Changes in movement characteristics are often predisposing factors for soft tissue overuse problems, and the development of an altered pattern can have a negative effect on foot function. Static malalignments or rear foot dominance during pronation have been associated with tendon overuse injuries. Finally, the effectiveness or motor pattern of the foot and ankle muscles plays a significant role in lower extremity function. This can be impaired by neural dysfunction or muscle weakness and can predispose to various overuse injuries.
A stress fracture is an example of an overuse injury and these are well-documented in the tibia and fibula, the second and third metatarsals, and the calcaneus. High loads and impact forces are predisposing factors, and intrinsic bone density is a determining factor in the development of stress fractures. Anatomic alignment plays a major role in foot function and may influence the development of several overuse conditions. Static alignment is assessed in terms of bony position and joint congruency. During weight-bearing, the primary function of the foot is to dissipate the energy created by the ground reaction force and to maintain a stable platform for the body. This is achieved through controlled pronation at the subtalar joint and maintained arch flexibility.
It is essential to ascertain the contributing extrinsic and intrinsic factors, which impair the tissue’s ability to adapt and to remove or modify those factors to a more favorable level. This paper reviews the etiology of overuse disorders involving the foot, ankle, shin, and thigh, and suggests guidelines for treatment and prevention of these conditions. In general terms, an overuse injury can be thought of as a tissue fatigue failure problem. Tissue fatigue occurs when the rate of tissue load application is too great, such that the adaptive repair cannot occur fast enough to prevent micro failure. Failure occurs in excess fatigue situations when the cumulative micro damage reaches a level, which exceeds the inherent capacity for load bearing.
Repetitive strain injuries and ailments involving the foot and ankle are a common occurrence and are a major cause of reduced athletic performance and a reduction in enjoyment of leisure pursuits. The lower extremity is frequently exposed to high loads during occupational, daily, and sport activities. These activities have been reported to potentially cause soft tissue and bony disorders about the lower extremity. Overuse phenomena occur when anatomic structures fail to adapt to imposed functional demands. This failure may be due to intrinsic or extrinsic factors which may make the functional demands excessive or the tissues’ ability to adapt inefficacious.
Overview of Repetitive Strain Injuries
There are 3 stages of RSI: 1. Pain or fatigue: This is an early sign of RSI and is reversible within 24 hours. 2. Tendon disrepair: This is a progressive stage that leads to tendon degeneration. 3. Degenerative tendinopathy: This is characterized by failed self-repair and tendon structure change, and it is often at this point that people seek advice from a medical professional about their RSI.
RSI develops when there is an imbalance between damage and recovery. If the rate of injury is too high and there is inadequate recovery time, the damage will accumulate. This is because there is a failure of adaptive remodeling in the tendon. The fibroblasts respond to the increased damage by producing type III collagen in an attempt to repair it. However, RSI tendon cells are found to have different behavior and metabolism, and this attempted repair is unsuccessful, and degenerative changes ensue.
Repetitive strain injuries (RSI) are a group of conditions which are characterized by an overuse of a certain body part, which leads to muscle imbalance and eventually muscle injury. The development of RSI is complex and is thought to be caused by a variety of extrinsic and intrinsic factors. It has been linked with certain occupations and activities that involve repetitive tasks, awkward postures, forceful exertions, and vibration. However, the link may not always be straightforward.
Understanding Foot and Ankle Pain
The second factor is the nature of the bone and its response to increasing or repetitive load. Wolff’s Law explains that in healthy individuals, bone will adapt to the loads under which it is placed. This is particularly relevant for the cuboid, especially in midstance, as it is a keystone for the midfoot transferring the load from the hindfoot to the forefoot. Excessive load or an abrupt increase in load can lead to stress reactions in bone and if not addressed can progress to stress fractures. Stress fractures are commonly seen in people in training or military recruits. The metatarsals are also a common site of stress fractures due to them being the longest bones in the foot and transferring a majority of the load from the ankle to the forefoot.
When considering what makes the foot and ankle unique in comparison to other weight-bearing structures or joints in the body, role and work demands are the first factors that come to mind. When examining the ankle, it is important to recognize the various angles and planes it is forced to adapt to as it is ultimately a compensatory structure between the relatively fixed position of the foot and the various demands required by the hip. The ankle is forced to provide both stability and mobility in different situations. Stability and propulsion are key roles of the foot in gait and locomotion.
Preventive Measures for Foot and Ankle Pain
For individuals with further bio-mechanical abnormalities, custom made orthotics may be necessary. This however is often an expensive option and so should be reserved for those with serious conditions.
There are some general guidelines for selection of proper footwear. Sports shoes are generally well cushioned and provide good shock absorption. If one has foot deformities such as flat or cavus foot, a shoe with good arch support is advised. This can be tested by removing the insole of the shoe and checking for the amount of indentation and shape it retains from the arch. High heeled shoes should be avoided, but if one insists on wearing them, restricting use to 3 hours a day is advised. The heel should also be less than 3 inches in height. Going barefoot should also be avoided. A supportive slipper or sandal can be worn indoors to decrease stress to the foot.
The topics of proper footwear and orthotics are minor yet common causes for foot and ankle pain. Shoewear is generally overlooked as a cause of musculoskeletal injuries. A study on army recruits showed that those wearing athletic shoes had a lower incidence of stress fractures than recruits wearing combat boots. Essentially, one should strive to wear shoes that are comfortable and provide good shock absorption.
Preventative measures for foot and ankle pain are essential for maintaining health in the lower extremities. Such measures include proper footwear and orthotics, stretching and strengthening exercises, and proper ergonomic workstation setup.
Proper Footwear and Orthotics
In cases of severe foot deformities or mechanical problems, a custom shoe or orthotic may be necessary. An orthotic is any device that is inserted into a shoe, ranging from felt pads to custom-made shoe inserts that correct an abnormal or irregular walking pattern. Orthotic devices come in many shapes, sizes, and materials and fall into three main categories: those that try to change foot function, those that are protective in nature, and those that combine functional control and protection. Wearing an orthotic insole can provide symptom relief and prevent future foot problems by controlling abnormal biomechanics. However, there is no universally accepted theory that will determine whether or not an orthotic will help a given patient, and it is trial and error with different types of orthotics.
In light of recent fashion trends of clogs and sandals, patients and consumers must be educated in knowing that these shoes can cause more harm than good. When worn for long periods of time, the rocking motion of the clog can overstretch the foot and calf and cause mechanical instability; and sandals do not provide the closed-in support that a shoe can offer. With emphasis on biomechanical principles, a stable foot is a pain-free foot, and shoes that do not support the biomechanics of the foot can cause many problems. Older individuals with balance problems would do better to avoid wearing clogs. In the event that one has foot deformities and foot pain, shoes with a wide and deep toe box are indicated. This will accommodate any inserts or orthotics that are used to support the foot and allow for natural toe movement.
For work activities, supportive shoes with a non-slip sole are very important.
The use of proper footwear is of utmost importance in preventing repetitive strain injuries and foot and ankle pain. Improper shoes can directly cause foot and ankle problems. Supportive athletic shoes are necessary when one is engaging in athletic activities; however, one must keep in mind that there is no one brand of shoes that is suitable for everyone. It is a good idea to find a shoe store that has informed sales personnel who can help you find the correct shoe for you. The brand of shoes that you find to be the most comfortable and supportive may not be the same brand that another person finds to be the most comfortable and supportive. This is because the base, arch, and ankle/heel support differ from shoe to shoe.
Stretching and Strengthening Exercises
Towel Scrunches: Sit with your shoes off and scrunch a towel with your toes. Try to pick the towel up and then spread it out and start over. This should be repeated for about 2-3 minutes.
Calf Raises: Stand on the edge of a step with just the balls of your feet. Let your heels hang off the edge. Push your body up using the muscles of your calf and ankle. Then lower your heels down and repeat.
Calf Stretch: Stand facing a wall at an arm’s length distance. While keeping your back leg straight and heel on the floor, step forward with your front leg. Bend your front leg forward and lean into the wall. You should feel the stretch in the back leg.
Stretching can help maintain flexibility in the ankle, foot, and leg, and strength exercises can help support the muscles of the lower extremity. The combination of the two can work to prevent an acute injury from occurring due to the fact that flexibility and strength are two key factors in warding off injury. Here are some simple exercises that can be done in a short amount of time, which can help prevent injury to the lower leg. Hold each stretch for 15-20 seconds and perform each strength exercise for 15-20 reps. Try to incorporate the stretching and/or strengthening exercises into your daily routine.
Ergonomic Workstation Setup
Phone placement is often overlooked in the workstation setup. Keep your phone within arm’s reach. If you are on the phone a lot and have to write or type, use a speaker or headset. Avoid cradling the phone between your head and shoulder. A lot of these suggestions are easily accomplished with regular household items, but if your employer is willing to purchase a few things, it may be worth considering ergonomic equipment.
The monitor should be placed directly in front of you with the top of the screen at or slightly below eye level. Keep the monitor close enough so that you can easily read text, but far enough so that you can read the text by looking down with your eyes rather than tilting your head forward. Use a document holder if working from printed material. Avoid using too much tilt or swivel in the monitor. The main idea behind the ergonomic workstation is to minimize awkward postures, and the best way to do this is to keep the work close and centered.
The desk or keyboard should be at about elbow height. The keyboard should be placed so that the shoulders are relaxed with the upper arms hanging by the body and the elbows at a 90-degree angle. Wrists should be kept in a relaxed position when typing—hence, the best position for the keyboard is probably just above the thighs. A wrist pad can help to maintain neutral wrist position, but keep in mind that this can also encourage excessive wrist extension. The default mouse position is a little to the side and in front of the keyboard. If there is not sufficient room to move the mouse, try moving the keyboard over and use a compact keyboard.
The chair is the most important part of the workstation. Use a chair that has a straight back or low-back support. The chair should swivel and have wheels. The height should be easily adjustable. Use armrests to support your lower arms, and remove any obstructions to your feet or legs. If your chair does not provide the correct support, use a small pillow or cushion to provide lumbar support. When sitting on the chair, your knees should be level with your hips. Use a footrest if it is not possible to keep your feet flat on the floor.
An ergonomic workstation setup is essential for preventing a repetitive strain injury. An ergonomic workstation is designed to fit you. It puts your work in the most comfortable position and allows for the most effective movement. The following are suggestions for creating an ergonomic workstation.
Rehabilitation Techniques for Foot and Ankle Pain
These guidelines can be applied for different foot and ankle injuries. Due to the diverse nature of lower limb injuries, individual rehabilitation protocols will vary. In the case of severe acute injury, surgery, prolonged off-loading, and even physiotherapy may be the only event. Other cases, especially those involving chronic and degenerative injuries, may need a modification of lifestyle to reduce the repetitive loads, which are causing the pain. This could be through losing weight, change of occupation or footwear, or avoiding specific activities.
The senior author has proposed a new model of rehabilitation in athletic injuries. This is a dynamic process of events based on a continuum from the conditions and events in the pathological state of the injury, to the repair and regenerative phases, and finally the drive to regain pre-injury functional or fitness levels. This is still in its validation process but shows promise in its ability to provide a clear and comprehensive treatment plan for different injuries. This essentially provides a chronological events menu for each injury type. This should be discussed with a physical therapist and tailored to match any other specific rehabilitation protocol.
Rehabilitation is the final step in eliminating foot and ankle pain. This process involves a return to regular sporting activity with rest day pain. This may take from weeks to a couple of months to achieve, depending on the severity of the original injury. The main aim is to get the functional outcome back to pre-injury levels. This is achievable in cases of acute injury. Delaying or preventing onset of chronic pain associated with poor injury rehabilitation is another key aim in treating foot and ankle injuries. Chronic pain can be highly debilitating and have serious effects on an individual’s lifestyle. This is achieved through a sequence of events, which are dictated by the nature of the original injury.
Physical Therapy and Rehabilitation Programs
A gradual reintroduction to activity and a carefully monitored increase in training loads are fundamental to the long-term management of a lower limb overuse injury. The individual must avoid any activity that provokes pain for the initial period. A general aerobic fitness program, using alternative forms of exercise such as swimming or cycling, may be indicated to maintain an acceptable level of fitness. This should be carefully monitored; if any symptoms are provoked during or after the session, then the activity levels are too high. Symptoms during the fitness program are a sign that exercise prescription is not appropriate for the condition. A more detailed gait analysis or a consultation with a podiatrist may be helpful during the later stages of rehabilitation or before a return to specific training or competition. This is particularly relevant if an anatomical abnormality has been identified as a possible contributing factor to the injury. A podiatrist may be able to modify shoe wear or design orthotic devices to alter abnormal foot mechanics and prevent recurrence of the injury.
Once the acute symptoms of repetitive strain injuries have subsided, the focus of treatment shifts toward the rehabilitation of the affected limb. Since pain in the lower extremities is a significant problem, a comprehensive training program is necessary to prevent the recurrence of an overuse injury. However, the goal of rehabilitation in a foot or ankle overuse injury is not simply to return the individual to the pre-injury state, but to also understand the factors that contributed to the problem. That way, the training program can be modified to prevent recurrence of the injury.
Pain Management Strategies
Proper identification and treatment of the site of pathology is necessary for effective exercise therapy, and if successful, the individual will experience less pain and a return to function.
Studies demonstrate that exercises that promote tendon gliding and exercises that improve wrist strength and endurance are effective in reducing symptoms of RSI. Tendon gliding exercises have been shown to improve symptoms of early onset RSI, as these exercises are best when they are used preventatively or when started early in the person’s symptoms. Exercises that improve wrist strength and endurance are effective for all levels of RSI, and although there is no consensus on the type, duration, or frequency of exercise therapy, these types of exercises involve less risk and cost than other treatments or interventions.
There has been debate about the effectiveness of R in the treatment of RSI, as it is so widely used in RSI. It is assumed to be effective, as it commonly forms part of an individual’s treatment. However, a recent review showed that there are no controlled trials that have evaluated the effects of R for treating RSI, and that these are necessary before any conclusions can be drawn about the value of this intervention.
Rest and Recovery Techniques
Taking on the holistic approach, sleep is also a key aspect as studies have shown a relationship between sleep and pain. Obtaining a complete night’s rest is beneficial for individuals with chronic pain, and sleep deprivation has been shown to lower pain threshold. It has been recommended that 8-9 hours of sleep is necessary to combat pain caused by exercise and sport.
Rest is a key component for allowing the body to adapt to the stress incurred by exercise and during sport, as the tissues within the body require time to repair. This is especially important for individuals who undertake strength training, as muscles only grow when at rest. Avoid the activity which caused the injury as rest does not necessarily mean complete inactivity and altering the method of activity is an effective way to reduce the risk of aggravating an injury. For example, switching from running to swimming reduces the stress on weight-bearing joints. Complete rest, however, is more appropriate for acute injuries as this can reduce the amount of bleeding and swelling which occurs in the acute inflammatory phase. Stepman and Harman suggest that logical rest involves an integrative approach in which rest is balanced with pain-free movement. This may also involve reducing the duration and frequency of an activity, or the use of taping and external supports to reduce stress on injured tissues. Simulation of the injured body part using isometric contractions has also been seen to prevent muscle atrophy, however, this would require the individual to seek guidance from a medical professional.
Performing regular exercise does not mean that one should not relax or that rest is not necessary. People who exercise on a regular basis need to rehabilitate after injury and workout sessions.
