We all know someone who's sprained a foot or an ankle due to a misstep during walking or running. Depending on the amount of force involved at the time of the incident and the position of the foot at impact, there is a good chance that one or more of the ligaments in the foot were injured.
Ligaments connect bones at moveable joints; without them, the skeleton would fall apart.
How Ligament Injuries Occur
Ligament injury occurs mainly when the joint is over-extended or moves farther than the ligament allows. Any joint ligament can be twisted, torn or otherwise damaged by a fall or other situation that causes injury. Ligament injuries can range from local tenderness at the site of injury to a complete tear. A Grade I ligament injury has no measurable stretching of the ligament, but local tenderness is noted. A Grade II ligament injury has tenderness and some stretching, or a partial tear. A Grade III ligament injury is a complete tear.
A stretched ligament does not have the inherent ability to regain its previous length. A common analogy is that of plastic which holds beverage cans together. If the plastic is stretched, it does not resume its original length. Similarly, once a ligament has been stretched it loses the ability to hold the joint it was supporting in the proper position. Subsequent repetitive microtraumas to the joint will lead to other degenerative conditions over time.
Chiropractors realize that adjustments to misaligned joints will influence neurophysiologic function in many ways, including disruption of collagenous adhesions, restoration of proprioception, reduction of muscular contracture, and prevention and/or reversal of degenerative changes.1 When ligaments heal with the joint in proper alignment, the joint will be better equipped to withstand the normal, everyday forces the spine and extremities encounter.
A joint that is not in proper alignment will shift one way or another; extra shifting causes stress on the articular surfaces of the joint, which will lead to advanced degeneration. In addition, the misaligned joint will not put pressure equally on the surface of the joint, which will lead to the formation of bone spurs. Bone spurs form because of Wolff's Law, which states that extra bone is deposited in stress lines and removed in areas in which stress is not applied.2
The Consequences of Lax Ligaments
Ligaments that are not holding their respective joints together properly can be said to be lax. Misdiagnosed or undiagnosed ligament laxity can cause years of chronic pain and inadequate treatment. It frustrates both the patient and the treating practitioner. In many cases the chronic pain may be due to ligament laxity that has resulted from a trauma in the patient's past history. Practitioners who are familiar with this condition and know how to perform appropriate physical exams can diagnose ligament laxity.
The unstable joint is subject to pain at the site of the joint and frequently distal to that joint. Patients suffering from pain due to ligament laxity will often experience relief of that pain from spinal adjustments, acupuncture, and physical therapy, but many times that pain recurs and sets up a cycle of chronic pain.
Flexible and Rigid Flat Foot
When we look at the adult foot, ligament laxity causes a common condition called flat foot. In this condition the foot does not have an arch. Flat foot is divided into two categories: flexible or rigid. In the flexible flat foot the arch can be seen when the foot is not bearing any weight or while walking on the toes, but as soon as weight is distributed across the foot, the arch falls and is flat to the surface the foot is standing on.
In most conditions of flexible flat foot, the heel will roll out, causing the foot to be in what is called a pronated position. The degree of pronation may vary from the left foot to the right foot. When an imbalance exists in the amount of pronation or flat-footedness from left to right, it will cause other biomechanical conditions to occur in the ankles, knees, hips, sacroiliac joints, and lower back.
Rigid flat feet, on the other hand, are caused by abnormal foot development and are associated with other conditions such as cerebral palsy, rheumatoid arthritis, and infections of the foot. In a rigid flat foot the arch is never visible. Causes of rigid flat foot include a malformation of a bone of the foot, or two or more of the foot bones fused together. Rigid flat foot often requires surgical correction.
Orthotic Support
Flexible flat feet usually does not require surgery. For most people, wearing a good shoe and having a custom-made, flexible orthotic is one of the best methods of treatment. When the arch has the proper support it will be able to withstand the stress of prolonged standing and walking.
Orthotics are not designed to completely correct the flat foot; they are designed to support the feet equally on both sides with an amount of support that will relieve tension and equalize any biomechanical imbalances that may be occurring. Ligament laxity has caused the foot to pronate and appear flat, which may be distorting the person's foundation for the rest of their body. For the person who seems to wear out shoes extremely fast because of a foot problem, a proper orthotic many times will allow them to wear their shoes longer.
The feet are the foundation for the rest of the body. They are designed to propel the body along during movement and to dissipate shock at the same time. They must be stable enough to withstand the stresses placed upon them, while being flexible enough to allow many complex movements required by activity. The ligaments along with the muscles of the feet are vital components for good foot health. Timely conservative intervention following injury can speed recovery and enhance performance levels.
References
- Glasco W. Conservative evaluation and intervention of a sport-related injury: turf toe. J Sports Chiro Rehab, 1998;12(2):82-86.
- Yochum TR, Rowe LJ. Essentials of Skeletal Radiology (first edition). Baltimore: Williams & Wilkins, 1987:422.
Dr. Manuel Duarte is a graduate of National College of Chiropractic and a diplomate of the American Chiropractic Board of Sports Physicians and the American Board of Chiropractic Orthopedics. He has extensive teaching experience and lectures on a variety of topics, including manual treatment procedures, rehabilitation, orthopedics, and sports medicine.