Pregnancy does not cause flat feet but the arch of the foot may become more flexible and flattened. This can produce pain from the arch (plantar) of the foot to the rear (heel) of the foot. The pain may cause a generalized aching or a stabbing pain and can range in intensity. Prolonged standing can often aggravate the pain. Fallen arches can also increase the likelihood of developing bunions and heel pain. A recent study has shown that foot size may increase by 1-10 mm in length and/or width increasing the risk of ill-fitting shoes. This is significant as ill-fitting shoes have been shown to be a factor in falls among the elderly. A larger foot combined with changed posture and balance could, in theory, increase the likelihood of falling during the later stages of pregnancy.
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During pregnancy, the body goes through many changes within a relatively short period of time. Key among these changes is loosening of the ligaments, which serves to enable the birth of the child by allowing the pelvic girdle to expand. However, the effects of this hormone-induced change can spread throughout the body. Many women with foot and ankle pain during pregnancy do not relate this to the increased laxity of their ligaments and instead consider it to be a localized problem.
Understanding Pregnancy-Related Foot and Ankle Pain
Common foot and ankle symptoms experienced during pregnancy include over-pronation, edema (swelling due to increased fluid build-up), changes to foot size and length, foot and leg fatigue, poor balance, and pain in the joints of the foot. These symptoms can result in pain in the feet, legs, and lower back. The pain may restrict the ability to exercise and lead to a less active lifestyle, but foot pain itself is often not enough of a motivation to act. By understanding the effects of pregnancy on the feet and the changes to foot structure, it is easier to see how foot pain can be detrimental to overall health during pregnancy.
Understanding pregnancy-related foot and ankle pain is the first step to making a healthy change. There are many factors that contribute to foot and ankle pain during pregnancy. The primary change that a woman undergoes during pregnancy is the increase in body weight. This results in a significant shift in the center of gravity, causing the arches of the foot to collapse and the knees to rotate internally. Furthermore, there is a natural release of hormones during pregnancy which cause the ligaments in the body to relax. This is essential for the birthing process; however, it can cause the bones to shift and the arch of the foot to flatten. Reduced muscle strength and tightness of the muscles can also have an effect on foot function.
Causes of Foot and Ankle Pain during Pregnancy
During pregnancy, your body is preparing itself for the experience of childbirth. The body releases a hormone called relaxin, which relaxes the ligaments in the pelvis to allow the baby to pass through the pelvis more easily during birth. The hormone is also present in a smaller quantity in non-pregnant ladies to aid in the movement of bones. It is increased dramatically in pregnant women, which leads to the loosening of all ligaments throughout the body. Loose ligaments can cause the bones in the feet to ‘spread’ and can cause pain in the feet and ankles. Relaxin remains in the body for up to 6 months following childbirth, so the pain will last during this time. Changes in posture, due to the growing fetus and increased lumbar curve of the lower back, cause considerable strain on the feet joints and muscles. Flat feet are a side effect of this and can cause pain in the feet. All of these issues tend to put strain on the heel and arch of the foot, causing a variety of heel and arch pain. High estrogen levels in pregnant women can lead to swelling in the feet and legs, which is also painful.
Because of the extra strain on the body, added weight, and changes in posture that pregnancy brings about, pregnancy can affect many females in different ways. For some people, it can be a painful experience. Pregnancy-related back pain is not at all uncommon, particularly in the lower back area. Fortunately, there are ways to combat this. In almost all cases, a lady is likely to put on weight during pregnancy. This added bodily load can cause pain and inflammation in your feet and ankles. This is not something that should be taken lightly. Ignoring foot pain can lead to more serious problems post-pregnancy. Mild exercise, rest, ice, and common sense are simple remedies for pregnancy-related foot issues.
Common Symptoms of Pregnancy-Related Foot and Ankle Pain
Swelling or edema of the feet is also an extremely common symptom of foot and ankle pain during pregnancy. This can lead to discomfort in normal footwear, and sometimes appropriate footwear cannot be found due to the increase in size of the feet. Edema is often further complicated by leg cramps, which are generally due to the changes in blood circulation. Erythrocyte production increases by approximately 30-50% in the 1st trimester of pregnancy, and plasma volume increases by 30-50% in the 2nd trimester. This is known as hyperdynamic circulation and is one of the causes of microvascular damage resulting in edema.
Whether biological, structural, or hormonal, there are a number of ways in which pregnancy can cause musculoskeletal problems. The obvious and most common explanation of pregnancy-related foot pain is the increase in weight in the latter stages of pregnancy. This is known to cause a change in foot posture, as the feet become flatter and more pronated. This tends to lead to arch and/or heel pain, although in some cases, it can result in overpronation – a painful and sometimes crippling condition more commonly known as flat foot.
Enlarged or changed foot size. Swellings or edema of the feet. Excessive overpronation. Short heel pain. Forefoot/rearfoot pain. Severe leg cramps.
Coping Strategies for Managing Foot and Ankle Pain during Pregnancy
Regulating foot and ankle pain possibly the most influential measure for first-time mothers who want to prevent foot alterations from having long-term effects. Addressing the pain issue will involve visiting a podiatrist, making use of analgesics, or opting for foot surgery. An actual cause and effect relationship with foot and ankle pain and its effects on foot health has not been well documented. Prevention of foot alterations can be achieved probationary for pregnant women experiencing foot pain. If using any of the following measures does in fact alleviate pain and reduce levels of foot alteration, it is recommended that these measures be continued until full term of pregnancy to avoid foot health risks and re-examined postpartum.
One study has shown that reductions in both heel height and shoe width significantly reduce both forefoot and lateral foot pressures. Size increases in toe box width and depth are recommended to alleviate forefoot pain and pressure. Width increases in the midfoot area should be gradual, with maximal changes made at the area of the bunion to reduce lateral foot pressure, foot width and arch height increases have been found to be highly correlated. Any increase of foot width or arch should be accommodated by changes in shoe width as well as increases in shoelace length. An increase of arch height should also be addressed by an add-on orthotic for increased support and cushion. 0.5cm increases in arch height have been found to significantly increase the probability of midfoot pain in both men and women.
Styles that do not constrict foot movement, yet supply maximum support and protection, are ideal. Wearing an athletic shoe with good arch support can provide added comfort and support. A shoe should be light in weight and provide cushion and shock absorbency. Available footwear may be limited for pregnant women with swollen feet and ankles, therefore maximizing the function and comfort of available footwear may be the best solution. This may involve altering a shoe for comfortable fit.
Expecting mothers may also alleviate foot and ankle pain by considering footwear. Visible signs of pregnancy include increases in foot width and arch height and changes in foot shape. Several studies have found that first-time mothers often experience changes in their foot dimensions. In most cases, these alterations were found to be permanent. Therefore, when levels of discomfort may be affected by changes in foot size and shape during pregnancy, women may not only need to have different-sized shoes, but also shoes of a different style than they originally preferred.
Footwear Choices and Modifications
The majority of foot and ankle pain experienced during pregnancy can be easily managed through appropriate footwear. This may involve wearing different shoes, using arch supports, or wearing graded compression stockings. Limited evidence suggests some reduction in foot and ankle edema with the use of graded compression stockings. However, in late pregnancy, it may be necessary to resize the stockings to fit the changing leg size better. Reduced stability exacerbated by changes in the lower limb during pregnancy means implanted functional instability or mechanical abnormalities. Foot orthoses are often required to control excessive pronation and prevent exacerbation of symptoms. Studies have found custom-made orthoses to significantly reduce general foot pain in late pregnancy. Women reporting increased foot size during pregnancy may find their newly purchased shoes are now too small. We recommend regular checks of foot size and, if necessary, the accommodation of a larger shoe width and depth. In general, shoes with a rounded toe-box and increased depth are more comfortable. Ultimately, footwear should provide adequate shock absorption and be supportive and stable on various terrains.
Stretching and Strengthening Exercises
There is some evidence to suggest that strengthening exercises are effective for prevention and treatment of low back pain, and the same principle will apply for the pregnant woman. When exercised correctly, the back and abdominal muscles are able to support the increased load of the baby more effectively and therefore reduce pain. However, caution must be taken not to overload the weakened quadratus lumborum (lower back) muscles, as these are already at risk of injury.
During pregnancy, hormones are released and kilos are gained. The increasing weight of the baby, placenta, and amniotic fluid also affect the expectant mother’s musculoskeletal system. The lumbar curve is accentuated to shift the load of the baby forward, thus changing the mother’s posture and the way her back muscles are able to stabilize. These changes, combined with the increased laxity of ligaments in pregnancy, can increase the mother’s vulnerability to injury and may increase discomfort and back pain. It is important to note that back pain experienced during pregnancy is not the same as back pain experienced at other times in a woman’s life. This is because the biomechanical factors contributing to the pain are different.
Rest and Elevation Techniques
When elevating your legs, utilize a pillow under each leg. This will minimize stress placed upon your hip joint, which may occur if you were to allow your feet and legs to hang off the end of a lounge or bed. Using a pillow will provide comfort and support and will encourage you to maintain this position for a longer duration. Note: when in the lateral rest position, avoid placing a pillow between your knees and under your bump. This will promote a change in the contour of your spine and lead to postural misalignment.
When at rest, elevate your feet and legs as often as possible. The level of elevation is important – the legs should be raised above the level of the heart. This will allow the force of gravity to be overcome, therefore reducing swelling and discomfort. Elevation is imperative for those with pitting edema. It will enhance the reabsorption of tissue fluid, evident by the indentation left in the lower leg when pressure is applied with a finger. Elevation is an activity that is simple, yet often forgotten by pregnant women. Make a conscious effort to incorporate it into your daily routine and aim for periods of 30 minutes on 3 or 4 occasions throughout the day.
Pain Relief Measures
Ice is effective for reducing pain and inflammation. Try one or more of the following methods to relieve foot and ankle pain during pregnancy. A frozen golf ball can be used to massage the bottom of the foot and is effective in treating conditions such as plantar fasciitis. Freeze water in a small paper cup, then tear the paper off the top and rub the ice directly on the painful area for 5-10 minutes. Ice massage can be effective in treating tendonitis and swollen areas. A bag of frozen vegetables can be molded to fit the shape of the foot/ankle and is effective for treating general pain and swelling. Wrap all ice treatments in a thin towel to avoid frostbite and skin damage.
Topical pain relievers such as Biofreeze or eucalyptus oil can safely and effectively reduce muscle and joint pain during pregnancy. Biofreeze is a menthol-based topical analgesic that provides temporary relief from minor aches and pains. Eucalyptus oil is a natural oil that, when rubbed onto sore muscles, acts as an analgesic and stimulates blood flow to the area, helping to reduce pain and speed up the healing process. Both are safe for pregnant women to use, but should not be used near the vaginal area, near the rectum, by those who are allergic to aspirin, or by those taking heparin or warfarin-type blood thinning medications.
Seeking Professional Help for Pregnancy-Related Foot and Ankle Pain
Specifically, a referral to podiatric care, particularly by the primary obstetric provider, is a low-cost, time-effective intervention for a common form of musculoskeletal maternal morbidity. It is evident that the obstetric community is in need of a clear, concise pathway to help them deal with pregnancy-related musculoskeletal pain. A clear plan of management is necessary for any new mother, and one that can be provided by a podiatrist. Evidence of the current gap in management for maternal foot pain and related symptoms, the opinion of obstetric care providers, and the need for management plans will be discussed throughout this review. A medical referral is necessary. The vast majority of musculoskeletal complaints during pregnancy are managed by an obstetric provider, and the opinion of these providers is crucial in the successful pathway to reduced pain for these women. A clear objective for this pathway is essential in gaining support from obstetric providers. This standard needs to be evidence-based and cost-effective. This can be achieved through education and awareness of the positive impact that podiatric interventions can provide to this population. Cost and availability of care are always a concern, but in comparison to the current treatment pathway, the cost-effectiveness of podiatric management can be a desirable form of intervention.
Consultation with a Podiatrist
During the study, those who had previously been pregnant and sought help from a podiatrist were questioned about their outcome. They replied by saying they wished they had sought help during the earlier pregnancy due to the successful intervention to reduce pain and increase mobility. This highlights that intervention from a podiatrist can be a successful mechanism to reduce foot pain during pregnancy.
With pregnancy, there are many associated types of foot pain due to altered foot posture and increased strain on the soft tissue. A recent study investigated the knowledge and significance of foot health in pregnant women. It was found that although many women experienced foot pain and lower limb issues during pregnancy, they were unwilling to seek help or treatment from a podiatrist. This is due to a lack of public awareness about the comprehensive care that is available from podiatrists and a reluctance to seek help, thinking that pain is normal with childbearing and will simply go away postpartum.
Podiatrists are a significant source of healthcare to which many people are not aware of. They specialize in the diagnosis and treatment of foot disorders and are qualified to treat a wide range of foot complications. Podiatrists play a strong role within the healthcare system, providing special assistance to those who have mobility issues. This assistance can range from the treatment of acute foot or ankle pain to the prescription of custom orthotics to offload debilitating foot conditions.
Physical Therapy for Pain Management
Maternal physiological changes during pregnancy can alter body biomechanics and foot shape. These alterations can cause various weight-bearing areas of the foot to absorb excessive shock. A recent study of 49 pregnant women found that those who experienced lower extremity or low back pain had a statistically significant decrease in both calcaneal stance time and a lower FPI total score when compared to the women who did not have symptoms. The long-term effects of excessive pronation can be associated with a number of musculoskeletal complaints. Over 20% of the women in the study who had musculoskeletal complaints had high symptom levels 2 years postpartum. This suggests that pregnancy may be a precursor to lower limb musculoskeletal pain and disorders. Therefore, it is important that these weight-bearing areas of the foot are supported appropriately during pregnancy to prevent increased stress and strain. Supportive taping of the foot and ankle can control ranges of abnormal motion and help to alter mechanical and proprioceptive input to the lower limb in an attempt to avoid feelings of pain. Although functional control of the foot and ankle can be greatly improved with the use of orthotic devices, the Insolia orthotic device was recently developed to efficiently reduce excessive pronation position of the foot by using a frontal plane motion control wedge. This device may provide a simple and effective way to reduce pain in pregnant women who are adjusting to the painful phase of excessive pronation.
Alternative Therapies for Relief
Some examples of CAM include herbs, chiropractic manipulation, dietary supplements, massage, and other non-invasive forms of bodywork, meditation, acupuncture, and homeopathy. While many of these therapies are pleasant and certainly will not be harmful to the woman’s general health or that of the pregnancy, they may not be entirely effective at providing foot pain relief because many have not been studied scientifically. For the acute, chronic, and often disabling pain and discomfort that generally accompanies specific foot and ankle injuries and conditions, it is recommended that the patient attempt to utilize a CAM therapy that has at least been studied in a controlled clinical trial. This may involve speaking with a CAM practitioner who is willing to provide the necessary treatment at no cost, in return for data gathering and patient outcome assessment.
Having ruled out traditional medical remedies, some women may turn to alternative therapies for relief from their pregnancy-related foot and ankle pain. This trend is known as complementary and alternative medicine (CAM). CAM is a group of diverse medical and health care systems, practices, and products that are not generally considered to be part of conventional medicine. They specifically make use of selected clinical and diagnostic entities known to be associated with pregnancy-specific foot and ankle pain and offer a variety of treatment modalities. An example is using ultrasound to diagnose a plantar fascia tear, then performing prolotherapy to correct the problem. Prolotherapy involves injecting an irritant solution into the fascia to stimulate and strengthen healing.
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