I was working as the Registrar in the Emergency Department of the Southend-on-Sea General Hospital in England, when one morning, I received a phone call from a local practitioner. He told me that his wife had slipped and sprained her ankle while descending the steps at home, and he wanted her ankle while descending the steps at home, and he wanted me to examine her. She came to my department with a limp. She was not able to put complete pressure on her affected foot. It was swollen and it appeared that she was in terrible pain. I examined her and then asked for an X-ray. The X-ray revealed no fracture in the foot and by looking at it, it appeared that nothing was abnormal. This was a simple case of a sprained ankle. When her husband arrived, I told him my findings and suggested that if I could manipulate her ankle joint, recovery would be fast. He agreed and I administered manipulative treatment to her foot. Following the manipulation, I strapped the foot for support and asked her to report back after three days. I was surprised when she walked in after three days without a limp. She had already taken off the strappings. The swelling had disappeared and she had no pain at all. Her happiness clearly indicated that she had never expected her foot to recover so fast. A recovery which could have taken three weeks and might have lasted as chronic pain and inconvenience for months or years, was completely cured.
The foot is an example of mechanical perfection. It bears the whole body weight and is often the site of pain, next in frequency only to backache. The following movements occur at the ankle joint:
- Upward movement of the foot called dorsiflexion.
- Downward movement of the foot called planter flexion
- Inward movement of the foot called inversion
- Outward movement of the foot called eversion
The ankle joint is classified as a hinge joint. The talus or ankle-bone wedged between the lateral malleolus (fibula) and medial malleolus (tibia) receives superimposed weight from the tibia. Dorsiflexion and planter flexion are major movements at the ankle joint. Eversion and inversion are negligible. Inversion and eversion movements are carried out mainly at foot joints or tarsal joints. These movements are better visualised by putting the foot firmly on the floor for bearing weight.
The arrangement of bones in the foot is such that it constitutes different arches in the foot. They are the medical arch, the lateral arch, and the transverse arches. The medial arch can be seen on the inner aspect of the foot while standing. It gives the foot a springing action and makes the foot more flexible and supple. The arches of the foot bear the weight of the whole body. Common causes of pain at the ankle joint and the foot are sprains, flat feet, bursitis of the sole, calcaneal spur and bad shoes.
A sprained ankle is one of the most common problems. It involves multiple joints in the foot and more than one ligament gets sprained. In due course one joint may recover, leaving chronic disability in another. This is the reason why many a time a sprained ankle does not heal completely and pain persists, which is not acute but enough to bother the individual and make a long walk uncomfortable.
In most cases the ankle gets sprained due to a sudden inward movement of the whole foot. All the bones of the foot do not return to their normal position after a sprain. Instead there is tautness in a particular ligament which does not heal and sometimes gets lengthened, causing chronic pain and making the ankle joint hypermobile in a particular direction. Manipulation of a sprained ankle helps the alignment of the foot bones and releases all the tension from the ligament. Recovery is spontaneous and complete. But many patients do not get this treatment and in its absence, suffer from a disability, a constant discomfort and nagging pain which reduces the ability of the foot to support the body, thereby reducing its suppleness. Sometimes deep massage done with the tip of the index finger or thumb on the aching ligament, for 10-15 minutes, 3-4 times a week, helps in complete recovery.
If the pain is acute and the ankle joint has considerable swelling, manipulation is not done for 2-3 days till the swelling has subsided substantially. When the swelling is slight, manipulation can be done. After manipulation, strapping is done to give the foot necessary support.
When the foot is sprained due to a sudden inward movement, after articulating and relaxing the muscles of the ankle joint, strapping is done in such a way as to maintain the foot in slight eversion. Keeping the foot in a bucketful of warm saline water, and moving the foot and ankle joint under water in all possible directions, helps to reduce the swelling faster and regain mobility. Trying to walk on the inner edge of foot is sometimes very helpful.
Chronic Case. An injured foot may face no problem while used for ordinary purposes, but may swell up and ache after vigorous and prolonged use. This means that a scar has been allowed to form in the process of incomplete healing. Treatment consists of manipulative rupture of the scar adhesions. This is a simple process and does not need any anaesthesia. One sharp twist articulating the foot, often accompanied by a crack, is enough to cure a patient completely in most cases.
This is a fairly common condition. The longitudinal arch of the foot is reduced. When a patient stands, the inner border of the foot is in contact with the ground. A flat foot is usually associated with a slight outward twisting of the foot. Sometimes it is hereditary or due to muscle weakness; at other times, there is no apparent cause.
All children have flat feet at the age of one to two years when they start to stand. Sometimes this deformity persists in adult life. Many children with flat feet do not complain of any pain but the shoes persistently bulge inwards and the heels wear off more quickly on the inner side. Some adults may have no symptom. A few experience an ache after walking. Manipulation helps a lot in a painful flat foot, but often has to be repeated every week for a couple of months. Alteration in shoes also helps in such cases.
The shoe should be tilted slightly on the outer side by inserting a wedge base medially in-between the layer of the heel (not the sole). This helps the inner twist and reduces the bulging of the shoes. In older children and adults, a few exercises are advised to strengthen the foot muscles. They are as follows:
- Walking on the outer border of the foot.
- Trying to lift glass balls from the ground with the help of the toes and the forefoot.
- Spreading out a small towel on the ground and trying to pull it near the foot with the help of the forefoot and toes.
Fascitis and Calcaneal Spur
Many patients complain of pain in the sole or the heel when walking and standing; they do not feel any pain while sitting and lying down. The pain is more severe when the patient gets up in the morning and puts his feet on the ground. He feels a little better after moving around for a while. While standing, the shape of the foot is maintained partly by the muscles. When the patient stands for a long period, however, this tires the muscles of the feet and they are not able to carry the burden of weight and soon become painful. On examination, the feet appear to be normal. But when deep pressure is applied by the fingers, they may feel tender at the inner aspect of the sole and the heel.
Continuous overstrain on the fascia (a thin sheet of fibrous tissue) may cause it to be pulled away from its origin at the heel or calcaneum. Periosteum being the outermost covering of the bone, a gap is formed which gets filled up with new bone formation often termed as a calcaneun spur.
A calcanean spur may occur without any pain in some patients, while many patients complain of pain without any spur formation. Once the spur is formed, it is permanent and even after the pain is completely cured, the spur remains.
Manipulation of feet is helpful. This may have to be repeated a number of times at weekly intervals depending upon the severity of the pain. Wearing a specially designed shoe where the heel and forefoot are brought nearer, thus relaxing the fascia of the sole, may provide relief. The heel is raised keeping its upper surface horizontal. The height of the heel is determined by asking the patient to stand on a wooden platform with varying levels of thickness, until the minimum height of the heel that removes the symptom is found. A correct-sized heel provides immediate relief. Now the short flexor muscles of the sole are energetically treated with exercise and deep friction. Manipulation is of the greatest advantage as it secures mobility in different joints of the foot.
Footwear can be a cause of pain in the feet. Shoes must be selected considering the weight distribution and mechanism of the feet. Badly designed, shoes not only hurt for a while, but become a cause of constant pain. Ladies’ shoes with high heels and pointed toes are particularly to be blamed.
- A 39-year-old man, doing business in tyres, jumped from a height of six feet while drunk. He fractured three bones in his right ankle and had to use a plaster for three months following manipulation under general anaesthesia. After the removal of the plaster, an X-ray was taken once again; it showed a complete union of the bones. But the pain persisted after the removal of the plaster. Even a little walking would cause swelling and pain. The patient consulted a few orthopaedic surgeons. One of them advised an operation and fusion of the bones; others were against such an operation. The patient was not able to sleep and began taking pain relieving and sleeping pills. He was frustrated because he was unable to look after his business properly. He then came to me. After articulation and manipulation of the ankle, strappings were applied to give support to the joint. In three months he was ninety-five percent fit and could walk without getting any swelling or pain. He went about his business and daily routine without much difficulty.