Did you know that pain in the ball of the foot may be due to an inability to fully bend your ankle joint? Did you also know that the type of shoes that you wear (i.e. high heels) may be at the root of the cause of the pain? Don’t despair. There are some simple exercises that may help to relieve the pain in the ball of the foot.
Pain-free walking requires the precise integration of numerous joints, muscles, tendons and ligaments. One of the most critical and complex joints involved this process is the ankle joint. The ankle joint is required to bend the foot downward, toward the floor, (plantar flexion), upward toward your head (dorsiflexion), rotate inward (inversion) and outward (eversion). For this discussion we are going to focus on problems caused by the limitation of ankle joint dorsiflexion during walking.
Inability to fully dorsiflex the foot results in a condition referred to as ankle equinus. It is called equinus from the term equine which refers to a horse. I am not implying that a person with ankle joint equinus has a hoof. However if you notice a horse’s hoof, the front of the foot points in a downward direction; it appears to be plantar flexed (pointed down toward the floor). The person with ankle joint equinus may appear to have a plantar flexed foot and may have a tendency to walk more on their toes.
Rarely, ankle equine is caused by a piece of bone from an old fracture blocking the proper motion of the ankle or by a congenitally short Achilles tendon that prevents full dorsiflexion of the ankle. Ankle joint equinus may also be caused by arthritis that results in deformity of the bones of the joint that interferes with the full dorsiflexion of the joint. Most commonly ankle joint equinus is caused by tight calf muscles. If the calf muscles are too tight the ankle is not able to fully dorsiflex the ankle.
Spending too much of your day in high heels can result in tight calf muscles and subsequently ankle joint equinus. The body adapts to the demands that are placed upon it. If you wear high heels the distance between the heel and knee is decreased and the calf muscles will contract in order to compensate for this shorter distance. Then when you put on your flatter shoes and try to walk the tight calf muscles interferes with the ability of the ankle joint to function as it should to provide pain-free walking.
The person with ankle equinus has a tendency to walk on the ball off the foot. They have difficulty keeping the heel on the ground as they walk and raise the heel off the ground early in the step cycle. Ankle joint equinus causes the normal biomechanics of walking to get all screwed-up. When humans have biomechanical problems that interfere with the normal biomechanics of walking they compensate. People with equinus compensate by walking on their toes. They may lift up their heel early in the step that makes them appear as if they are bouncing along as they walk. They may compensate by flattening out their arch in order to take some of the load off the front of the foot. Sometimes they turn their feet to the outside as they walk and contact the ground with the inside part of the heel. All of these compensations disrupt the normal biomechanics of walking. When the biomechanics is disrupted the joints are not loaded as they should, the muscles, tendons and ligaments are strained. Strained muscles, tendons and ligaments cause pain.
People with equinus deformity may experience pain in the ball of the foot because they tend to toe walk and overload the front of the foot. They may develop pain in the mid foot from compensating by flattening out the foot and overstretching the plantar fascia, the may develop heel pain by the tight Achilles pulling the at its insertion point on the heel.
In order to properly treat the pain associated with equinus it is first necessary to determine the cause. Obviously if the problem is due to a piece of fractured bone blocking motion at the ankle joint or a congenitally short Achilles tendon, this would require an evaluation by an orthopedist for possible surgery. However if the ankle equinus is caused by tightness of the calf muscles, which is often the case, this can usually be treated conservatively.
The goal of treatment for someone with tight calf muscles is to first reduce the strain in the calf muscles and bring the floor up to meet the heel. This is usually accomplished with a heel lift inside the shoe that is used temporarily as the calf muscles are slowly being stretched through exercises. The patient may also require a custom orthotic to support the arch. The orthotic may incorporate what is called a metatarsal pad that fits just behind the heads of metatarsal bones (long bones of the foot) to take the load off of the ball of the foot. The long term treatment however involves stretching exercises and making sure the patient is placed into appropriate footwear. In addition your doctor may prescribe what is called a dorsal night splint which holds the foot in a dorsiflexed position as you sleep to facilitate stretching of the calf muscles. Let me describe some simple techniques that are used to stretch the two main calf muscles, the soleus (sole-ee-us) and the gastrocnemius (gas-trock-knee-me-us).
To stretch the gastrocnemius muscle you stand facing the wall with your feet about 12 inches from the wall. Step back about 6 inches with one leg. Then while keeping your rear knee straight, your forward knee slightly bent, your back straight and both heels on the floor, lean into the wall. When you feel the muscle start to stretch hold the position for 10 seconds. Do this stretch ten times in a row for each foot and repeat 3 times per day.
To stretch the soleus muscle stand facing the wall as described above for stretching the gastrocnemius with one foot further back. However this time squat down as if in a seated position while keeping your hands on the wall for balance. When you start to feel the muscle stretch as you lean toward the wall, hold the position for 10 seconds. Do this stretch ten times in a row for each foot and repeat 3 times per day.
These stretching exercises together with a temporary heel lift and possibly a dorsal night splint will reduce the pain in the ball of the foot as our biomechanics improve. If however these measures do not improve your symptoms you may want to consider a custom foot orthotic.
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