The Foot Joints – Part Two
Our modern habit of confining our feet into the prisons of our shoes may be partly responsible for some of the problems we face. Our feet have evolved to manage the changing levels and types of surfaces as the toes grip the ground and reinforce the arches. With the universal use of shoes almost all of the time we have given our feet a much reduced role and they do not have to be able to manage the ground surface, being given a smooth firm plastic or leather one instead. The small intrinsic foot muscles weaken and lose function as they are deprived of their natural job, reducing the foot\’s effectiveness.
With the increasing weakness of the intrinsic muscles of the foot comes a reduction in the function of the foot arches and the toes, which find themselves unable to grip the ground effectively. The toes adopt a bent posture known as clawing and this can progress to a complementary shortening of the toe extensors. This moves the pads away from any weight bearing situation in front of the foot and draws them up, pressing them against the top of a shoe or forcing them to bear weight on the tips. Accompanying arch height reduction reduces function further.
As the inside and long ways arch loses height, perhaps connected to the tendency to roll the foot inwards excessively in walking, the tissues under the arch become strained as they are put under tension stretch. This can cause pain and aching with time on the feet such as standing or walking for a while. The smaller front arch across the foot can also give problems if it loses some of its strength and tension. This allows the underneath of the head of the second metatarsal to contact the ground and take body weight pressure, a job it is not designed to do.
The second metatarsal does not have a great degree of fatty padding underneath it so it does not suit the job of bearing the weight whilst walking or standing, with patients often reporting they feel they have a stone under the forefoot. Areas of hard skin known as calluses can develop over these areas and show where abnormal weight is being taken. The weight of the body can be thrown forward onto the fronts of the feet by wearing high heels and the ability to push off with the toes can be compromised by the narrow fronts of the shoes.
Another abnormality which might develop is a bunion, an enlarged and often unsightly joint between the big toe and the first metatarsal. This can be something which is familial to some degree as many patients report their relatives are similar to them. As the joint enlarges it can become painful and the big toe deviates gradually towards the outside. Along with the loss of the strength of the foot arches this turns the foot from a dynamic movement tool to a static platform which is difficult and often painful to use.
The relationship between the big toe joint and the first metatarsal is not the whole determinant of a bunion problem, as the first metatarsal is typically angled towards the inside and this makes the abnormality worse. Orthopaedic surgeons can approach these problems with a number of operations with differing goals, the first metatarsal osteotomy being a common intervention to restore the natural alignment between it and the big toe. Day case surgery has taken over from overnight admission or longer in cases where the patient can learn to mobilise quickly either weight bearing on the heel or hopping and if the pain can be well controlled.
Physiotherapists who specialise in the area of foot assessment and subsequent treatment manage many of the less severe foot disorders due to abnormal foot postures. This needs specific training in the assessment and the use of the large variety of pre-formed insoles, typically called orthotics, to correct the postures of the hind foot or to give support to the arches of the foot. Exercises are often prescribed at the same time to attempt to restore strength and function in the intrinsic muscles which maintain the foot arches.
Jonathan Blood Smyth, editor of the Physiotherapy Site, writes articles about physiotherapy, physiotherapy, physiotherapists in Haywards Heath, back pain, orthopaedic conditions, neck pain and injury management. Jonathan is a superintendant physiotherapist at an NHS hospital in the South-West of the UK.
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