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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.
Sprained
Ankle
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.
Treatment
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.
Flat
Foot
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.
Treatment
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.
Selecting
Shoes
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.
Case
History
- 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.
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