A Note From Dr. Fields
Below is a description of most common conditions for lower extremity pain. While I hope this info helps to provide some insight, it is not a substitute for a doctor’s visit. There are some other very serious reasons behind pain that may require immediate medical attention, so please don’t take the risk of self-diagnosing. Please see a physician like a Chiropractor who can differentiate between a musculoskeletal cause of your pain, and other more serious conditions.
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Note that NERVE PAIN is addressed in a different section here.
Lower Extremity Conditions
The specific location of pain can give some insight to what the trouble might be. There are five areas of symptoms that I find are the most common when my patients report they are having hip pain: the sacro-iliac region, the trochanteric region, the groin region, the iliac crest, and the anterior hip.
This is the area of the body in the upper inner buttock that is close to the spine. In the
medical world, this is actually not referred to as the hip, but rather the right or left SI region. Though, it doesn’t matter what we physicians call it, because most patients just complain about the hip and point to this area…which is good enough for me. The SI joint is composed of two big bones. This is the sacrum and the ilium. It is a large fibrous joint that has much less movement than your typical joint, but is very important for posture, gait, and weight bearing. The SI joint rocks forward and up or back and down.
Sometimes tight muscle groups or unlevel pelvis causes this joint to rock out of place one way or another and this causes excessive stress resulting in a deep achy or sometimes sharp pain that can travel up the back or down into the buttock. Correcting the joint position, rebalancing the muscle groups, and leveling the pelvis are the biggest points of care when I am treating an SI joint issue.
The side of the hip bone right where the femur meets the pelvis is another area of
hip pain. We call this the trochanteric region because the big bony area of the hip joint is called the trochanter. Lots of important structures lie in this area. The two biggest players are the tensor fasciae latae muscle which connects to the iliotibial band, and the trochanteric bursae. By far, these two structures are the most common sources of lateral hip pain. A tight tensor fasciae latae will pull on the iliotibial band causing tightening across the joint that leads to irritation and inflammation of the underlying trochanteric bursae. Typically, both problems occur together. In fact, the insurance companies code these two problems with the same code: Iliotibial band syndrome and trochanteric bursitis.
I find most people with this problem usually have a short leg and an unlevel pelvis. My treatment plan for this problem usually includes ultrasound/electro stimulation, manual release of the tensor fasciae latae and iliotibial band, and adjustments to correct the unlevel pelvis that includes the affected hip joint. There is typically spinal misalignment (normally a lumbar tilt) associated with this type of problem, so I usually end up treating the low back as well. Often the tension in the tensor fasciae latae and iliotibial band runs down the side of the leg and may even affect the outer knee. In this case, I may also need to address the knee joint.
The inner part of the hip joint is referred to as the groin…not that anybody needed me to explain that. Most all of us have “Pulled our groin” during some activity. This is typically a pulled adductor muscle. The problem affects younger patients who are active in sports, but can occur at any age. There is however another culprit that I see regularly: Osteoarthritis. This is a type of arthritis that is due to the wear and tear of joints and typically affects joints that bear more weight. Osteoarthritis of the hip is almost always described as hip pain that is achy and sharp on the inside of the groin.
Iliac Crest Pain
The region at the top of the hip bone on the side of your body is the iliac crest.
We call it this because it is the upper most portion of the ilium. Just like the crest of a mountain. Attaching to the iliac crest is the quadratus lumborum muscle. If there is a misalignment in the pelvis or spine that causes tilting of the lumbar spine, this muscle becomes over active trying to fight the forces of gravity while in an upright position.
Eventually this can lead to pulling and irritation of the insertion of the quadratus lumborum right on the iliac crest. Typically I find that a patient tends to lean towards one side during lifting activities. This habit can lead to this sort of dysfunction. Stretching this muscle and aligning the spine and pelvis usually do the trick, but I always address proper lifting and bending habits to make sure it doesn’t come back.
Anterior Hip Pain
In medical terminology, anterior simply means front. Below are a few causes of frontal hip pain. By far the most common cause of anterior hip pain that I see is a strain/sprain. Strain means damage to a muscle, and sprain means damage to a ligament. Sprains are far less common than strains, but do occur during an injury when the leg goes back behind the body. Strains in the hip flexor groups are fairly common in sports. Soccer players reaching for balls, runners overexerting themselves, contact sports that require rapid muscle recruitment. In fact, any action that forcibly brings the leg forward against resistance can cause these types of injury. It can happen with one big traumatic movement, or it can be a repetitive trauma, or a little of both.
The hip flexor muscles include parts of the quadruceps (namely the rectus femoris), the iliopsoas complex, and the gracilis. The iliacus muscle sits inside of the iliac bone and attaches to the upper part of the femur. The psoas muscle stretches from the upper part of the femur to the side of the lumbar spine. These two muscle’s fibers blend together and are therefore called the iliopsoas group. The rectus femoris is one of the four branches of the quadruceps muscle. It runs all the way from the base of the knee to the front of the ilium. It is the only part of the quadruceps to cross the hip joint. The graciliis is a small thin muscle that wraps around the leg starting from the front of the iliac bone down to the inside of the knee. Tears in any of these muscles can create anterior hip pain. Strains and sprains are addressed with P.R.I.C.E (protection, rest, ice, compression, elevation-when relevant) acutely within the first few days. Ultrasound helps to speed up healing. Rehab of the affected tissues is also important to regain functionality of the muscle/ligaments that have been damaged.
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The menisci (plural of meniscus) are two cartilaginous pads in the inside and outside of the knee joint. Their purpose is to protect the joint, help to make motion more fluid, and act as a shock absorber. We name these two pads by their position: the medial (inside) and the lateral (outside). Menisci can become injured during activity or simply wear out if the dynamics in the joint become altered. This usually leads to tearing and the pain is felt as a sharp or lancing sensation deep inside the joint. Altered positions of the joint are important considerations when evaluating the knee. People who are valgus (knock-kneed) tend to wear on the lateral meniscus, while people who are varus (bow-legged) tend to wear out the medial meniscus. Chiropractors can help by repositioning the joint and retraining the knee to function correctly again.
Medial and Lateral Collateral Ligaments
There are two collateral ligaments in the knee and they are named just like the menisci. The inside of the knee has a medial collateral ligament and the outside has a lateral collateral ligament. The purpose of ligaments is to provide stability in the joint and keep the joint from falling out of place during movements. The MCL and LCL mostly help to keep side-to-side movement in check, but also help to prevent rotation of the knee. A valgus position of the knee stresses the medial collateral ligament while a varus position stresses the lateral collateral ligament. Damage to this structure is felt more superficially as a sharp achy soreness on the inside or outside of the knee and usually causes the knee to be tender on the inside or outside aspect.
Anterior and Posterior Collateral Ligaments
Just like the ligaments above help to keep side-to-side motion in check, the anterior collateral ligament (ACL) and the posterior collateral ligament (PCL) help to keep front-to-back motion in check and also contributes to keeping rotation in check. The more common injury is to the ACL which usually happens in sports when abruptly changing the direction of motion as when breaking and cutting a run during football or soccer. This situation usually results in immediate collapse of the individual and most of the time requires surgery. The PCL is less commonly injured because it is a bit beefier than the A CL, but injury still occurs. The mechanism of injury of the PCL is typically during a tackle where a substantial amount of force is applied to the front of the lower leg while the knee is bent.
Hyperextension-type injuries can also lead to PCL damage. Just like its cousin the ACL, the PCL typically requires surgery. The balance of the quadriceps and hamstring have more to do with protecting the ACL and PCL, so there is definitely training that can be done to give these structures some extra defense against injury. But… in many situations, the trauma is so great that no amount of training would have prevented the injury. Luckily a good surgeon can repair and re-pin the torn ligament the majority of the time. However, after the surgery, a good rehab program is essential for regaining functionality.
Chondromalacia Patella & Patellar Tracking Disorders
You may not know this, but your knee cap is not really a normal bone… It is a sesamoid bone (No, not the seeds that come on hamburger buns). A Sesamoid is a bone that develops inside of a tendon (the part of a muscle where it attaches to the bone) that helps to guide the motion of the joint and protect the tendon as the tendon glides over a groove in a bone or surface that creates a lot of stress or friction. Sesamoid bones occur in several places in the body, but the knee cap is the biggest. Without the knee cap, your tendon would fray and become damaged when you move your knee. The knee cap is shaped to fit and slide across the front of the knee joint. When you contract your quadriceps muscle, the knee straightens and the knee cap helps to guide the motion keeping the tendon centered across the front of the knee. People who have varus or valgus positions of the knee can cause scraping of the knee cap across the inside or outside of the groove. The underside of the knee cap is made of a slick cartilaginous substance that helps to reduce friction. When the knee cap tracks to the inside or outside of this joint, it can wear on that surface creating micro damage that accumulates over time and the once slick surface now becomes rough and cannot do its job of reducing friction. Over time, the damage gets bad enough that the surface is significantly changed and pain and inflammation quickly follow. The pain is felt under the knee cap and occurs especially when the knee is flexed under a load as when walking up and down stairs. Chondromalacia patella is the name we use to describe the damage under the knee cap, while patellar tracking refers to the movement of the knee cap across the front of the knee. You can now see how these two things are related.
Also known as degenerative joint disease and nicknamed the “wear and tear” arthritis, OA is the most common type of arthritis. OA can occur in any joint in the body, but is much more common in the weight bearing joints of the body. The knee is definitely one of these joints. Osteoarthritis is AL WAYS secondary to some other process. Most of ten that process is a joint mis alignment and muscle imbalance. Just like the nickname implies, wear and tear that occurs over time is the underlying reason for all kinds of osteoarthritis. Any of the above problems if left unchecked will eventually lead to arthritis. That old trick knee or sports injury can cause enough repetitive damage in the joint that the cartilage will be lost and joint will begin to calcify and change shape. Please don’t ever tell yourself that your arthritis is just due to old age. This is not true, and usually leads to a person thinking that there is nothing that can be done, so they don’t. This is false.
Maybe the joint can’t be 100%, but there is sure a lot we can do to improve the dynamics of the joint and at least stop it from getting worse. You will note one reoccurring theme throughout this article: Knee problems are almost always due to a dysfunction in the alignment and movement pattern of the joint. Even if the injury requires surgery, rehabilitation of the knee is still necessary to address the underlying altered joint dynamics. It is much more preferable to address these joint dynamics before injury occurs rather than after.
Please, if you have knee pain then make an appointment today. Let’s get to the bottom of it before the problem becomes any worse. If you have questions, I would be happy to sit down with you and talk before your examination at no cost to you.
Your health and livelihood is my primary concern.
Medial Tibial Stress Syndrome more commonly known as shin splints is a condition associated with stress and pain at the inner border of the lower leg. It is specifically the inside of the tibia bone that is affected. This is particularly common in running and jumping sports but can occur during any activity that causes repetitive stress in this area. Activities that involve running up or downhill or on uneven surfaces are associated with developing shin splints. Recent changes in footwear or beginning a new exercise regimen can also be associated with onset of symptoms.
The pain is produced when there is damage done to the fibers that connect the muscle and fascia to the shin bone. Muscle and fascia connect to the periosteum (membrane that covers the bone) of the tibia via Sharpey’s fibers. Contraction of the muscles produces a force that pulls on this connection causing microdamage and inflammation. Shin splint pain can be a deep, dull throbbing or razor-like and sharp. This of course is worse with activity. Being that Sharpey’s fibers and the periosteum are what carry the sensation of the bone, it can almost feel like a fracture. In fact, stress fracture is something that a physician needs to rule out during examination. It is also possible for repetitive strain of the muscles of the front of the shin to be confused with shin splints. This condition is typically associated with faulty mechanics like over pronation of the foot, flat feet, tight gastrocsoleus complex (calf muscles), achilles abnormalities, weak intrinsic foot muscles, and weak dorsiflexors (especially anterior tibialis).
Acute care involves rest, ice, and gentle therapies like pulsed ultrasound and soft tissue techniques. As care progresses joint manipulation by our Chiropractor, rehab, and foot orthotics should be considered. The goal of treatment is to change the biomechanics improving the efficiency of the patient’s gait and thereby reducing the repetitive stress.
The majority of ankle problems I see at my clinic are usually related to a strain/sprain from “rolling” the ankle. Either the initial trauma or the lasting effects of that injury alters the mechanics of the joint. The resulting dysfunction leads to years of maladaptation and repetitive microtrauma with the most common outcome as osteoarthritis of varying degrees. As such an important foundation and weight-bearing structure, these injuries need to be resolved as soon as possible to avoid such damage accumulating over time.
The tibia and fibula are the two bones of the lower leg. These two bones sit on the talus which is the topmost foot bone. The junction between these three bones is the talocrural joint, commonly known as the ankle joint. The majority of the movement at this joint is a forwards and backwards motion (dorsiflexion and plantar flexion), but there are also components of side to side motion and minor amounts of rotation.
Typical strains/sprains occur as the ankle encounters a motion that causes the foot to roll inwards or outwards and overwhelms both the muscular force and the ligamentous barrier along both sides of the joint. This damage can range from being minor to severe and requiring surgery. It is very common for a patient to allow the ligament to heal by itself and simply protect the ankle for several weeks or months not realizing that the injury has resulted in altered joint mechanics.
The truth is often that the ligaments have been damaged and stretched and can no longer hold the bones in the correct place during movement and weight-bearing. With the muscles strained, these too cannot manage to correctly stabilize the joint and the result is a chronically stressed structure. One of the tell-tale signs that this is occurring is clicking and popping or a sense of the joint feeling different.
As you might imagine, re-injury is also quite common rolling the joint a second time or more. Over time, the condition results in repetitive damage of the cartilage in the joint and degenerative/arthritic changes set in. Correction involves not just realigning and re-balancing the joint with manipulation, but also strengthening the surrounding musculature to protect and restrict the motion in the joint. This gives the ligaments a chance to heal and shrink back up. This is in fact the nature of ligaments… they shrink and tighten over time. This is beneficial in most cases of healing, but can also result in dysfunction in other cases.
It takes the right kind of physician to know whether ligaments need to be lengthened or shortened to correctly balance a joint. If you suffer from ankle pain, see a Chiropractor or other qualified physician that specializes in biomechanical injury.
The longer you let the problem ride, the worse it is likely to become.
Plantar fasciitis is an irritation of the connective tissue of the foot that runs from the toes and ball of the foot to the heel. Recent studies show that plantar fasciitis is less inflammatory and more degenerative in nature leading to some professionals wanting to change the name. The plantar fascia structure is important in maintaining the arch of the foot and even acts as a spring that assists gait.
So why does it become so irritated? You can think of the plantar fascia as a fibrous web that connects from one end of the arch of the foot to the other. The plantar fascia is actually more of an aponeurosis than a fascia. This structure is almost like a ligament in that it helps to check the motion of the foot and ties structures together and gives the arch a bit of spring. If you jump up and down, the weight of your entire body is loading on the arch of your foot. The plantar fascia helps to maintain that arch during such times of loading. It acts like an ultimate barrier. The muscles in the foot are supposed to be powerful enough to maintain that arch, but can become weak or inactive and passes this stress onto the plantar fascia. If the stress occurs for long enough it begins to repetitively damage the plantar fascia and it will eventually become symptomatic.
Surprisingly enough, high arches (which would indicate a tighter/shortened plantar fascia) as well as flat arches are associated risk factors for developing plantar fasciitis. In fact, so is just about any factor that would alter or increase load to the plantar fascia or inactivity of the supporting musculature including: obesity, change in foot wear, change in exercise habits (especially excessive or in bad form), tight calves, leg length inequality, sedentary life style, or standing on hard surfaces for long periods. I know that some of those factors sound contradictory, but remember that all of those things can change foot structure and change the muscular and mechanical dynamics of the arch. It is common for structures in the body to become calcified when under stress. This is true of the plantar fascia at its insertion on the heel. This is the body’s attempt to reinforce the area under stress by depositing calcium in soft tissues. This can lead to a heel spur at the calcaneal bone, but please understand that this is a reaction to the problem and a heel spur is not itself the problem or cause of plantar fasciitis, though it can help with diagnosis.
Treating plantar fasciitis usually involves ultrasound to promote healing, manipulation by our Chiropractor to correct bony alignment, stretching the calf muscles, and strengthening the intrinsic foot muscles. In more serious cases, I may refer out for shockwave therapy (originally designed to break up kidney stones). In some cases, certain injections may be warranted. Personally, I do not recommend any release surgery because this alters the length of the plantar fascia and usually does not have a good long-term outcome.
Pes Planus is commonly referred to as flat foot/feet. This is a condition where the arch of the foot is lost under weight-bearing conditions and the top of the foot typically rolls inward during gait. Pes planus usually leads to altered mechanics and stress in joints which can cause arthritis, plantar fasciitis, corns, calluses and general foot pain. The solution usually involves foot orthotics, manipulation of the foot, and strengthening exercises to retrain the arch of the foot.
Just like flattening of the foot, a high arch causes altered dynamics of the foot as well and can lead to excessive stress. There is a propensity to develop hammer toes with pes cavus which can lead to arthritis and tendinopathy. Manipulation and stretches is warranted for this condition. Shoe inserts can help. In severe cases, surgery may be necessary.
Morton’s Neuroma is a kind of benign tumor (not malignant) that can grow on the nerves that pass between the metatarsal bones in the foot causing compression of the nerves. Symptoms include pain and numbness or altered sensation in the foot/toes. Avoiding compressive footwear is important. I refer out for this condition, and only do minimal treatments myself.
Bunions are a bony outgrowth of the base of the big toes and an altered angle of the toe and foot. This condition actually begins in the midfoot at the base of the metatarsal bone at the tarsal-metatarsal joint. The angle of the metatarsal is altered causing the bone to travel outward while the toe compensates by leaning inward. Manipulation, ultrasound, and rehab are the mainstay of conservative therapy. Altered footwear and/or inserts are warranted. However, there is a misconception about footwear’s roll in this condition because even people who have never worn shoes in their lives have developed bunions. In severe cases, surgery is necessary.
Gout is a systemic arthritis. It is one of the metabolic arthritides associated with increases in uric acid levels. In high concentrations, uric acid can aggregate and form crystals in the joints that irritate and cause damage. The first place this shows up is usually the base of the big toe. Changes in diet and exercise are very important to treat this condition. Ultrasound and gentle manipulation are a good conservative approach, but I also refer out for this condition to the patient’s family doctor or a rheumatologist. Gout is a team approach.
Tarsal Tunnel Syndrome
Tarsal Tunnel Syndrome is a space along the inside of the ankle where the tibial nerve and artery pass from the lower leg into the foot. Inflammation, irritation, trauma, misalignment of the bones of the foot, and arthritis can all cause compression of the nerve and/or artery in this space. Symptoms are typically heel and foot pain with numbness, but if the entrapment occurs high enough the entire foot can become involved. It is more common for pain to radiate into the big toe and the or first three toes. Manipulation and retraining the arches of the foot are key here.
Also called the wear and tear disease of the joints, OA can happen anywhere in the body but prefers to develop in weight bearing joints. Manipulation and ultrasound can work wonders in the foot and ankle. See the section on arthritis for more detail.
Matatarsalgia is essentially stress on the balls of your foot. There are bones in your feet called the metatarsals. These are long bones that connect to your toes also called the forefoot. People who have mechanical changes that result in shifting more weight to their forefoot are at risk for developing this. For example: during pregnancy, changing shoe ware, change in activities, tight calves, or lax plantar fascia can all start overloading the heads of the metatarsals experiencing pain and inflammation in the balls of their feet. Manipulation and foot taping along with ultrasound are great care combos for metatarsalgia.