Dr. Christopher Bourke is a board-certified podiatric surgeon with the Mid-Atlantic Permanente Medical Group. He sees patients at the Kaiser Permanente Caton Hill Medical Center.
We are grateful that military personnel and first responders serve our country and our community. While they serve our country bravely and heroically, they put their bodies at risk of developing different health problems, including mental health challenges, lung conditions, neurologic disorders, and chronic pain.
As a podiatric surgeon, I also see how grueling serving in the military can be on the feet. Carrying heavy equipment, enduring demanding days of boot camp, walking and running on uneven terrain, and sustaining periods of activity can all lead to foot and ankle injuries.
This Veterans Day and Military Family Appreciation Month, I want to take the opportunity to share information about common foot problems I see among active-duty personnel and veterans, while also noting that these conditions can affect anyone who puts a lot of stress on their feet.
Tendons are tissues that connect muscle to bone. Tendon problems can include the following:
- Acute tears/ruptures, which are tears that happen suddenly;
- Tendinosis, which is chronic degeneration/thickening of the tendon;
- Tenosynovitis/peritendinitis, which is inflammation of the sheath around the tendon.
There are many different tendons that could be affected in the legs and feet:
- Achilles tendons — The Achilles tendons connect the calf muscle to the back of the heel.
- Extensor tendons — The extensor tendons run on top of the foot.
- Posterior tibial tendons — The posterior tibial tendons connect the calf muscle to the bones on the inside of the foot. Posterior tibial tendonitis is often seen in patients with flat feet.
- Peroneal tendons — The peroneal tendons run along the outer ankle bone. Symptoms of peroneal tendonitis may be felt when walking on uneven terrain.
Symptoms of these conditions may include swelling and pain that comes and goes, but typically improves with rest or cessation of activity. Treatment includes rest, ice, compression, and elevation. Often, a patient will need bracing or immobilization. Anti-inflammatory medications can help alleviate pain.
A stress fracture is a complete or partial bone fracture, which often is caused by having repeated, cumulative stress applied to the foot. Stress fractures are most likely to occur when someone increases their frequency of activity, the duration of their activity, and/ or the intensity of their activity. Change of terrain and/or abrupt change in shoe gear, such as those soldiers experience when serving in the military, can increase a person’s risk of developing a stress fracture. There is some evidence that doing strengthening foot exercises can prevent stress fractures or stress-related injuries in the feet. Your podiatrist can show you how to do appropriate foot exercises.
The most common area to get a stress fracture is the third metatarsal of the foot, the long bone behind the third toe. The second and fourth metatarsals also are prone to stress fractures.
Symptoms of a stress fracture include persistent pain, noticeable swelling, and difficulty running or walking.
The treatment for a stress fracture includes rest, immobilization in a boot, or protection of the fracture site for about four to six weeks, ice, compression, and elevation. Your physician may have you do a Vitamin D lab test to see if your levels are low. Vitamin D and calcium supplements have been shown to decrease the risk of future stress fractures, particularly in Navy recruits.
Ankle Sprains and Lateral Ankle Instability
Ankle sprains are very common among the military and first responders due to unstable terrain. The best way to initially treat a sprain is with rest, ice, compression, and elevation. Bracing can allow ligaments to heal. Physical therapy and at-home exercises, including peroneal strengthening and balance/proprioception retraining, can be vital to ensuring the ankle heals well.
If a sprain isn’t well treated, it can lead to chronic lateral ankle instability, a condition in which the ankle essentially gives out, especially on uneven train. Depending on the extent of the condition, physical therapy can help, or arthroscopic lateral ankle ligament reconstruction surgery may be necessary. This surgery, known as the Brostrom-Gould procedure, is an outpatient surgery in which a camera is inserted into the ankle to guide the surgeon. It is less invasive than open surgery, and patients tend to recover more quickly and with fewer complications.
The plantar fascia is the thick ligament – or band of tissue – that connects the heel bone to the toes. Plantar fasciitis occurs when the plantar fascia is strained and damaged faster than it can heal. Military personnel and first responders, who carry extra loads and equipment, are at high risk of developing plantar fasciitis. Like other foot conditions, plantar fasciitis can be caused by increased frequency, increased intensity, and increased duration of activity.
Heel pain is the most common symptom of plantar fasciitis. Most people experience the worst of the pain first thing in the morning, when they step out of bed, or after periods of inactivity. The pain then transitions from a stabbing pain to a dull, achy pain as the day progresses.
Treatment for plantar fasciitis includes rest, ice, elevation, foot and leg stretches, anti-inflammatory medications, corticosteroid injections, orthotic footwear, and rarely minimally invasive surgery.
Preventing Foot Injuries
While we are fortunate to have many ways to treat foot injuries – from at-home remedies such as ice and rest to medical procedures including surgery – our main goal is to prevent foot injuries from happening in the first place. Here are some tips for our service members as well as for anyone who spends a lot of time on their feet:
- Wear appropriate shoes. Shoes should be supportive, having cushioned soles and good arch supports. Avoid training in shoes that are worn. I recommend changing your training shoes or orthotics every 300 to 500 miles, or every three to five months depending on activity level, because the midsole cushioning wears out and increases the stresses/impact on joints, bones, and muscles.
- Stretch and warm up before training or exercising. Stretch again when you complete your routine. Intrinsic foot strengthening exercises have been shown to prevent stress-related foot injuries.
- Increase the duration, intensity, and frequency of your activity gradually. I recommend a 10 percent rule. That means, for example, if you are training 200 minutes a week, the next week, increase that time by no more than 10 percent, to 220 minutes. A slow and gradual ramp up is kinder to your feet than making sudden changes to your training regimen.
- Reduce total running or activity mileage and increase the variety of activities.
If you know you are about to train in a boot camp or participate in a demanding activity program, reach out to your physician before you start. You can discuss appropriate stretches, be fitted for orthotics, and develop a personalized plan for other preventive care measures.
The Mid-Atlantic Permanente Medical Group is honored to provide outstanding medical care to members of the military, veterans, first responders and their families. Our team will work together, across departments, to give you the best, most personalized care you deserve. If you have are facing a foot condition, don’t suffer in silence. Reach out to your physician, who can develop a personalized treatment plan.
Feature image by Marc Calleja/stock.adobe.com
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