Foot and Ankle pain can often be a complex disorder that is a combination of ligament and tendon injuries in the ankle as well instability in the hip and or weakness in the knee. Every time we take a step forward we are balancing on one foot for a moment. The ankle either stays stable or rolls in and out due to lack of support locally in the ankle or systemically from buckling of the knee and hip due to weakness of the inner quadriceps or hip stabilizers.
When a podiatrist or orthopedic surgeon specializing in foot and ankle evaluates foot and ankle pain they rarely extend that evaluation beyond the foot and ankle. This is a major mistake and it is often why patients who end up with a boot will start to notice hip pain that they had not felt before. A boot unlevels the hips further often exaggerating leg length discrepancy. Neglecting the hip and knee involvement also means that these issues will continue to contribute to ankle pathology and in many cases cause it to be persistent or recurrent.
As one of the few doctors certified in Interventional Regenerative Orthopedic Medicine (IROM-C) and ARDMS certified as a Musculoskeletal Sonographer (RMSK), I evaluate the ankle with a greater degree of attention to the relationship between ligamentous laxity, chronic and acute tendon injury as well as the relationship between hip and knee injuries feeding into foot and ankle pathology.
For instance, a patient with morton’s neuroma may see a Podiatrist and receive steroid injection or prescription for a boot which can help to reduce inflammation around the nerve and in some cases it may not return. In no cases does this resolve the underlying cause of the issue, which should really just be thought of as the body’s attempt to tell you that there is a deeper pathology that needs to be corrected. In many cases, either the issue returns or other associated injuries begin to show up. A morton’s neuroma is inflammation of a nerve that produces a sac of inflammatory fluid surrounding it due to friction from an abnormal rubbing across other structures along the nerve’s path to its final destination between the toes at the bottom of the foot. Commonly this is the tendons of the flexor hallucis longus or flexor digitorum but it can also occur under the metatarsal heads due to ligamentous instability of the forefoot due to loose Lis Franc ligaments at the tarsal-metatarsal joint. Both of these issues are exacerbated due to hyperpronation (the arch collapsing at the end of a stride).
Hyperpronation can be caused by loose ankle ligaments of the arch such as the spring ligament, short and long plantar ligament, loose ligaments of the tibio-talar joint such as the deltoid, Anterior and Posterior Talofibular, Calcaneofibular ligaments or loose ligaments of the tibio-fibular joint such as the anterior interosseus membrane or proximal and distal tibiofibular ligament. Hyperpronation can also be mediated by chronic strain into the posterior tibial tendon and peroneus longus tendon which form a sling around the arch of the foot providing a balanced tension when they are healthy. Lastly, a much greater force causing hyperpronation and ankle instability is weakness of the gluteal muscles and inner quadriceps, which cause buckling of the knee and collapsing of the arch with every step that requires balancing on one foot.
Evaluating each of these areas requires advanced musculoskeletal imaging skills and technology and treating them in a concerted fashion requires skills and experience using regenerative agents such as stem cells and platelet rich plasma to repair these areas that have a poor blood supply, which is often compounded by their distance from the heart. Knowing when to brace and when start physical therapy is essential to successfully rehabilitating these areas.
Orthotics and supportive shoes are essential when trying to rehabilitate an injured ankle and foot but these are rarely curative on their own. Knowing when conservative treatment is enough and when a regenerative treatment is necessary requires a robust evaluation that can help to inform a treatment plan no matter what level of intervention both the patient and doctor decide to start with.
At the San Francisco Institute for Integrative and Regenerative Medicine, we take a robust approach to diagnosing and treating foot and ankle pathology that involves understanding and treating the biomechanical chain causing that pathology. Aside from a robust approach to musculoskeletal medicine, we look deeper at the patient as a whole to address any systemic causes of inflammation that may be perpetuating chronic degeneration of soft tissue. This added layer of depth is sometimes necessary in order to fully resolve musculoskeletal conditions and support a healthy host that will maintain a healthy foot and ankle.