Chiropractic care is practiced worldwide and is recognized as a valid and effective form of treatment for various ailments. However, global utilization of chiropractic care for foot and ankle pain is seemingly limited. The foot serves as a complex force mediator between the body and the ground during weight-bearing activities, and the ankle, with its unique structure, allows a wide range of movement, making it susceptible to a myriad of tissue injuries and degenerative disorders. Despite this knowledge, the healthcare community lacks consensus on how to best treat lower extremity ailments and often defers to traditional treatments such as medication, injections, and surgery. Many of the current conservative treatment options have limitations and side effects and can often be costly. This has paved the way for a paradigm shift towards alternative treatments, one being chiropractic care.

Understanding Foot and Ankle Pain

The foot and ankle complex consists of 26 bones, 33 joints, and a myriad of muscles, tendons, and ligaments, to say nothing of blood vessels and nerves. The complex is designed to provide a stable, shock-absorbing platform from which to propel the body in any desired direction, over any type of terrain. The forefoot, midfoot, and rearfoot components work in unison to bear the body’s weight, absorb impact, and adapt to walking and running surface changes. When any part of the foot and ankle is not functioning in this harmonious manner, the rest of the body must compensate, often leading to adverse effects on other joints higher in the kinetic chain. Due to the fact that the foot is so far away from the heart, any loss of mobility of a specific foot joint will diminish the flow of the body’s life-giving blood to that joint. Without an adequate supply of blood, the cells in that joint will begin to degenerate, leading to an arthritic condition. Since the foot is such a mobile and adaptive structure, the gait cycle can often be a good indicator as to the mechanism of injury or cause of a specific condition. Understanding the cause of an injury to the foot or ankle is crucial in both treating the current pain and preventing a recurrence. Unfortunately, the mechanism of injury to the foot or ankle is often vague or forgotten by the person with the pain. A chain of events, it is often where the foot or ankle failed to perform its intended function at a specific point during the gait cycle that is the cause of the problem. The inability to perform this function could be from a traumatic injury or an overuse repetitive type injury. There are many reasons that a person may experience pain to the foot and ankle. It can be quite a daunting task to determine the cause of the pain, let alone to devise a treatment plan. Pain is the body’s method of indicating that there is something wrong and that it needs to be fixed. But not all pain has a simple solution. At times, the cause of the pain may be multifactorial and the comfort of the patient in the treatment of the cause will greatly depend on their personal beliefs and lifestyle.

Causes of Foot and Ankle Pain

Arthritis can also cause foot and ankle pain. There are many forms of arthritis; the most common form, osteoarthritis (“wear and tear” arthritis), can affect any joint in the body. In the foot, it often affects the big toe, causing stiffness and pain. Rheumatoid arthritis is a systemic disease that affects the joints throughout the body. It is symmetrical and can cause deformity of the joints of the foot and ankle. Gout is another form of arthritis that can also cause foot and ankle pain. It is a type of inflammatory arthritis that is caused by the crystallization of uric acid in the joint. The joint at the base of the big toe is affected most often in a gout attack. The best treatment is prevention with a diet low in uric acid, but a gout attack can also be treated with anti-inflammatory medication. An affected joint can also be aspirated or injected with medication. Sometimes the early stages of arthritis can actually be painless, with the pain coming later as the condition progresses.

Foot and ankle pain can be caused by traumatic injury or by structural changes in the foot. The most common traumatic injuries that cause foot and ankle pain are sprains and fractures. This occurs when the foot twists or rolls on an uneven surface. In the case of a sprained ankle, the patient will often hear or feel a “pop” and then have difficulty walking on the involved leg. This is due to the stretching or tearing of the ligaments. If the ligaments are not rehabilitated properly, chronic pain and instability of the ankle can result. A fracture of a bone in the ankle or foot will cause immediate pain, and the patient will not be able to bear weight on the affected area. It is important that fractures are diagnosed early, so they can be treated appropriately.

Common Foot and Ankle Conditions

Achilles Tendinopathy: This condition is characterized by a pain in the back of the leg along the Achilles tendon due to overuse. This can be caused by intense running or walking exercise and makes it difficult to continue with any of these activities. This can create continued pain and problems which may persist if not assessed and treated properly.

Plantar Fasciitis: This condition is an inflammation of the plantar fascia, a thin layer of tough tissue supporting the arch of the foot. This can cause an intense pain on the bottom of the feet and has the potential of creating chronic issues. This is often caused by wearing shoes with inadequate support, lack of stretching or exercise, high heels, or change in activities.

Flat Feet: As the name suggests, people with flat feet have little or no arch in their feet. This can cause an imbalance in the feet, leading to a greater impact on certain areas of the feet (i.e. overpronation) and lead to other chronic problems in the future.

Understand common foot and ankle conditions and their basic treatments can assist people who are suffering from these ailments. In broad terms, common foot and ankle problems are usually the result of an impact/stress, a wound, wearing too tight/loose shoes, or physiological changes due to aging. The most common conditions and their brief descriptions are as follows:

Chiropractic Approach to Foot and Ankle Pain

A comprehensive approach to the treatment of the foot and ankle by a Doctor of Chiropractic is necessary to ensure long-term success. Often, the foot may be the victim of various other conditions. For this reason, the DC must evaluate the alignment of the entire lower extremity – knee, hip, and pelvic alignment can have a direct effect on the mechanics of the foot. Correcting the alignment of the foot is key in ensuring proper mechanics. Custom-made orthotics can be an extremely beneficial treatment. Often, the so-called custom orthotic is simply a very expensive arch support. A true custom orthotic is designed to control abnormal motion. The use of a custom orthotic can be key in a complete resolution of numerous foot conditions. Manipulation of the foot and ankle itself can be successful in restoring proper function. In severe conditions or in the presence of arthritis, a referral to an orthopedic or podiatric specialist may be necessary. There have been numerous cases where patients have been advised to undergo corrective bunion surgery. The chiropractor is able to resolve the bunion through proper manipulation and the use of custom orthotics. This is a perfect example of a case where the MD diagnosis is correct, but the treatment is overly aggressive. An additional method of treatment that has shown to be very beneficial is the use of acupuncture. Thirty years of research in acupuncture has proven the existence of a neurological relationship between the body and “acupoints”. Utilization of local points can be very effective in normalizing the biomechanics of the foot and ankle.

Benefits of Chiropractic Care

The use of chiropractic care in patients suffering from foot and ankle pain is utilized to provide comfort and stability to those who are in need. Chiropractors use a vast array of techniques in order to pinpoint the source of pain and to effectively treat the patient. They believe that by correcting any functional disturbances, patients can have a higher quality of life with an increase in mobility and activity. By manipulating and adjusting any irregularities found in the feet and ankles, chiropractors can decrease inflammation and discomfort in these areas. This treatment prevents further damage and debilitation that can be caused by the body’s attempt to immobilize a painful area. Doing this will allow for a quicker recovery time with less time away from work or being taken out of activity. By treating foot and ankle pain, global foot function is improved and everything from knee to lower back pain can potentially be decreased. A study was even done by a podiatrist showing that custom orthotics made by chiropractors are effective in treating and preventing lower extremity pain in adults. 347 adults with lower extremity pain were randomized during a 12-week period and it was the end result that custom orthotics significantly improved the patient outcomes. As seen, there are multiple effective ways that chiropractic care can treat foot and ankle pain.

Techniques Used in Chiropractic Treatment

Soft tissue work can also be beneficial to sufferers. In a context where lower leg problems and foot pain persisted, a patient sought chiropractic care before looking into orthotics to correct the alignment in their feet. After treatment was administered to the lower leg and feet, the patient found that the original problem was resolved and there was no need for orthotic usage. Other types of soft tissue such as cross fibre frictions and myofascial release can be performed to relieve tension in muscles of the foot, ankle, or lower leg.

The techniques a chiropractor may use can greatly depend on your individual case and can range from slight adjustments to more involved taping, ultrasound, and stretching. One commonly used technique is manipulation. This is a higher success rate than medication usage, night splints, taping, or orthotics and much safer than corticosteroid injection or surgery. Another study reported that a patient received one adjustment to their ankle and a chiropractic extremity adjustment. After two sessions of the same treatment, their pain was completely gone. This is only one other case of many that have seen improvement or resolution of symptoms of foot and ankle pain. Other types of manipulation can be used as a mobilization technique or adjustment to the affected joint, foot, or ankle.

Case Studies and Success Stories

A variety of cases have been studied to determine the effects of chiropractic treatment. One example of a study conducted was on a 25-year-old national level soccer player complaining of bilateral hallux rigidus of two years duration and chronic recurring ankle sprains. Chiropractic spinal and extremity manipulation was used on the patient. At the two-month re-evaluation, the patient was symptom-free with full function and has since reported no recurring problems with his condition and continues to compete in soccer at a national level. An important factor in this case was the use of manipulation subsequent to an injury sustained during a game following the diagnosis of hallux limitus, which returned the player to full function within two days. Treatment utilized in this situation could provide valuable information for professional and amateur sports competitors with a similar injury. Another study was undertaken on a sedentary 35-year-old male with a clinical and radiological diagnosis of bilateral osteoarthritis at the first metatarsophalangeal joint, resulting in pain, limited and altered gait, and loss of function. The patient was using anti-inflammatory and analgesic medications on a daily basis and had been advised to consider joint replacement procedures. The patient underwent a regime of manipulative therapy at an average frequency of 1.4 treatments per week over a 9-month period and experienced a decrease in pain, increased function, and improvement in gait. At 3 months, a reduction in medication usage was noted. Simulation of the situation of this patient is common, and the study suggests the use of manipulative therapy as an alternative, less invasive, and less costly treatment option in similar cases.

Integrative Treatment for Foot and Ankle Pain

A large percentage of patients with foot or ankle problems have sought care from other healthcare providers with little or no improvement. Chiropractors are often an overlooked and yet viable resource in the management of lower extremity pain. With extensive training in the diagnosis and conservative management of lower extremity neuromusculoskeletal disorders, chiropractic physicians are well-equipped to treat patients with foot and ankle pain. Chiropractors, as primary care physicians, are trained to determine the cause of the symptoms and to make a working diagnosis. Once the diagnosis is established, treatment can commence. Treatment of foot and ankle pain among chiropractors includes a wide array of manual therapies. Chiropractic joint manipulation is frequently performed on the ankle and foot. In the acute stage, the adjacent joints must be mobilized to prevent joint dysfunction. Studies have shown that joint manipulation is effective for pain, swelling, and even improved weight bearing in patients with unilateral plantar heel pain. Other manual therapies include soft tissue techniques and even the use of therapeutic modalities if necessary. The care plan for each patient is specifically designed for the type of injury and the patient’s needs.

Collaborative Approach with Other Healthcare Professionals

Control subjects within a trial investigating the effects of a heel lift on chronic knee pain suggested a trend towards the group under the care of a chiropractor receiving improved outcomes. In the study of this trend, it is hard to draw any definitive conclusions but it may be acceptable to say that chiropractors are well placed in assessing clinical biomechanics and gait with leg length inequality to effectively manage this condition.

An often overlooked contribution to foot pain is that of leg length inequality. Studies have shown that most people have some form of leg length discrepancy with around 7% stating that it is the principal factor in their painful musculoskeletal condition. It is well within the scope of the chiropractor to address this issue with the use of a heel lift. A review in 1991 suggested that the use of a heel lift was relatively under prescribed by orthopedic physicians. One of the reasons cited was the lack of awareness or understanding in identifying the presence of a leg length inequality. This represents an ideal situation in which a collaborative management of patients between chiropractors and orthopedic physicians may benefit patients with conditions related to leg length inequality.

Patients with complex foot and ankle conditions may benefit from a multi-modal treatment approach. In this instance, chiropractic care may be one of several interventions employed in managing the patient’s condition. It may be necessary to use complex deformity management systems and some form of immobilization in the case of severe joint contracture, avascular necrosis or fracture non-union of the hind/mid foot and ankle. If such specialist intervention is required, it is important for the chiropractor to work closely with the relevant healthcare professionals to ensure that all aspects of treatment are coordinated to provide the best possible outcome for the patient.

Exercise and Rehabilitation for Foot and Ankle Pain

Furthermore, strengthening exercises can be employed to increase the stability of the affected area. This is especially important if the injury is related to a functional instability of an area. An example of this would be a lateral ankle sprain involving damage to the anterior talofibular ligament, which is the most commonly injured ligament in the body due to its weakened position on the lateral aspect of the ankle. One effective exercise used in the strengthening of the peroneus longus, which is an important lateral ankle stabilizer, is having the patient place a band around the foot of the affected ankle and the other end of the band around a fixed object. The patient can then evert their foot against the resistance of the band, providing a low-impact method to strengthen the muscle.

One of the most highly regarded stretching techniques is that of active isolated stretching (AIS), which is a type of stretching that is held no longer than two seconds and is performed in sets of ten repetitions. The use of AIS has been said to be very effective in the treatment of chronic conditions and is employed by many professional sports trainers and physical therapists. In addition to AIS, the use of joint mobilization techniques may also be employed to improve the range of motion of an affected area. This involves the usage of hands-on techniques to increase the mobility of a joint that has been determined to have an abnormal accessory motion.

Research has shown that one of the most effective modes of care for the treatment of foot and ankle injuries and pain is that of exercise therapy and rehabilitation. Considering the multitude of intricate joints and muscles in the lower extremity, it is imperative that an injury be completely rehabilitated to prevent recurrence or a chronic condition. The overall goal of therapy is to improve the strength, flexibility, and functional ability of the lower extremities. Whether the injury is a sprained ankle or chronic plantar fasciitis, an assessment of the range of motion and strength of the individual is required to outline the course of treatment. A well-rounded regimen to increase flexibility of tight tendons and muscles, involving stretching and deep tissue massage, can begin very early in the course of treatment.

Lifestyle Modifications for Pain Management

Diet and nutrition are essentially a part of overall health, and for some patients, it will be the motivation behind their attempts at other lifestyle modifications. For example, an overweight patient with foot or ankle pain has added stresses acting on weight-bearing joints, elongating the recovery process or directly worsening their condition. In order to inspire diet changes in patients, the chiropractic professional must realize a patient’s emotional attachment to food and empathize with the perceived sacrifices required. Assurance that the diet changes do not have to be immediate and suggesting small progressive substitution of unhealthy foods with healthier alternatives may be a more feasible way to inspire change. For some patients, referring them to a dietitian for professional advice may be necessary. A chiropractor can further assist patients by suggesting specific diets aiming to reduce inflammation, such as a Mediterranean-style diet. By engaging in the diet changes themselves, chiropractic professionals can display empathy with patients through shared experiences and show how they have or are benefiting from the diet changes.

Supplementation of chiropractic care with other conservative treatments (like custom orthotic stabilizers) is common, but frequently the ease at which a patient can simply pop a pill and/or get a corticosteroid injection is chosen over the more discomforting effort of other non-invasive conservative measures. This is where the knowledge to inspire patients in lifestyle modifications for pain management is beneficial, both in the increasing effectiveness of chiropractic care as well as overall patient health. Understanding the value of such lifestyle modifications and how to inspire patients to proactively engage in them is vital for all chiropractic professionals.