Better Injury Care

John (that’s not his real name) is one of those rare gentlemen who has continued to play competitive soccer well into his late 50s. He is in really good shape, which you need to be to play football at that age—good shape except for his left leg. His left leg is not in good condition at all. In fact, once you get to know his left leg a bit better, it becomes apparent that it’s miraculous that he’s able to run at all,  Let alone the type of running required to play competitive soccer against younger men. John’s left leg is riddled with arthritis.

John’s arthritic left leg is an anomaly because the whole rest of his body is extremely strong, mobile and healthy for its age.

To understand a left leg like Johns, you have to view it in its context. John’s whole body is exceptionally mobile and healthy for his age, he has the look of a lifelong athlete and all-around strongman because that’s what he is. No part of him is 30 years old any more. But he has no signs of stiffness or weakness anywhere in his arms, spine, or right leg. His overall mobility is excellent for his age, hence in part, the long soccer career. 

John’s left leg is another story. It has advanced osteoarthritis in every major joint. His knee, hip and ankle are all severely arthritic. They stand in complete contrast to the rest of his body which is not even mildly arthritic, let alone suffering from advanced cartilage loss. He has had four separate arthroscopic surgeries at different times. All on joints in his left leg.

It’s all a bit surprising until you look closer – firstly, at John’s gait pattern and, secondly, his health history. Once you have understood those, the left leg makes perfect sense.

Computerised gait analysis measures the distribution of weight in each foot during walking and running in great detail. It then compares the left with the right to establish whether there is a gait insufficiency or asymmetry compared with the normal population. Essentially, it’s a dynamic postural analysis of the lower limb.  

Gait analysis of John’s left leg reveals a catastrophic degree of pronation (arch collapse) with every step. While John’s healthy leg only exhibits the slightest amount of pronation (the amount he was born with). The pronation reveals that his gluteal muscles have wasted away to nothing on his arthritic side. His knee, ankle and hip all collapse inwards with every step – Millions of times yearly on the same side as all the arthritis.

Based on all this, John’s case starts to look like the healthcare equivalent of a murder mystery with no suspects until you go back far enough. 

It’s all a bit surprising until you look closer – firstly, at John’s gait pattern and, secondly, his health history. Once you have understood those, the left leg makes perfect sense.

Computerised gait analysis measures the distribution of weight in each foot during walking and running in great detail. It then compares the left with the right to establish whether there is a gait insufficiency or asymmetry compared with the normal population. Essentially, it’s a dynamic postural analysis of the lower limb.  

Gait analysis of John’s left leg reveals a catastrophic degree of pronation (arch collapse) with every step. While John’s healthy leg only exhibits the slightest amount of pronation (the amount he was born with). The pronation reveals that his gluteal muscles have wasted away to nothing on his arthritic side. His knee, ankle and hip all collapse inwards with every step – Millions of times yearly on the same side as all the arthritis.

Based on all this, John’s case starts to look like the healthcare equivalent of a murder mystery with no suspects until you go back far enough. 

When John was 16 years old, the full weight of an adolescent rugby scrum collapsed onto his left ankle. The resulting sprain was so bad that he was on crutches for five months. He confesses that his ankle never felt the same again. He also recalls that he sustained two further bad sprains during his late teens and early 20s. Mystery solved.  

The joint trauma, scar tissue and muscle wasting left in the wake of the ankle sprain left John with a severely unstable foot and ankle. And if you have an unstable ankle, you have an unstable leg, foundations being what they are. The chronic instability caused chronic wear and tear, not only in the ankle but also in the knee and hip. Yet it was more than three decades before John started to really feel the longer-term impact his ankle injury would have on the hip and knee.

As for John playing masters football on such a severely compromised leg, that was easily attributable to a combination of innate athleticism and sheer belligerence. Despite this, once he had seen the results of his gait analysis and finally understood why his left leg was so compromised, he played the last two matches of the season. Finally, he retired—instead, choosing to pursue general exercises and rehab to prevent further unnecessary joint degeneration. He had never connected the ankle sprains with the arthritis he had in that leg, nor had any of his previous healthcare providers.

Despite the common and somewhat irrefutable nature of case studies like John’s ankle, there is still some scholarly debate over the true prevalence of joint degeneration after injury; because the current data is far from conclusive. Yet there is so much data, clinically, statistically and anecdotally, there is a consensus about there at least being some level of correlation. And arthritis aside, there is certainly no doubt about the high prevalence of further pain and injuries after ankle sprains and the like.

A study published in the Journal of Athletic Training in 2019 highlighted what countless clinicians have known for a long time. Up to 70% of people who sustain an acute ankle sprain develop some level of residual physical disability in that leg. This study highlights the devastating potential of ankle sprains; and also the fact that we struggle to effectively rehab even the most straightforward musculoskeletal injuries.

We need to do a better job of injury care if we are going to conquer the pandemic of chronic pain we live in at this point in history. Unrehabilitated injuries and complex injuries contribute significantly to the pain burden. Walking must always come before running, individually and collectively. So, if we can’t get to grips with the humble ankle sprain, what chance do we have of conquering back pain, complex PTSD-associated pains and an opioid epidemic?

Improved injury management is as much a mindset as it is a set of rehab approaches. 

If we adopt a mindset where we assume that all but the most extreme injury events have something to reveal about the integrity of our musculoskeletal chains, we have made a giant step towards better care of injuries, complex injuries and complex pain.

If we adopt a mindset where we assume that the injuries seen on scans and x-rays are just the tip of the injury iceberg; and that other more subtle but significant soft tissue injuries play out ‘under the medical radar’. A world of injury and pain healing approaches opens up to us.

If we adopt a mindset where we are willing to give our painful and ‘injury-prone’ body parts the kind of long-term attention we give our teeth, we will have made another quantum leap towards preventing long-term pain and disability.

Once we have made this small handful of shifts in our belief structure around injuries and rehabilitation, we become open to proper use of the full injury and pain rehabilitation toolkit, in which the techniques and approaches are often surprisingly straightforward. Just like flossing your teeth daily and seeing a hygienist twice a year is straightforward.

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In the same way that our posture needs to be in a sweet spot (not too hunched – not too upright) – our arches are happier when they are not too high/not too low.

A high arch is an unstable affair – that can easily cause foot pain / ankle pain / knee pain / hip pain / lower back pain.

Arches are part of the body’s shock absorbing system. 

A very low arch makes us like a car with bad shock absorbers – good suspension is useful when we live on hard modern floors. 

Poor shock absorption can contribute to back / hip / knee / ankle / foot pain in a big way!

#2 MULTIPLE RECURRING LOWER BODY PAINS.

Having a history of multiple pains  – injuries that heal slowly – recurring injuries –  in the lower back and legs is a sign of underlying biomechanical issues. Often with the feet. 

Having multiple / persistent / re-occurring / slow healing pain issues in our lower body means GET CHECKED OUT BIOMECHANICALLY! Just like sight failing means get the eyes checked!!!!

#3 BEING WOBBLY!

Try standing on 1 leg – even when we are 70+ there should be no wobble if all the joints and muscles are in good condition.

When we can’t stand steady on both legs it’s a big problem. It means we are not fully STABLE when we are standing / walking and running. (When we walk and run we are on 1 leg most of the time!!!!! ) 

Glutes not firing in combination with poor foot & ankle stability is the most common ‘combined cause’ of this serious issue. 

Instability can even lead to accelerated wear and tear if we aren’t careful. 

AND 3 SOLUTIONS…

#1 CUSTOM ORTHOTICS

Custom orthotics replace the natural support our ancestors had when they walked bare foot on soft ground – their whole lives!!!!

If we have low arches – custom orthotics can provide extra shock absorption and take strain of our joints.

If we have high arches – custom orthotics can help increase the stability of our feet when we stand / walk / run.

At FPC – our custom orthotics are made of ultra ultra tough – super flexy space age nylon – they are made to survive pandemics, earthquakes and meteor strikes! 

#2. GENERIC INSOLES

Generic insoles do basically the same job as custom orthotics – just not quite as well. 

Generic insoles are an excellent option for people who have pain that relates to their feet  but who can’t afford fully custom orthotics. 

** double whammy is we are currently offering 2 pairs of insoles for the price of 1 at our clinic. 

#3. BALANCE EXERCISES

Balance exercises done correctly and safely are a major part of the solution for most people with foot problems. 

Living on hard flat ground for a lifetime (as we do) means most of us don’t have healthy ‘tone’ in the muscles of our hips legs and feet.

Daily balance exercises tones the muscle that supports out feet – ankles – knees – hips – backs. We have completely lost count of the number of lives we have seen completely transformed by this knowledge!!!!

Those who want to learn correct balance exercises need look no further – we do tailored rehab programs for that exact purpose. Learning balance exercises that we can do at home is like learning to ‘catch our own fish’ !!!!

Whether our feet are causing our pain or some other movement issue – pain was not designed by Mother Nature to be ignored – or self diagnosed – or labelled as ‘just old age’.

We are supposed to listen to our bodies when they ‘talk’ to us and seek solutions! 

The reward we get for ‘listening’ is FREEDOM – to enjoy a happy normal life where we can stand / walk / sit / sleep / connect without pointless suffering. 

Suffering that serves no purpose other than to make us feel crappy and not enjoy our time!!!!! 

Well done if you made it to all the way to the end – that was long

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 There are worse things in life than flat feet, there are also worse things in life than poor posture. Neither will kill you both can seriously impact your quality of life, especially as you get older. 

Flat feet are feet that don’t have great alignment. In the same way that here is definitely such a thing as ideal spinal posture there is also such a thing as correct foot alignment. Flat footedness leads to your body weight being transitioned along the inner margin of foot instead of along the centre of the foot when walking and running. When the weight transitions along the inner margin of the foot due to flat footed-ness the knee and hip twist awkwardly during weight bearing. 

 When the hip and knee twist awkwardly as they do with flat feet repetitive strain can build in the joints and soft tissues. Muscles tend to become achy, sore and tired with increased activity and mileage especially around the hips and glutes. Over time the soft tissues and joints suffer and can become predisposed to injuries more often than in those without flat feet.  Examples of this are the increased risk that flat footed people have or cruciate ligament injuries in the knee and episodes of back pain.

 If you can find ways to stop your flat feet from causing strain in your ankles, knees, hips and spine you can have a very good chance of preventing injuries and pain. The key to dealing with the long-term effects of flat feet is to stop the arch from dropping under your body weight when you walk and run.

Strengthening The Glutes

One major role your glutes play is in preventing flat feet and fallen arches. Your gluteal muscles are an integral part of the mechanism that prevents the arches from dropping when you run and walk. By cranking hard on your femur (thigh bone) as you heel strike the glutes control the body weight as it travels through the leg to the foot. 

 All glute exercises are helpful but especially those that are ‘functional’, which basically means they are strengthened during weight bearing instead of in a sitting or lying down position.

If you don’t have someone like me to coach you on how your glutes  overcome flat feet just use a wobble board often and master your balance. Your glutes are absolutely key in balancing, so if you go on a balance board every day for at least 10 minutes you will be giving them a good amount of the love they need. Using resistance bands to create resistance as you hold your knees wide when you squat at the gym is also a great way to strengthen the glutes if you have flat feet.

Supporting the Arch

Your ancestors walked almost exclusively on soft contoured surfaces, you walk almost exclusively on hard flat surfaces. These hard, flat surfaces are a major issue for everyone but this is dramatically more serious for those with flat feet. Before the industrial revolution and the invention of modern concrete, tarmac and paving flat feet received a great deal of support from the squishiness and unevenness of natural ground.

Custom orthotics mimic the uneven and shock absorbing quality of natural surfaces. The 2 primary benefits that custom orthotics offer to flat feet are shock absorption and positional control for the poor old heel and support for the poor old arches. Help for the heel and help for the arch are both a blessed relief to flat feet because the relationship they have with concrete is similar to the one your teeth have with sugar .. properly dysfunctional ya hear ! 

Wear The Right Shoes

Tying in neatly with the topic of arch support is the topic of appropriately supportive footwear choices. The primary role that shoes perform these days is not fashion, its protection of our soft domesticated footsies from concrete, tarmac and paving slabs. We are reliant on footwear in the same that we are reliant on roofs over our head and winter jackets, we are no longer equipped for everything the outdoors throws at us.

Wearing the right footwear provides some protection from hard ground for your feet, that includes the skin and the connective tissue in the sole of your foot. If you have flat feet, shoes will also make up for some of the shock absorption you are missing due to the lack of an arch.

For those with flat feet who have had a significant history of back pain, ankle pain, foot pain, knee pain or hip pain the right footwear can perform an additional service. Appropriately supportive shoes with a substantial (not too flimsy) sole and sufficient width form a solid platform for the custom orthotic insoles that your flat feet need for support.

Go Barefoot Outdoors

As we stated previously your ancestors spent their lives outside with their bare feet in the mud. Having your feet fully connected to what mother nature has laid on for them is an extremely healthy passtime. The action of soft uneven surfaces tones the muscles of the feet and leg, stimulates nerve signals in the feet, stretches the feet and increases blood flow in the connective tissue of the feet.

Imagine the many benefits inferred when a severe couch potato gets up and goes for a brisk walk in nature. If your feet spend their lives in an office wearing corporate footwear they may receive a similar level of benefit. Our bodies were designed to express free movement and our feet are no exception.

If you have flat feet specifically, it is the toning and stretching effect of being outdoors in bare feet that you will benefit most from when you spend time outside in bare feet.

Wear Insoles At Home

Another chance to beat you about the head with the fact that hard modern surfaces are hard on our bodies.

The concrete and hardwood floors in our homes can be almost as hard on flat feet as the paving, tarmac and concrete in the urbanscape. Wooden flooring is less harsh and the carpet/underlay equation definitely help but they are not enough to provide natural support to the arch.

I have met countless flat footed patients over the years who have figured out for themselves that they suffer more pain if they go barefoot at home for extended periods. There have also been many others who hadn’t realised that was causing increased pain but found their pain reduced once appropriate measures were taken.

The practical side of protecting ones flat feet from domestic surfaces can be a little sticky for some and easy for others. Wearing some slippers or Ugg boots in the winter and having a comfortable but supportive orthotic or insole is usually not an issue. Summer can be a little more challenging however, it’s nice to let one’s feet breathe in warmer weather.

For some, finding a pair of sandals or Crocs what will accept an orthotic or insole works our well, for others something like a Berkenstock with its own intrinsic arch support works better.

Conclusion

Having flat feet is definitely not the only way you can end up with chronic pain in your life, but it is definitely a common one. Perhaps part of the reason this has become such a serious topic for many of us is how long we live these days.

Generally speaking your ancestors only needed their ankles, knees, hips and spine to last them 4 decades or so, you are probably going to double that mileage. You are in this for the long haul, and when you hit 75 you will probably want to be active (like travel and play golf) as much as you do now. Tending to our biomechanics and listening to our aches and pains as we go are excellent ways to try and squeeze as much juice out of the orange as we possible can.

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The best way to get fitted for custom orthotics is to work with practitioners who specialise in treating, correcting and rehabilitating stubborn pain conditions. The right practitioners will take your full history of pain into account and conducts in depth analysis of your biomechanics. In depth history taking, orthopaedic testing and computerised gait analysis are the hallmarks of the best way to get fitted for custom orthotics.

There is a bit of work involved in getting fitted for custom orthotics but you mobility and wellbeing are at stake so it’s well worth the effort. The following 3 step process is the bets way to get fitted for orthotics.

Step 1

Make an appointment with a pain clinic who specialise in managing a range of pain conditions. This is especially important if you have had more than one stubborn pain in your lower body (eg. plantar fasciitis and lower back pain). Many people who need to get fitted for orthotics have more than one pain and it’s best to work with practitioners who understanding extends beyond issues with the foot.

Step 2

Have a full history taken so that you practitioner understands your history of lower body pains and lower body injuries in detail. When you get fitted for custom orthotics it’s important that all your past and present pain is taken into account.

Step 3

Get a computerised gait analysis done. The best way to make fitted orthotics is to correct the movement of the foot as opposed to the shape of the foot. Computerised gait analysis creates a detailed image of the movement of your foot so that your practitioner knows exactly where the movement issues lie.

Concluding Thoughts

Once your practitioner has a clear and in depth picture of your pain complaint history, a good impression of how your joints and muscles are functioning and a clear record of how your foot moves they will be able to get you fitted for custom orthotics.

This might all seem like a bit of hassle but the fact is that getting fitted for custom orthotics in the best way possible is a vitally important process. The wellbeing of the tissues in the entire lower half of your body are going depend on your fitted orthotics for years to come.

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