Keeping in Step with Summer

May 2, 2004
Outside Magazine
Outside magazine, June 1995

Keeping in Step with Summer

Preparation for these sunny times shouldn't stop at the quads or biceps. Your feet need a hand, too.
By Sara Corbett

Summertime--when we trot up and down mountains, sashay through 10k races, leap for a Frisbee on the beach, and, of course, fend off barking dogs. That is, our feet hurt: When we outdo ourselves on in-line skates, a mountain bike, or a rock face, it's not only our hamstrings, backs, and shoulders that suffer. Our feet follow right along.

The unpleasant truth is that 85 percent of us will at some point be temporarily sidelined by foot problems. That's because each time you take a step, you're asking 26 bones, 130 ligaments, and 40-some muscles and tendons to act in concert, performing a series of sophisticated machinations so that the foot can be rigid enough to propel you while remaining flexible enough to absorb impacts. A regular regimen of jumping, twisting, and pounding only makes matters worse. "Take a runner who goes just one mile," says Tom Shonka, a Boulder, Colorado-based podiatrist and board member of the American Academy of Podiatric Sports Medicine. "In that distance, she logs somewhere between 800 and 2,000 steps, at a force three to five times greater than her body weight. All of that motion wreaks havoc."

The problem is that there's a fine line between building feet up and breaking them down. Foot fitness is, to some extent, achieved unwittingly; even those short walks to the photocopier help strengthen the foot's stabilizing muscles, improve its flexibility, and make it more durable by building bone mass.

But laps around the office in your Florsheims can't match miles spent in lightweight running shoes, heavy hiking boots, stiff cycling shoes, or confining in-line skates, in which you can push your feet too hard and never notice it. Sure, they'll recover from a long off-road run, but head down that trail too often, repeating those same motions time after time, and you'll start doing small but impactful damage. Most chronic foot injuries are the result of months or even years of enduring such microtraumas to the bone and soft tissue. "I've seen 30-year-old marathoners with feet that resemble those of a relatively inactive person of 60," says Shonka. "At that age, muscles fatigue and bones and joints tend to give less. If your feet are that old--even if the rest of your body is half the age--you can reasonably expect to have some problems."

Appropriate Support
How do you keep your feet from taking early retirement? First, look out for those muscles and tendons, which have to make up for your genetic shortcomings every time you stride. "Most of us are going to have natural imbalances in our gait, and that's a direct result of the feet we inherit," says Jeffrey Ross, a Houston podiatrist. "Without a helping hand, those imbalances can cause muscle strains and tendinitis."

That helping hand can be found, first and foremost, in the right pair of shoes for your sport. The imbalances Ross speaks of often manifest themselves in pronation, the foot's natural inward roll as you stride from heel to toe. We've all heard that most of us overpronate or underpronate, but here's the fallout: Overpronators, whose feet roll inward excessively, continuously torque the muscles and tendons of each foot, which can strain the connective tissue and cause muscle pain. Underpronation undermines the foot's natural shock-absorption capabilities, and the potential results are soreness and stress fractures.

If you don't know which side you lean toward, a good shop person can figure it out by watching you walk or jog. Basically, overpronators should seek out more stability; underpronators, more cushioning.

But controlling what's around your foot isn't enough. The same muscles and tendons that you're trying to protect with proper gear should also be conditioned with focused exercise. It's a matter of working some specific foot muscles--namely the intrinsics (in the forefoot and arch) and extrinsics (in the heel and ankle)--on a regular basis (see "Getting a Foot Up on Overuse Injuries" below). "Even if people do ankle exercises, the intrinsic muscles of the foot are often overlooked," says Tom McPoil, an associate professor of physical therapy at Northern Arizona University who specializes in feet. "That's a big mistake, since strong intrinsics are crucial to stability."

Finally, take care of your arches--if you've got them. The arch helps keep the foot somewhat rigid throughout the gait for built-in motion control. If you weren't born with flat feet or have yet to develop them at the hands of gravity, protect your arches with some firm support. If your feet are already pretty flat, go with as much arch support as you can comfortably tolerate--it will help with stability.

The Plantar Fascia Tug-of-War
The single most troublesome part of an athlete's foot, however, is the plantar fascia, a flat band of extremely inelastic fibrous tissue that runs from the heel bone to the ball of your foot. Whenever you come down hard on your foot (running or skiing) or overstretch your arch area (rock climbing or hiking uphill), the plantar fascia gets a yank. "And every time you work out, your plantar fascia plays tug-of-war with your much stronger Achilles tendon," says Shonka. "The former attaches at the bottom of the heel and pulls it forward; the latter attaches at the top of the heel and pulls it upward. Usually the fascia loses and is forced to stretch--and you ultimately feel it." What you feel, he says, are the effects of small tears: If you've ever stepped out of bed to a crippling, shooting pain in your heel, it's most likely your injured plantar fascia saying good morning.

Unfortunately, things easily get worse, or at least no better. The body repairs a microtear by zipping the two sides of the wound together with scar tissue, which is even more inelastic than the original tissue. The result is a stiffer plantar fascia and the possible development of inflammation, or plantar fasciitis. Now, along with heel pain, you'll feel a dull ache across the arch of your foot.

While some of the discomfort of plantar fasciitis dissipates as your fascia stretches slightly each morning, it's hard to get completely out of the nasty tear-scar-tear-scar rut. So it's important to treat plantar fasciitis when you first notice the pain: Rest, apply ice, take anti-inflammatories (like ibuprofen), avoid hill workouts for a couple of weeks, and support your arch with the right athletic shoe. Working the intrinsic and extrinsic muscles will help, as will Achilles tendon stretches and self-administered foot massages. Surgery in which the fascia is severed is a last resort, since it'll keep you from exercising for four weeks while the fascia rebuilds itself in a slightly longer form--hopefully preventing future strain.

Cushioning the Metatarsals
If your fascia doesn't get you, your metatarsals might. These five thin bones run much of the foot's length and come together to form a particularly vulnerable bridge, the metatarsal arch, directly over the ball of the foot. Because the metatarsal arch is on the receiving end of a lot of stress--the ball of your foot gets pressure from your body weight as well as from the momentum of your stride-- the bones can literally be jostled, and it's common for one metatarsal to drop lower than the others, ultimately creating a pressure point and discomfort.

The catchall name for pain in this area is metatarsalgia, and while it may initially be merely annoying, like a pebble in your shoe, it can eventually put you off your foot altogether. Notorious among climbers and cyclists, metatarsalgia is best treated by increasing the padding in your shoes or inserting orthotics. Padding is available in aftermarket shoe liners, made by companies like Sorbothane, for around $20. Orthotics can also be purchased over the counter, and most doctors recommend that you try that before spending at least $85 to have your gait professionally analyzed and your inserts custom-made. Whatever you decide on, don't ignore the pain. If a bone has collapsed, it can fracture.

Reasons for pain at the metatarsals can also be traced elsewhere. Strap yourself too tightly into a pair of in-line skates, cycling cleats, or climbing shoes, and the bones can pinch a nerve, usually between the third and fourth toes, causing numbness or tingling. If you act quickly, the solution is simple: Loosen your shoes.

However, says Shonka, "If the tingling persists, or if it starts feeling really painful, you may have done some damage." That damage, he says, may lead to nerve inflammation. If you try different shoes but the tingling doesn't stop--or if it turns into a consistent, burning pain--it's time to punt. Go see the foot doctor.

Likewise, you'll need a doctor's help if you notice a tingling or shooting pain that originates at the ankle and extends toward the toes. This is tarsal tunnel syndrome, and it's similar to the much-discussed carpal tunnel syndrome, in the wrists, in that it's an overuse injury: TTS is often a result of the repetitive motion of overpronation. Basically, it's caused when the posterior tibial nerve, which runs past the ankle, is aggravated by the tunnel of thick ligaments that swell around it.

What's curious about TTS is that it often gets masked by other injuries, as the foot and ankle make adjustments to protect the nerve. So you're likely to suffer from plantar fasciitis, Achilles tendinitis, and even knee problems--which can all hide the tingly feel of nerve damage--as the body tries to set itself straight. Your foot specialist may refer you to a neurologist, or you may just need orthotics.

But when it comes to our feet, most of us, thank goodness, should never have to bounce from one waiting room to the next. With the majority of injuries, a little respect, rest, and common sense will put us back on our feet or in our skates in no time. Which is pretty fortunate, considering how things could have turned out. "For the most part, our feet are very functional," says McPoil. "You know, we could have been born with hooves."

Sara Corbett, a frequent contributor to Outside, wrote about sports nutrition and psychology in the May issue.

See also:

Regimens: Getting a Foot Up on Overuse Injuries

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