OUCH!
I have pain in my ankle, foot or toes when I run & I don’t know why?

When you have pain in you’re Ankle/Foot/Toes & treatment to the area has not resolved your symptoms you may be experiencing a phenomenon known as “Referred Pain.”

Pain in itself is not a simple sensation. Pain is a very complex sensation that encompasses a broad spectrum of components such as physical, emotional and psychological in nature. As a clinician, your pain description & pain pattern is an essential aspect during the evaluation. It is imperative that your medical provider ferret out the “pain generator “ (the source of your pain) In referred pain the sensation of pain is interpreted as coming from one area although it actually originates elsewhere. One of the most commonly recognized examples of referred pain is when a person is having a “heart attack” they often feel pain in the jaw, left arm and around the scapula(shoulder blade).

It is beyond the scope of this article to list and discuss in detail the many theories of referred pain. Suffice it to say, Neuroscientists still do not agree on the exact mechanism.
In the early 1950’s, a physician named George Hackett discovered after years of treating patients, that injury to a ligament in one part of the body can refer pain to another part of the body. He mapped out the referral patterns of ligament “trigger points” after injecting 20,000 ligaments with prolotherapy* in nearly 1900 patients over a 20 year period.

Dr Hackett was not alone in is work. Janet Travell, MD, the White House physician for President’s Kennedy and Johnson was studying and mapping out referral patterns of muscular trigger points. Dr. Travell coined the term “trigger point” in 1942. Side by side comparison of Travell and Hackett’s work shows similarities in their findings. This makes perfect sense given the etiology of laxity in ligaments and myofascial/muscular trigger points are the same. Usually some sort of trauma that results in a sprain or strain of the ligament or muscle respectively. Ligaments when injured are termed “sprained”; Muscles when injured are “strained.” In the instances where the ligament or muscle is still intact and attached completely at their prospective sites; the sprain or strain is essentially tearing or disruption of the fibers on the microscopic or macroscopic level.
Janet G. Travell, MD and David G. Simons, MD published Volume 2 of the Myofascial Pain and Dysfunction Trigger Point Manual for The Lower Extremities in 1993. Wherein several different types trigger points are defined. “An Active Myofascial Trigger Point: a focus of hyperirritability in a muscle or its fascia that is symptomatic with respect to pain at rest, and/or on motion that is specific for that muscle. An active trigger point is tender, prevents full lengthening of the muscle, usually refers pain on direct compression…………………………………”
Okay, I usually try to give my readers a laugh or two in my writings so I am definitely dating myself when I tell you that I had the privilege of having a Professor (A.J. as he was called by all the students) who worked directly with Dr. Travell and is even pictured in her book. Yep, I am getting up there in age and had to quit turning 39(again) when March 15th rolled around this year!
Landing the Plane: Although this article is focusing on the ankle/foot complex, the scope of the information applies to your entire body. So if you have unexplained pain in an area and all the examinations and diagnostic testing is negative for positive findings; start looking elsewhere especially if the onset of your pain started around the time you may have experienced an injury higher up the chain or even months later.

Common places that refer pain to the foot & ankle are:
(1) The ligament on the inside of your ankle, The Deltoid ligament can reproduce pain directly at the site but also refer pain to your 1st & 2nd toes.
(Hackett)

(2) --American Academy of Pain Medicine Poster Presentation at the 22nd Annual meeting February 2006
The retrospective study involved 51 patients who had positive hip pathology on X-ray or MRI AND had a greater than 90% reduction in hip pain while performing activities that were usually painful 30 minutes after their hip was injected with a potentially therapeutic agent. A total of 12 pain referral patterns were noted. Classic pain patterns for this population are groin pain and thigh pain 55% and 57% respectively. Pain referral was also seen in the buttock 71%, the lower leg 22%, the foot 6% and the knee only 2%. None of the patients reported referral of pain into the low back.
(3) The hip joint ligaments refer pain down the leg to the big toe (Hackett)
The sacrotuberous and sacrospinous ligaments refer pain to the heel
(The above mentioned ligaments are located around the low back and sacrum region)
(4) The sacroiliac ligaments refer pain to the lateral/outside part of the foot which often causes a mis-diagnosis of sciatica. Pain traveling down the back and into the leg and foot is usually from ligament weakness (Hackett) in the sacroiliac joint; not from a pinched nerve. *Prolotherapy is performed by injecting the weak ligament with anesthetic and sugar-water to irritate the ligament to stimulate the healing process and with the influx of scar tissue, stiffen the lax ligament. Prolotherapy remains controversial in the medical field. There are world renowned MD’s that swear by its efficacy. However, there are limited studies to prove it works. This author received several sessions of prolotherapy in my neck and lumbar spine; well over a 100 injections each sessions with no relief. MRI of the neck reveals a problem not amenable to prolotherapy. FWIW.

(5) The sciatic nerve can become entrapped within the piriformis muscle. In severe cases, pain will radiate down the leg and into the foot mimicking a herniated disc. Atrophy (loss of muscle size and strength) can also be symptoms

A herniated lumbar disc or Protruding disc and possibly a “bulging” disc can refer pain to the foot. Depending which level you injured and the size of the disc injury will dictate if and where you will feel the pain. From my own clinical experience, individuals who experience leg or foot pain & do NOT have back pain usually think they have “pulled” their hamstring muscle and believe it or not, have full, pain-free range of motion in the spine. Most herniated discs can be effectively managed with physical therapy focusing on a progressive core stabilization program, Pilates & body mechanics training, lifestyle modifications, epidural injections & pain management.

Depending on which level is affected, you could potentially feel all, some or none of the following symptoms: pain, numbness, tingling, electrical burning sensation, weakness. If you are having trouble walking because your foot “flops” when you step you need to seek medical attention from a reputable spine surgeon for a consultation. You are welcome to contact our office if you need references. Or if you have bowel or bladder changes, contact your physician immediately or go to the emergency room.

Prevention is always the best key to avoiding a back injury or insidious onset of back pain. While excellent “Core Strength” is the buzz word these days; you need overall good strength and whole body flexibility. A thorough evaluation from the Physical Therapists at our office can identify areas of imbalance, weakness, stiffness or myofascial restrictions all of which are pre-cursers to eventual problems. Even if you are not symptomatic, the Physical Therapists at XCEL PT can establish a proper home exercise program for you to do at home or add to your gym program. We have gym memberships and Pilates Studio memberships available on a month to month basis; no initiation fees or contracts to sign.
Individuals must be trained by XCEL PT or another qualifying studio to be eligible to use our fantastic Balanced Body Pilates Equipment in our private beautiful studio on an independent monthly basis.

Devra A. Bommarito, PT
Co-Owner XCEL Physical Therapy
Stockton 209.546.0944 / Ripon 209.599.7073