Foot, knee and hip pain can be the result of biomechanical foot imbalance. Excessive pronation (feet rolling in too far, very low arched feet on weightbearing) or excessive supination (feet rolling out, very high arch on weightbearing) creates poor foot and leg alignment when walking, creating an unstable and inefficient base of support for your body. As a result, detrimental changes will continue up the leg, through the knee, hip and pelvis.
The resultant change in joint alignments will cause increased wear and tear on joint surfaces and overload soft tissue structures such as muscles, ligaments and tendons.
Malalignment will make these soft tissues and joints much more prone to sports and overuse injuries, and over time, this will contribute to arthritic and other degenerative changes in the joints.
Malalignment in Children
Young children have soft bones, prone to distortion or developmental changes when accompanied by alignment problems. Feet, knees, hips, and the lower back can be affected during growth and development contributing to pain in later stages of life.
Children do NOT usually "grow out of" foot problems. In fact they are most often the beginning of foot, knee, hip and back problems that present in adulthood.
Malalignments such as in- and out-toeing and excessive flat footedness are best addressed when children are young and their bones still growing as there is potential for correction at this stage.
Apart from obvious physical alignment problems, other signs for concern are clumsy running, frequent tripping, tiring easily, aversion to sports/games involving running, and pain in the feet and/or legs.
Appropriate orthotics for foot support/correction combined with muscle strengthening and stretching programmes can improve the childs' foot position and create a stable base for a well aligned skeletal and muscular system.
It is never too early to have an assessment of your childs' walking and foot position. Your Podiatrist will advise when or if intervention is necessary. Often no immediate action is needed, particularly prior to school age, with annual reviews being adequate for early detection of possible problems much like preventative vsits to the dentist or opthalmologist.
Foot and/or Leg Pain
The foot is a complex structure of bones, muscles, ligaments, tendons, nerves and blood vessels. These tissues usually work together as you walk enabling the foot to perform different functions at various stages in the process, i.e., to adapt to the ground surface and absorb shock on initial weightbearing, keep the body upright and balanced in mid stride, and then to "lock up" to provide a stable lever for the muscles to use to propel your body forward for the next step. Your feet work hard, carry many kilograms of weight, and are required to perform reliably for up to 10,000 (or more) steps per day!!
What Goes Wrong?
Many factors can contribute to foot pain. The main causes are discussed below including poor foot function, trauma and disease, and footwear.
Foot Function - Good foot function is needed to avoid foot problems developing. Your body weight added to the stresses on feet from ground surfaces, footwear, and activity level means that minimal malalignment of muscles and bones are required for foot pathology to develop. Eventually, entire body posture is affected, with knee, back or hip pain traceable to foot function for its cause.
Some results of poor function include symptoms such as:
- Heel pain e.g. Severs Disease, Achilles Tendonitis, Plantar Fasciitis
- Claw Toes/Hammer Toes
- Metatarsalgia (forefoot pain)
- Corns and Callous
- Pain in legs and knees, e.g. shin splints, patello-femoral syndrome, Osgood-Schlatters Disease, arthritis
- Aching Feet
- Morton's Neuroma
- Muscle Strains/Cramps
What can be done?
Podiatrists treat symptoms such as corns and callous, carry out biomechanical assessments, and prescribe orthotics to achieve realignment of the foot. They may use Trigger Point and Clinical Acupuncture therapy and can recommend muscle strengthening and stretching programmes to relieve pain, improve function, and prevent further or future injury or deformity.
Shin Splints (Medial Tibial Stress Syndrome) can be use as a good example - Shin splints are related to excess strain and stretching of soft tissue along the tibia (shin bone) and is often due to overpronation (feet rolling inwards) in active people.
Excessive pronation causes the lower leg to rotate internally, placing tractional stress on the muscles of the leg and interfering with their normal angle and degree of contraction. An overuse injury results where microscopic tears occur at the site of muscle attachment to the bone, and in extreme cases or when early symptoms are ignored, hairline fractures of the bone itself may present. This causes pain and sometimes swelling along the shin.
Sudden increases in distance or intensity of a workout schedule often initiates symptoms of shin splints.
By controlling overpronation of the foot via customized orthotics, accompanying stress placed on the muscles and bones in the lower leg is reduced allowing healing of the injury and preventing further damage. Trigger point and acupuncture therapy may be indicated to speed up response to mechanical treatment by restoring optimal muscle function and interrupting referred pain cycles. A specific stretching programme may also be added to the training schedule by the Podiatrist.
Trauma or Disease - Injury to, or disease of, any structure present in the foot, leg, or back will alter the mechanics of the lower limb and resultant symptoms will depend on the severity of the trauma or disease. Sometimes treatment is straightforward and quickly effective, but at other times a return to normal function is a prolonged affair or, at worst, not possible. Biomechanical anomalies can lead to or complicate the process.
Common causes of foot pain related to trauma or disease are:
- Ligament strains/tears/sprains, muscle strains, fractures, tendonitis
- Bruising, blisters
- Burns and cold injuries
- Arthritis, Diabetes, Peripheral Neuropathy, Peripheral Vascular Disease, Warts, Chilblains, Bacterial and Fungal Infections
Footwear - Properly fitting footwear is essential for general foot health, function, and comfort, particularly in children. Poorly constructed and fitted shoes contribute to physical deformity and pain in feet and should be avoided.
Footwear factors pertinent to preventing foot pain include:
- Wearing shoes and socks appropriate to your activity
- Good foot hygiene and the use of proper fitting shoes can help prevent blisters, ingrown nails, corns, callouses, stress fractures, metatarsalgia, Morton's neuroma, hammer toes, and plantar fasciitis
- Ill-fitting footwear can worsen the effect of poor foot mechanics, and well-fitting footwear can go a long way in minimizing the effect of poor foot mechanics
- Sports shoes lose the elastic properties of the soles through usage and age. A fair recommendation is to replace your shoes every six months or more often with greater wear. The use of replacement insoles can increase shock absorption and add support to the foot if necessary.
As Podiatrists we mainly see patients with knee pain caused by overuse injuries and those related to malalignment of the foot and lower leg. A vast majority of all lower back and knee problems, not caused by direct injury, are actually related to abnormal foot function and leg alignment. Studies show that foot related postural problems can refer pain to other parts of the body.
Factors contributing to overuse injuries of the knee include:
- Poor footwear
- Inappropriate training programmes and surfaces (hard/soft/uneven)
- Excessive pronation - an overpronated foot results in excessive internal rotation of the lower leg causing a twisting effect through the knee. The alignment of the knee joint itself and of the kneecap (patella) to the knee is affected. With increased load and use, as happens in sport, damage frequently occurs in and around the knee. The knee can suddenly become painful, inflamed, and swollen or as more often is the case, it comes on gradually as more wear and tear occurs.
- Excessive supination - a supinated foot is generally a poor shock absorber, causing impact forces during walking and running to be transferred up the lower leg and be absorbed by the knee. The knee then becomes prone to injury.
Some Common Knee Problems:
Patello-Femoral Syndrome - Inflamation and pain at the underside of the patella.
- Overuse/overload, biomechanical problems (pronation/supination), and muscular dysfunction (weakness of quadriceps muscles). The patella can track diagonally across the knee joint rather than within its normal channel causing joint damage.
- Repeated weightbearing impact and the demands of repetitive knee flexion and extension as in nearly every sporting situation.
- Squats, steps, hills, and uneven surfaces tend to exacerbate patellofemoral pain.
- Footwear should be assessed and appropriate footwear types prescribed
- Orthotics to control foot overpronation will reduce the twisting effect through the knee and promote normal knee function; orthoses to control excessive supination will stabilize the foot and provide cushioning and arch support. An orthotics effectiveness is greatly enhanced when used in conjunction with appropriate footwear.
- Prescribed stretching and strengthening exercises will assist the recovery process.
Iliotibial Band Syndrome (ITB) - the ITB is a fibrous band of tissue that begins at the front of the hip bone and extends down the outerside of the thigh to insert just below the knee joint. When the knee is extended (straight) the ITB is in front of a bump on the lower outer femur (thigh bone), but when the knee is flexed more than 30 degrees it flips behind it. ITB syndrome is caused by abnormal friction between the band and this prominent part of bone. When a foot overpronates (rolls in too much and for too long) this band of tissue is relatively tight and the friction it receives during activity is increased leading to inflammation and pain on the outside of the knee.
- Control of excessive pronation with the use of orthotics to allow the foot, leg, and knee to function in a better position, correctly distributing forces throughout the leg and decreasing tension/tightness in the iliotibial band.
- Additional therapy, stretching, strengthening exercises may be prescribed as might an enforced period of complete cessation of activity for a time.
Osgood-Schlatters Disease - Occurs commonly in growing children, particularly those involved in sport, most often between the ages of 10-14. Pain is caused by inflammation to the growth plate below and in front of the knee where the quadriceps muscles attach to the lower leg via the patella tendon. The patella tendon is a relatively thick tendon (much like the Achilles tendon at the ankle) as it needs to be strong enough to withstand the forces applied to straighten the knee from a fully flexed position under extreme load. In children, excessive pulling at this site can cause separation or traction injury to the growth plate creating pain. The growth plate fuses with the main body of the tibia at around the age of 14 and this area of relative weakness no longer exists. Therefore, the condition is self-limiting but nevertheless can interfere with normal leg function and ability to play sport when severe.
- Avoid activities that aggravate the condition such as kneeling or excessive flexion of the knee e.g. squats, cycling, inclines, running
- Ice the area when pain and swelling is evident
- Anti-inflammatory medications may give temporary relief
- Control underlying poor foot mechanics via orthotics to stabilize the knee
Excessive internal rotation of the femur is very often caused by biomechanical factors that present in certain foot types. If the structure and function of our feet creates lower limb instability, then it is quite possible that the hips may suffer as a result of this poor motion and alignment. Hip pain can often be traced to excessive rotator muscle activity and changes in pelvic alignment, and is often associated with compression of the sciatic nerve.
Hip pain may be the end result of poor mechanics through the lower limb, but conversely, restrictions in hip range of motion and function can be the causative factor of problems found further down the leg.
Careful assessment is necessary to determine the amount of influence the feet are having. Treatment may include hip stretches, strengthening exercises for muscles associated with pelvic stability, and prescription foot orthotics to improve pelvic stability.
One common overuse injury causing hip pain is Greater Trochanteric Bursitis. This is particularly common in women due to increased hip width.
Greater Trochanteric Bursitis - The greater trochanter is the boney prominence able to be felt on the outer side of the femur and is the outermost part of the hip joint. There is a bursa (sac filled with lubricating fluid) which is trapped between the prominent bone and the muscles and tendons that move the hip joint. The bursas job is to stop wear and tear of those soft tissues as they pass over and around the outer hip. This bursa can become very inflamed and painful as it absorbs the shearing stress from moving soft tissue and bone.
As with most injuries or pain, symptoms can either be acute (where the pain will appear suddenly) or chronic (where the pain increases over time) due to wear and tear.
Podiatrists usually deal with the overuse injuries as they are often due to abnormal foot biomechanics. The cause of the bursitis is often unstable pelvic movement and therefore treatment often involves orthotics to stabilize the motion of the feet, legs, and pelvis.
Treatment may also involve rest, stretching and strengthening exercises. Physiotherapists and Podiatrists may work hand in hand to achieve optimum results for the patient.