Chronic foot pain is extremely common and vastly misunderstood when it comes to rehabilitation. When it comes down to returning to prior activities, the prognosis is mixed. When it comes to a rehab model, a variety of options are available for treatment. So with all the options and treatments available, why aren’t patients getting better?
I think the answer lies in the fact that not all foot pain is created equally. When it comes to assessment of the foot, precision, observation and differential diagnosis is crucial. Roughly, I estimate 60% of the patients I see for foot issues don’t have true foot problems. Rather, the foot is sacrificed due to other structures not playing their part. Often, an underperforming hip or innate lack of proprioception at the hip, or knee is the culprit, not the foot itself.
Additionally, there are a vast number of issues that can cause foot pain: sciatica, hip weakness, ankle stiffness, lack of pronation, excessive pronation, intrinsic foot weakness, diabetes to name a few. A careful exam can narrow the causes down substantially. This means a great deal of time removed from ‘going back to the board ‘ during treatment.
Treatment may vary based on the exam. For the acute injury – treatment may involve a more passive approach of soft tissue work, joint mobilization, Edema reduction, pain control. Working through pain will not only run the risk of further flare up but also inhibit surrounding structures from optimal performance (think about hitting your thumb with a hammer, how hard is it to make a fist after that?) , Additionally, it also further sacrifices the already injured area-creating damage that may or may not be repairable.
On the flip side, for the patient with chronic foot pain, irritation and inflammation control may be less of a primary problem and a joint, tissue, or capsular mobility restriction may be more paramount in the problem list. It’s these patients who present to me when local injections for inflammation have failed or were limited in success. Often when pain has persisted, chronic inflammation creates significant tissue fibrosis that can be very limiting and create further limitations. The original inflammation that was present is no longer the pain generator for this patient. The treatment approach for this foot pain presentation may involve more aggressive tissue work and joint mobility drills as well as a home program heavy in self mobilization and tissue work.
Custom orthotics are often deemed as a solution to foot pain. And they can be. But I fear they are often over utilized. If you are a patient with severe foot and hip instability and you get an orthotic, you may address the foot problems, but the hip remains an issue and the problem will likely continue. From my perspective one needs to address all the problems up the kinetic chain prior to resorting to orthotics. When appropriate, they can really help. But often you find expensive orthotics are only correcting the heel and don’t form to the whole foot, instead stopping at ‘arch support ‘. If you are going to get orthotics, pay out the wazoo for them, you deserve to have the whole foot corrected, not just the heel or the arch. If you aren’t being told about forefoot correction – please ask for a second opinion.
Foot pain is variable and requires accurate diagnosis for proper treatment. When you have foot issues and have been through the gamut of foot treatments, you deserve to be evaluated by a professional who will take the time to assess your whole presentation, not just your foot.The are a multitude of treatments available, among which physical therapy is a significant part of and while orthotics may help, if they are fixing only part of the problem or not addressing the issue at all you deserve better care.