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Poor Unfortunate Soles, Part 1: The Foot
Me: The only way to get comfy feet … is to get comfy shoes yourself.
Customer: You can do that?
Me: My dear, sweet child, that’s what I do. It’s what I live for. To help unfortunate soles like yourself.
Yes, I am a shoe expert who is happy to help you find the perfect shoe. (Well, shoes. You really need at least two to rotate between, but I’m getting ahead of myself.) But lest we find ourselves like mice knowing the ultimate answer to life, the universe, and everything is 42 without knowing the question being asked, you cannot find the perfect shoe without knowing your foot and its needs.
Let’s start with the bones.
A couple things I want you to note here: first, there are a lot of bones. While the foot seems pretty solid and inflexible, it is so because of strong ligaments and tendons, not a solid skeletal structure. Note that the biggest bone is the calcaneus or heel bone, and that it has a rather odd shape compared to the overlying skin. That large apparent backward protrusion is actually the anchor for two important connective tissues: the Achilles tendon going up the leg and the plantar fascia that goes along the underside of the foot. The “ball” of the foot is where the five metatarsal bones meet up with their corresponding phalanges, and the first metatarsal/phalange joint is known as the hallux. This is a major trouble spot. If the joint cannot bend in the walking process, one’s walking pattern will adjust, and the adjustment is normally to start rolling over the side of the big toe. This pushes the second big toe phalange into the other toes and the first phalange out the side of the foot. The protrusion it makes is what we call a bunion.
Let’s move to the nerves of the foot.
The big thing to note here is that if you scroll between this picture and the bones one, you’ll note that at the ball of the foot, the nerves actually run between the metatarsal bones. A shoe that is too narrow in the ball of the foot can cause the bones to pinch and aggravate those nerves, causing shooting pains, tingling, and numbness in the toes. (Proper name: metatarsalgia) The nerve between the third and fourth toes is so commonly aggravated it has its name: a Morton’s neuroma. (Quick and easy diagnostic tool for this ailment: lean in close to the foot. Push the third toe up and the fourth toe down, then alternate. If the bones are rubbing against each other enough to cause a neuroma, you’ll often be able to hear them click together as you manipulate the toes.)
Let’s add some connective tissue. This is a lateral (or outside looking towards center) view of the right ankle.
The picture shows all the different connections (and you can see how incredibly complex the foot is), but two tendons are noteworthy for their common problems: the calcaneal (or Achilles) tendon going from the back of the calcaneus up and the Fibularis (or peroneus) short tendon that connects the fibia to the fifth met. The Achilles tendon has two common issues: if the tendon is very tight, a shoe with no or even a negative heel will cause tendonitis, and if the back of a shoe is too tight, it can pinch, blister, or otherwise damage the tendon. The Fibularis tendon can be stretched if the foot is rolling out when one walks (a process called supination) or pinch if a shoe is too narrow.
For the king of foot problems, though, we have to go to the fascia. Fascia is the webbing under your skin that holds everything in place, and the plantar fascia on the bottoms of the feet is the cause of probably 75% or more of foot problems.
Quick note on terminology: “plantar” refers to the bottom of the foot. The suffix “-itis” means swelling. Thus, “plantar fasciitis” means nothing more than “swelling of the fascia on the bottom of the foot.” The main symptom is pain at the base of the heel where the plantar fascia meets the calcaneus, most prominently during the first few steps in the morning. Why? Well, the fascia has some small amount of elasticity, and all night long, it is unstressed. When one stands up in the morning, it is stretched, but it resists. In fact, it tears, and that is the pain one feels. As one walks around more, the fascia warms up, relaxes, and is better able to stretch with one’s movements. However, if left unchecked, the body will create its own solution to keep the fascia from tearing — it’ll just grow bone spurs to extend the calcaneus to meet the short fascia.
I would be remiss if I didn’t talk about another big cause of foot problems, though one that doesn’t start with the foot: diabetes. High blood sugar can damage and eventually kill nerves, and the nerves of the foot are often the first affected. Neuropathy generally starts with tingling in the foot and can lead to numbness or even complete loss of sensation, with all the problems that affect lepers.
Over the course of several posts, I’ll talk about how different shoes will help various different problems, but I also have some handy pain relief and foot health tips that require no shoe purchases at all. Really.
- Cool water foot baths. Whether you’re dealing with plantar fasciitis, tendonitis, or neuromas, the single best thing to take down the swelling is cold. If you read plantar fasciitis advice, everyone has a variation on this recommendation: rest frozen peas on your foot! Roll a frozen water bottle on the floor! I recommend just a cold water bath for a couple reasons. First, it’s much easier to keep your feet in cold tap water for ten minutes than tough out the pain of the ice; after all, nothing is less effective than therapy you don’t do. With cold water, you don’t have to worry about frost burns. Immersing your foot in water both increasing the surface area of your foot being exposed to the cold for better results, and more water means that it can trap more heat from your feet. You can use a fancy foot bath or just sit on the kitchen counter and let your feet soak in the stopped up sink.
- For ball of the foot pain (metatarsalgia) or neuroma: buy a set of pedicure toe spacers (<$2). While sitting or sleeping, wear them. This will gently pull the heads of the metatarsal bones apart and relieve the pressure on the nerves.
- For plantar fasciitis, stretching. Everyone again has their own version of this. (pull against a belt! write the alphabet with your toes!) I recommend a simple one, on the basis again that minimal compliance is always better than noncompliance. Before you take your first steps in the morning, sit up on the bed. With both feet, point your toes down. Slowly draw a circle with your toes so that at the top, your heel is pointing out and your toe is pointing towards you as much as possible. Then slowly finish the circle. Do this several times before you stand up. I like this stretch because it warms up not only the plantar fascia, but also the Achilles and all those other tendons shown above.
- On the subject of stretching, another good one for foot and leg health is to rest the bare foot against the modesty panel on your desk as close to straight out as you can get. Then try to sit up straight. If you’re like me, you’ll feel the stretch in your calves, thighs, and lower back, and as you get better about it, you’ll notice less sciatic pain.
Join me next time as I move from feet to the most important part of the perfect shoe: the perfect fit.
This series was inspired by @westernchauvinist here.
Part 2 has been posted here.
Published in Healthcare
Ever see ballerina feet? (Gag Warning)
Thank you for this post. Looking forward to more about feet. I rarely wear shoes in the house. I have balance problems and use my toes to help with grip and keep me oriented to the floor. However, some weeks ago I slammed my left foot into the support bar of an exercise machine. Left me with a broken fourth toe and a badly bruised third one. My PT told me to stretch and rotate my feet the way you described before getting out of bed.
Woot! Thanks Amy!! Well done!
I just love Frank Netter’s drawings.
I developed some plantar fasciitis from riding horses. I don’t have a lot of natural heels-down flexibility, so sometimes one foot really hurts, especially in the morning like you say. I find using KT tape for several days to be very helpful.
I’m looking forward to your perfect fit…though I dont know that it will help me…I have such a small foot that finding shoes in my size is always a challenge (and children’s sizes are just wrong, anatomy-wise). I am always about comfort and support. Nothing ruins your day faster than sore feet.
Now that is just wrong. I danced for many years and never had problems. Talk about ill-fitting shoes. When you develop proper foot strength, wear pointe shoes that are correct for your foot and protect your toes with lambswool you will never have these issues. Sheesh.
Hey! How did you know I had that problem???
How much of a problem is it if my foot starts growing extra bone?
My Kaylett was into ballet and was taught early on how to care for her feet. She went from ballet to horses and she still has beautiful feet. And she can wear Stilettos.
Also, you’re seriously saying it’s getting more tears every day?
Oh, my poor left foot!
Here’s a tip: Before you start going to work at your new job in Hong Kong, GET BETTER SHOES!
Fascinating post. Thank you so much.
I broke my ankle years ago, and the orthopedic guy told me that the tendon at the spot where the bone broke was actually stronger than the bone it was connected to and that it was actually the tendon that pulled on and broke the bone. I never knew what he meant. Now I think I do. :-)
I’m looking forward to the rest of the posts.
About two years ago, I developed a pain in my left heel when running. Went to the foot doctor. “Haglunds Deformity, my lad, time to cut!” But my other foot doesn’t hurt a bit, I said. It will someday, he replied. I decided to wait, but the pain didn’t go away so just after Christmas I let him invade my body and cut off the top of my heel bone. Dumbest decision I ever made.
For some reason this weakened my heel bone and it cracked. I had a broken heel bone in addition to whatever my original problem might be. And in the course of trying to heal my heel over the next few months I developed all sorts of tendonitis and fasciitis of different sorts.
And I still have my original problem. I think. I’ve had so much pain and soreness on every part of my heel for so long, I can scarcely tell one day from the next where the pain is or was. We’re working through it, and maybe before I die I will be able to run again.
I think if I ever can run again, I will run every day for the rest of my life because this bothers me a lot.
I think medical science is sometimes more accurately described as just guessing, because that’s certainly what my experience has been with my foot.
What a fantastic anatomy and physiology lesson!
I love my feet (narrow size 9s), and almost always wear Haflinger wool clogs in the house and Crocs or Danskos outside. Crocs is summer, Danskos is the rest of the year.
My neurologist was trying to tell me that my neck joint degeneration is due to me not wearing Danskins. I held up my shod foot and said, “I think you mean Danskos.” No, no, little woman, the doctor said Danskins!
So now I have a note in my medical files from my neurologist suggesting I wear Danskins or Sketchers.
Danskins makes leotards and other dance clothing.
I will not be trading in my Danskos or Crocs or Haflingers.
A medical degree does not a smart mind make…
Very informative post. Looking forward to the rest of the series.
Nowhere close to the ugliest feet I’ve seen. They all have ten toes and ten toenails, for starters.
It’s a problem, but not an unsolvable one. If you do the cold treatment and stretches and wear good arch support as much as possible (I’ve even sold waterproof orthotic flip flops so sufferers can wear them in the shower, and I have a whole post coming about orthotics alone), the fascia will heal and the body will start reabsorbing the spurs.
My first bout with it was at 19, and all I knew was that my three inch heels were the most comfortable shoes I had first thing in the morning. Elevating the heel reduces the stretching of the fascia. Of course, my heels were a half size too short and pinched my metatarsals and toes terribly, so after about three hours I’d switch to flats that aggravated the fascia.
Darn it Amy. Now I have that song stuck in my head again!! Therefore I must inflict it upon everyone else.
I wish this story surprised me, but I’ve heard far too many stories of foot surgeries that cause complications without resolving the original complaint. I won’t accuse podiatrists of being ignorantly cut happy, but I don’t think they get nearly enough education on non – surgical treatments, and well, when you’re a specialist who gets paid to hammer, everything looks like a nail.
I’m very conservative when it comes to podiatric surgery. Most foot problems are caused by bad walking mechanics, so surgery to remove the consequences (like bunion removal) that isn’t done in conjunction with changing those mechanics is likely to be a short term solution at best — like a liposuction without changing one’s diet. Second, given how far the feet are from the heart, they heal very slowly, which makes reinjuring the wound almost inevitable.
I won’t deny that surgery can be a life saver; I just don’t recommend it until the likely problems are less scary than the current problems.
Oh, man, after the stories I’ve heard, there’s no way I’m letting those guys come at me with a scalpel. I’ve refused injections, too, although I have been seeing an acupuncturist who seems to be doing something for the fasciitis.
So, I did your recommended fascia warm-up this morning and it seemed to help. I’ve not tried the cold foot baths yet, but I’m wondering how long, how cold, and how often?
Uh, how many jobs do you have?
Dude, my prayers for you – that sucks.
How long have you been enduring it?
Unexpected convergence of seemingly random areas of expertise–it’s one of the finest things about Ricochet.
Cold water from the tap is fine. I find most of the benefits happen in the first 5 – 10 minutes, and doing it every night for a week or so did wonders for me. I’ve been fasciitis free for years now, but I’ll still do a foot bath at the end of a long walking day (like a convention) to help with all kinds of foot pains.
At the moment, one — doc review. But I sold shoes during undergrad, in my gap year before law school, and for four years after I graduated law school. Had I the opportunity to redo my 20s, I would skip law school and become a certified pedorthist.
We’re traveling for the next couple weeks. Do you suppose packing a couple zip-lock bags to stick your feet in would work in place of a basin? I’m trying to pack light.
It is one of the great Disney songs of all time.
Honestly, I’d just keep the hotel bathroom counter clear and soak them in the sink, or fill the tub and sit on the rim.
Ever see a LesFranc fracture?
I had to come out from the sidelines and comment on this one!
I apparently developed Insertional Achilles Tendonitis that went untreated (despite Dr. visits). This led to developing bone spurs at the back of my heels. One spur has been inflamed for a couple of years. The podiatrist who diagnosed me recommended against surgery, as the potential complications involved in removing/reattaching one Achilles tendon are unpleasant.
I don’t have pain as long as I wear shoes that are backless and have a wedge heel at least an inch high. As one might imagine, this limits my footwear. I really dislike doing yardwork in Crocs sandals (regular Crocs don’t have a heel.) Thank goodness I live in FL, because sandals are the main type of shoes that meet this category. I also take Alleve daily. Mornings are rough, since my Achilles tendon is really tight when I get out of bed in the morning.
It slowly seems to be improving, and I’ve been considering trying to find a shoe with a soft back I can wear. I try to do heel lifts, because I read that they are better than the runner’s stretches for alleviating inflammation.
Any advice for me?
Two years. But it’s not a constant pain. It only hurts if I run. Normal walking doesn’t bother me. So, no tears for me. I’m just getting fat.