How To Evaluate Your Foot Pain

The cause of most foot related problems such as ‘plantar fasciitis’ can be traced back to your poorly fitting shoes. With this understanding we can start a screening process to uncover the cause of your foot pain by evaluating your footwear!

This is part 5 of a series titled “Foot Pain (How To Fix ‘Plantar Fasciitis’ and Other Common Foot Problems)”  

As we have discussed in prior blogs, many of the foot problems we develop begin with shoes that are too narrow. In Dr. Ray McClanahan’s experience, only 10% of people have feet that fit the “normal” narrow shoes you’ll find in most stores, 90% do not.

Now many of you may be thinking to yourself right now, “But my shoes aren’t that narrow!” Well, let’s find out. I want you to try a simple experiment Dr. McClanahan taught me called the “Shoe Liner Test.”

Pull the insole or “shoe liner” out of your shoe and stand on it barefoot. Let your toes spread out naturally and see if any part of your foot falls over the edge of the liner.

What did you find?

For many of you, the edges of your big toe and/or pinky toe will be partially falling over the edges of the insole. This means in order for your foot to fit within that shoe, your toes must be crammed together.

I now want you to experience how your foot stability can be positively or negatively affected due to the position of your toes. With your foot still on top of the shoe liner (and all of your toes within its borders) see how far your foot can easily pronate and collapse over. Most people will be able to effortlessly move their foot into excessive pronation and flatten their arch to the ground.

As you perform this action, notice what happened to the position of your knee. As the foot pronates excessively and the arch breaks down, the knee is pulled into a valgus (collapsed position). This test is showing you what research has confirmed; altering the position of the big toe has a detrimental effect on the function of the entire foot and has a direct impact on the control and balance of the rest of the body.^1,2 

Normal function of the foot and the rest of the lower body largely depends on the position of the big toe. While the action of pronation is a normal and safe action of the foot/ankle complex during movement (like walking or squatting) excessive pronation is not and can be directly linked to poor positioning of the big toe. This uncontrolled movement of the foot increases risk of breakdown in stability of the entire leg (decreasing the efficiency of your lifting technique, running mechanics, etc.) and may increase  risk of injury over time.^3-5

Now try the next part of the test. Return to your prior starting position, take your big toe and spread it out away from the other toes. For most of you, your big toe should now be positioned partially (or even completely) off the medial border of the insole. This is the position the big toe should assume when in a correctly fitting shoe.

Slowly allow your foot to pronate back to the floor as you did a minute ago and notice what happens. Most of you will notice your arch will not flatten out (pronate) as much and will eventually hit a hard “stop.” This test shows you how the splay of the big toe (that is dictated by the type of shoes you wear) will determine how much pronation can occur when moving. If the big toe is allowed to spread out into its natural position away from the other toes, the arch of the foot will pronate normally (not excessively) and the foot will assume a strong stable position.

As you performed this last motion, immediately look up at the knee and you’ll notice it remains in a stacked position aligned directly over the foot. The position of the great toe therefore has a direct connection to the functioning of the foot and the stability of the knee. This is a reason many athletes fail to correct “knee cave” (valgus collapse) when lifting despite constant coaching cues and corrective exercises aimed at strengthening the hip. It is not until the athlete changes shoes and improves their foot positioning that the technique fault can be truly corrected.

Ankle Mobility Screen

Many foot problems (including plantar fascia pain) are associated with restricted ankle mobility.^6-9 It may surprise you to learn that the two main muscles of your lower leg (gastrocnemius and soleus) are actually connected to your plantar fascia by small connective tissues. Over time the raised heel and toe spring of many modern shoes position the foot in such a way that chronically lengthens the plantar fascia and shortens the calf muscles.¹⁰

To see if ankle mobility is something you need to work on, perform the half-kneeling dorsiflexion test. This specific test has been used numerous times in research to assess ankle mobility.¹¹ I first learned this screen from physical therapist Dr. Mike Reinold who recommended it for its ability to provide quick and reliable results without the need for a trained specialist.

Find a wall and kneel close to it with your shoes off. Use a tape measure and place your big toe five inches from the wall (if you don’t have a tape measure, using your fist plus an extended thumb is a good alternative). From this position, push your knee forward attempting to touch the wall with your knee without your hips swiveling to the side or your knee caving inwards past your big toe. Your heel must stay in contact with the ground.

What did you find?

If you found a restriction in your painful side compared to the pain free side, it means your foot symptoms may be connected with your limited ankle mobility. If this is you, I’d highly recommend starting some of these corrective exercises in the below video.

That’s it for today’s blog article! Next week we’ll jump into the rehabilitation process for many foot pains!

Until next time,

References

1. Nix SE, Vicenzino BT, Smith MD. Foot pain and functional limitation in healthy adults with hallux valgus: a cross-sectional study. BMC Musculoskelet Disord. 2012 Oct 16;13:197.
2. Chou SW, Cheng HY, Chen JH, Ju YY, Lin YC, Wong MK. The role of the great toe in balance performance. J Orthop Res. 2009 Apr;27(4):549-54.
3. Hintermann B, Nigg BM. Pronation in runners. Implications for injuries. Sports Med. 1998 Sep;26(3):169-76.
4. Resende RA, Deluzio KJ, Kirkwood RN, Hassan EA, Fonseca ST. Increased unilateral foot pronation affects lower limbs and pelvic biomechanics during walking. Gait Posture. 2015 Feb;41(2):395-401.
5. Neal BS, Griffiths IB, Dowling GJ, Murley GS, Munteanu SE, Franettovich Smith MM, Collins NJ, Barton CJ. Foot posture as a risk factor for lower limb overuse injury: a systematic review and meta-analysis. J Foot Ankle Res. 2014 Dec 19;7(1):55. 
6. McPoil TG, Martin RL, Cornwall MW, Wukich DK, Irrgang JJ, Godges JJ. Heel pain–plantar fasciitis: clinical practice guildelines linked to the international classification of function, disability, and health from the orthopaedic section of the American Physical Therapy Association. J Orthop Sports Phys Ther. 2008 Apr;38(4):A1-A18.
7. Patel A, DiGiovanni B. Association between plantar fasciitis and isolated contracture of the gastrocnemius. Foot Ankle Int. 2011 Jan;32(1):5-8.
8. Lareau CR, Sawyer GA, Wang JH, DiGiovanni CW. Plantar and medial heel pain: diagnosis and management. J Am Acad Orthop Surg. 2014 Jun;22(6):372-80.
9. Bolívar YA, Munuera PV, Padillo JP. Relationship between tightness of the posterior muscles of the lower limb and plantar fasciitis. Foot Ankle Int. 2013 Jan;34(1):42-8.
10. Csapo R, Maganaris CN, Seynnes OR, Narici MV. On muscle, tendon and high heels. J Exp Biol. 2010 Aug 1;213(Pt 15):2582-8.
11. Bennell K, Talbot R, Wajswelner H, Techovanich W, Kelly D. Intra-rater and inter-rater reliability of a weight-bearing lunge measure of ankle dorsiflexion. Australian Journal of Physiotherapy. 1998; 44(3):175-180.