Foot pain can be one of the most debilitating types of pain and discomfort for both the average individual and the athlete alike. To put it simply, when your feet hurt, everything hurts. The foot is essentially the foundation of the body; it is the first thing to touch the floor each morning and the last thing to leave the floor each night. Therefore, if the foot isn’t feeling or functioning its best, then the rest of the body is likely to suffer as well. Hawke and Burnes (2009) suggested that foot pain affects up to 42% of the population at any given time. They continue that foot pain is defined as an unpleasant sensory and emotional experience following perceived damage to any tissue below the ankle.
One of the most common sites for foot pain is the arch or mid foot, followed closely by the ball of the foot, and then the heel. Furthermore, foot pain is associated with reduced functional ability, including self-care, increased risk of falls, depression, and reduced physical and mental aspects of quality of life (Hawke & Burnes, 2009).
Overuse Injury
Most foot pain is due to musculoskeletal overload or overuse. As Hawke and Burnes (2009) stated “many common types of foot pain are primarily attributed to stress that exceeds the maximal tissue threshold, which is frequently experienced in long duration, low magnitude stress or repetitive moderate-magnitude stress.” Thus, when the stresses on the foot exceed what they are accustomed to, then the chances of an overuse injury greatly increases.
During the holidays many people begin traversing the shopping mall, strolling to view holiday lights, participating in holiday parties (think dancing in unforgiving shoes!), and many other activities that overload what the foot considers normal. The body is an adaptable organism that, if given time, will evolve to handle the new stress. However, given the rushed and progressive nature of the holidays, the tissues of the foot rarely have time to strengthen enough to handle the abuse.
Relationship to Weakness
Foot pain in itself is not inevitable and is not entirely due to spending a few more unexpected hours on your feet. Latey et al. (2017) identified a significant relationship between foot pain and foot muscle weakness. In a review of several studies, the authors found that plantar fasciitis and heel pain were associated with toe flexor weakness. These findings suggested that if muscle weakness is a precursor to foot pain, then more progressive resistance training and other foot exercises might be effective.
It should be noted that foot pain is not isolated to foot muscle weakness; other muscles up the kinetic chain also play a powerful role in the stresses placed on the foot. Friel, McLean, Myers, and Caceres (2006) suggested that the gluteus medius functions to decelerate pronation at the subtalar joint upon heel strike when walking and running. In the cases of excessive pronation or pronation that occurs too quickly, overloading the plantar fascia, the glutes may be weak.
In addition, Shirey et al. (2012) indicated that core muscle function is imperative for optimizing stabilization at the knee. We can infer from these findings that if a weak core is associated with knee pain then a weak core may also have a negative impact on the stresses placed on the foot.
Furthermore, while foot muscle weakness is an important consideration and strengthening should be implemented, if the glutes and core are neglected then you can perform foot strengthening exercises until you’re blue in the face and it may not reduce the excessive tissue stress and chances of injuries.
Therefore, a comprehensive foot pain prevention/reduction program would include flexibility, activation, and strengthening for the entire lower body and the core.
Prevention Process
Plantar fasciitis is one of the most common reported painful conditions of the foot. In a survey of more than 500 physical therapists, all said that plantar fasciitis was the most commonly treated painful foot condition (Martin, et al., 2014). There are more than 2 million new cases of the condition per year and at any given time it affects as much as 10% of the U.S. population. Martin et al. (2014) suggested that decreased dorsiflexion range of motion and high body mass index were the two leading risk factors for plantar fasciitis.
The researchers also found that calve and hamstring tightness, as well as excessively pronated feet, were associated with the condition. Thus, a program should address these in an attempt to rectify plantar fasciitis. Clinicians suggest a multifaceted approach to treating plantar fasciitis:
- Soft tissue massage to the soleus and gastrocnemius
- Calf stretching to improve dorsiflexion range of motion
- Joint mobilization to the talo-crurual and subtalar joints as necessary
- Strengthening of the foot and hip muscles (Martin et al., 2014).
You may be thinking that the above approach looks very familiar as it follows almost the same progression as the NASM Corrective Exercise (CEx) model. NASM CEx uses the following four-step process when seeking to improve overall movement patterns or to prevent injuries:
- Inhibit overactive musculature through self-myofascial release (foam rolling)
- Lengthen shortened tissue through static stretching
- Activate underactive musculature through isolated activation exercises (a form of low-threshold strengthening)
- Integrate by using total body movement patterns to improve motor control and coordination (NASM, 2014).
As you can see, there are two distinct differences between the approaches. First, joint mobilization techniques are outside of the scope of a personal trainer. Thus, they are not included in NASM’s corrective exercise recommendations.
However, clients can choose to perform joint mobilizations on themselves if they would like. Another difference is that Martin et al. did not list integrating total body movement patterns after the isolated strengthening. While many great physical therapists do perform this, it is often times overlooked.
However, it is important to note that isolated strengthening alone rarely leads to improved performance. Thus, it is imperative to include total body movements to essentially re-teach the nervous system how to move properly, reducing the excessive stress on select tissues.
Identify Dysfunctional Movement
As underlined in the NASM-CES Course, before trying to fix a problem it’s important to identify the root cause of the problem. In many cases, movement is the key to identifying underlying causes of pain and dysfunction.
This is indeed true for foot pain. The overhead squat is a great assessment that provides valid information about total body flexibility, coordination and strength. There are several movement impairments that may relate to foot dysfunction. Beginning at the foot and ankle complex, an individual may demonstrate feet flattening or feet externally rotating during the squat (figure 1).
When either of these occur, it indicates that excessive and unnecessary stress may be placed on the supportive structures and tissues of the foot.
<Figure 1>
Many foot impairments are directly related to foot dysfunction, however, many are not. Knee adduction during the squat (figure 2) may also be related to foot pain. When the knees adduct, it can easily overload the medial structures of the foot, such as the plantar fascia that supports the medial longitudinal arch.
Thus, if an individual is continuously demonstrating knee adduction during walking, climbing stairs, and squatting it can contribute to plantar fasciitis. Furthermore, knee adduction may indicate that the glutes are not firing quick enough or are not strong enough to stabilize the knee. As was mentioned above, non-optimal gluteus medius function could be a prime contributor to foot pain.
<Figure 2>
Programs
The above compensations may occur independently or simultaneously. It is not uncommon for an individual to demonstrate knee adduction solely because the feet flatten. Or the reverse, an individual may demonstrate feet flattening because the knees move in. Below are sample programs that may be utilized for individuals according to their compensations. Each program will include foam rolling, stretching, isolated activation exercises, followed by total body integration.
It is important to point out a few key factors. First, it is not recommended to use deep aggressive rolling on the bottom of the foot in cases of medically diagnosed plantar fasciitis. Plantar fasciitis indicates that the plantar fascia is irritated. Thus, there is no need to roll aggressively irritating it more. However, some light rolling on the bottom of the foot, with minimal pressure or a soft roller, is great to help encourage circulation and to simply massage the foot.
In this case, roll slowly through the bottom of the foot for 60-90 seconds. In cases of foot pain not diagnosed as plantar fasciitis, it may be acceptable to roll on a harder or smaller roller or with more pressure. In this case, a smaller roller is great to massage the bottom of the foot and to encourage movement of the muscles (and even bones) of a foot that has been stuck in a shoe for hours. On this note, some rolling of the bottom of the foot can be great to perform several times per day when spending hours shopping/walking through a crowded mall, simply to keep things moving and to kindle the sensory environment of the foot.
From the programs below, choose what best fits the compensation and repeat it every day before activity (even if the activity is heading out to spend the day with family). If there are multiple compensations then choose the one that is most apparent to be the primary, then second most apparent to be the secondary, etc. With multiple compensations, the programs can be rotated throughout the week.
Program 1: Feet Flatten
SMR—hold tender spots for 30-60 seconds
- Plantar fascia
- Peroneals
- Calves
Static Stretching—hold first point of tension for 30-45 seconds
- Standing calf stretch
- Peroneal stretch
Activation—perform 12-20 repetitions
- Towel scrunch
- Posterior tibialis
Integration—perform 12-20 repetitions with perfect form
- Single-leg balance with reach
Program 2: Feet Turn Out
SMR—hold tender spots for 30-60 seconds
- Calves
- Short head of the biceps femoris
Static Stretching—hold first point of tension for 30-45 seconds
- Standing calve stretch
- Supine biceps femoris stretch
Activation—perform 12-20 repetitions
- Calf raise with internal rotation
- Tibial internal rotation with band
Integration—perform 12-20 repetitions with perfect form
- Box step-up to balance
Program 3: Knee Adduction
SMR—hold tender spots for 30-60 seconds
- Adductors
- TFL
Static Stretching—hold first point of tension for 30-45 seconds
- Standing adductor stretch
- ½ kneeling hip flexor stretch
Activation—perform 12-20 repetitions. Hold plank for 10 “reps” of 10 second holds.
- Side-lying wall slide
- Stability glute bridge
- Prone Iso-ab/Plank
Integration—perform 12-20 repetitions with perfect form
- Lateral tube walking
References
Clark, M. A., Lucett, S. C., & Sutton, B. G. (Eds.). (2014). NASM essentials of corrective exercise training (1st ed.). Burlington, MA: Jones & Barlett Learning.
Friel, K., McLean, N., Myers, C., & Caceres, M. (2006). Ipsilateral hip abductor weakness after inversion ankle sprain. Journal of Athletic Training, 41(1), 74-78.
Hawke, F., & Burns, J. (2009). Understanding the nature and mechanism of foot pain. Journal of Foot and Ankle Research, 14(2), 1-8.
Latey, P. J., Burns, J., Hiller, C. E., & Nightingale, E. J. (2017). Relationship between foot pain, muscle strength and size: A systematic review. Physiotherapy, 103, 13-20.
Martin, R. L., Davenport, T. E., Reischl, S. F., McPoil, T. G., Matheson, J. W., Wukich, D. K., & McDonough, C. M. (2014). Heel pain—plantar fasciitis: Revision. Journal of Orthopaedic & Sports Physical Therapy, 44(11), A1-33.
Shirey, M., Huributt, M., Johansen, N., King, G. W., Wilkinson, S. G., & Hoover, D. L. (2012). The influence of core musculature engagement on hip and knee kinematics in women during a single leg squat. International Journal of Sports Physical Therapy, 7(1), 1-12.
