Are you putting your best foot forward?

Osteopaths treat all sorts of musculoskeletal mechanical disorders and patients seem to come in waves with disorders of particular areas of the body…this week it has been feet.
I have to confess I always approach someone’s feet with trepidation.   They aren’t always pleasant and perhaps more importantly they can be tough old things to sort out.  We stand on them, and they bear our weight, they’re strong.  Similar to the hands I find that I am actually using my hands to make the changes I want, rather than gravity and my bodyweight with other areas of the body, and as a result after treating someone’s feet my hands are usually bright red.  As a positive aside I don’t seem to suffer from cold hands as much as I used to before practising osteopathy!
So they’re hard work and not always pleasant to work on but feet are so important, for those of us who can stand and walk, they are our foundation and yet we treat them with disdain.  When did you last look at your feet to make sure they’re OK?   Do they match?  Have they changed?  Do they move how they should?
Patient 1 had a stress-fracture of their 2nd metatarsal for no apparent reason 6 months ago, no bone density problems.  It got better and then she started getting pain under the metatarsal heads (the pads just before the toes).  When I looked at her foot the medial (inner) arch of the foot was all flattened and the whole foot was twisted so that excessive pressure was being placed on the big toe…and that had responded by developing a valgus (toe bends inwards towards foot at joint) and a bunion, this takes the pressure off the 1st toe and puts it on the 2nd particularly if they have a long 2nd toe, known as a mortons toe…and may explain the fracture.  Shockingly the podiatrist prescribed insoles without touching the patient’s feet.  The patient was worried their toe had fractured again. 
I was able to articulate the medial arch to reform but the patient still had pain however we were able to identify it was no longer where the fracture had been, I then worked on the transverse arch, this is the arch across the foot where the pads are just before the toes.  Sometimes these can drop and some gentle encouragement can persuade them to pop back into a nice arched shape and voila, no pain.  The next step (pun intended) is to see if the foot is capable of holding this improvement without orthotics, and if not, to try with orthotics.
Patient 2 had pain in the outside aspect of her left foot, which she had been told was due to an avulsion fracture 2 years ago.  On observation the foot had an overly high arch and the toes pulled back almost like a cats claw ready to pounce.  She was very hypermobile in her hands and feet, that means her ligaments had much less recoil than usual.  She’d been to see a range of practitioners and nobody had questioned this hugely deformed foot, suggesting the pain was just down to a detached bit of bone and she’d have to live with it.  Perhaps they thought the foot was like this due to a developmental deformity, it certainly looked like it but I asked the patient about it and the foot hadn’t always been like that, so I decided to see what could be done.   Below the talocrural joint there is a joint called the subtalar joint.  When we sprain our ankle, it is usually the talocrural joint but can sometimes be the subtalar joint.  The subtalar joint was stuck twisting the foot inward and the rest of the mid and forefoot was twisted the other way so the front of the foot could present flat to the ground.  After I had released the restricted joints the arch normalised and most of the toes released and sat almost flat, I then massaged the short toe flexor muscles in the arch of the foot and the longer toe flexors and extensors in the leg.  The foot straightened out, almost entirely, this crippling condition apparently 90% resolved with 10 minutes work.  I think that the patient had just sprained her subtalar joint and in order to protect the hypermobile foot in this less stable position the nervous system had activated both flexors and extensors to hold the foot rigid.   Again we need to see how much of the improvement is maintained but even if it starts to revert, this opens new avenues of treatment to explore.
The moral of this story is, look at your feet and get problems resolved (including that revolting athletes foot) because feet that function well don’t just help protect against foot and ankle pain but they absorb forces to protect the rest of the leg, the knees, the hips and even the back.  Don’t necessarily expect other professionals to identify resolvable biomechanical dysfunctions.  Orthopaedic surgeons are primarily looking for things that require surgery, a podiatrist who is an expert in orthotics will probably make you some lovely orthotics.  I’m not sure this should be seen as criticism…I’d do a lousy job of removing your bunion and you’ll be pleased to know I wouldn’t dream of trying.  “Render unto Caesar…” and all that, there’s a place for podiatry and for surgery but I hope you will now consider that there’s a place for osteopathy in the care of your feet, even if that does mean I have to handle more of the darn things.