole Searching – The shoes are typically the source of your problem.  Old shoes, improper shoes and worn shoe soles are common factors that lead to arch pain and burning feet.
  • Ice is Your Friend – It’s a reality check:  Ice hurts but it’s exactly what you need for this injury.  The Pro’s will tell you that ice is their best teammate.  Stop complaining and do what you know you need….ICE and lots of it.
  • What to Expect – The recovery time for heel pain is typically minimal.  As long as there is no stress fracture, large bone spur or significant plantar fasciitis, the downtime for this injury can range from a couple of days to a few weeks.  Treat it early to determine the source(s) of the problem, correct it and you’ll be back in the game before anyone knew that you were icing your heel!