Why Foot Pain Keeps Coming Back: The Missing Link No One Is Assessing

One of the most common frustrations for both clients and clinicians is persistent foot pain that fails to resolve despite “doing all the right things.” Exercises are completed, orthotics are worn, footwear is changed, and yet symptoms linger or recur.

This pattern is not a failure of effort. More often, it reflects a failure of assessment and sequencing.

At The Stabilisation Academy, we see this repeatedly: pain is addressed, but function is not restored. When this happens, tissues continue to absorb load in inefficient ways, and symptoms inevitably return.

This article explores why pain-focused and isolated approaches often stall, why foot posture is not the same as foot function, and why stabilisation and movement control are the true foundations of lasting change.

Pain Is the Output, Not the Origin

A fundamental principle of contemporary pain science is that pain is not a direct measure of tissue damage.

Pain reflects how the nervous system interprets load, capacity, and perceived threat based on prior experience and current context (1,2). In persistent or recurrent foot pain, tissues may be structurally intact but remain sensitive due to repeated overload or poor load management (2).

This distinction matters clinically.

When pain is treated as the problem rather than the output, interventions tend to focus on symptom suppression rather than addressing the underlying drivers of inefficiency. This helps explain why imaging findings often correlate poorly with symptoms and why treating the painful tissue alone rarely leads to durable outcomes (1).

In short, pain tells us that something is not coping, not necessarily what is wrong.

The Cost of Isolated Thinking

The foot does not operate independently. It functions as part of an integrated kinetic chain involving the ankle, knee, hip, pelvis, and trunk (3).

Load is transferred continuously through this system during gait and other weight-bearing tasks. When one segment lacks control or mobility, compensatory strategies emerge elsewhere (3).

Common examples include:

• Reduced ankle dorsiflexion increasing plantar loading through the midfoot (4)

• Poor proximal control altering foot loading patterns during stance and propulsion (5)

• Inadequate trunk control influencing lower limb force transmission (3)

When assessment and intervention focus solely on the symptomatic structure, these relationships are missed. Symptoms may temporarily improve, but the movement strategy remains unchanged - setting the stage for recurrence.

For clinicians, this is often where clarity is lost and frustration sets in.

Foot Posture Does Not Define Foot Function

A visually flat foot is not inherently dysfunctional.
A high-arched foot is not inherently stable.

Foot posture offers limited insight into how the foot behaves under load (6).

Functionally, the foot must be able to:

• Accept and attenuate load

• Adapt to surface variation

• Transition into a stable lever for efficient propulsion

During normal gait, this requires controlled pronation following heel strike to allow shock absorption, followed by timely supination to create rigidity at push-off (7).

Both excessive stiffness and excessive collapse disrupt this sequence and impair efficiency, balance, and load distribution (6,8).

This distinction is critical when considering external support. Orthoses may reduce symptoms, but without restoring neuromuscular control, they do not address the underlying movement strategy (9). Support can assist function - but it cannot replace it.

Stabilisation Precedes Strength

A common rehabilitation error is prioritising strength before control.

Strengthening exercises are frequently prescribed early, yet strength without stabilisation does not produce functional resilience (9).

Stabilisation is a neuromuscular process. It requires coordinated activation of intrinsic and extrinsic foot musculature to regulate motion during dynamic load (9,10).

Intrinsic foot muscles play a critical role in:

• Supporting the medial longitudinal arch

• Controlling midfoot motion

• Enhancing balance and postural stability (10,11)

When stabilisation is inadequate, the nervous system compensates through increased stiffness, toe gripping, or load avoidance strategies, all of which increase tissue stress over time (2).

Evidence supports the prioritisation of intrinsic foot muscle training to improve arch control and functional outcomes, even when pain reduction is not immediate (11). This reinforces a key principle: movement quality must improve before strength gains can be meaningfully expressed.

What Effective Assessment Prioritises

When symptoms persist, the most important clinical question is not:

What exercise is missing?

It is:

How is load being managed during movement?

Effective assessment considers:

• Gait mechanics

• Load transfer through the midfoot

• Push-off strategy

• Integration between foot, ankle, hip, and trunk (3,7)

This approach shifts the focus from chasing symptoms to understanding movement behaviour. When inefficient strategies are identified and addressed, tissue tolerance improves and symptoms often resolve as a secondary outcome.

This is where clarity - for both clinician and client emerges.

Foundations of Function – Facilitating Ideal Foot Motion (Perth)

For clinicians seeking to apply these principles with confidence, Foundations of Function – Facilitating Ideal Foot Motion will be held in Perth Sat February 7th  at UWA.

This practical, in-person workshop is designed to:

• Refine observation and assessment of active foot motion

• Clarify stabilisation before loading

• Integrate foot function into whole-body movement strategies

The focus is not on adding more exercises, but on improving decision-making, sequencing, and clinical reasoning.

Further details are available via the course link here [Register for Foundations of Function Here]

Closing Thoughts

When foot pain persists, the issue is rarely the tissue alone.

By shifting focus from posture and pathology to function, control, and load management, we create the conditions for sustainable change.

This is the foundation of effective rehabilitation,  from the feet up.

References 

1. Moseley, G.L. (2003). A pain neuromatrix approach to patients with chronic pain. Manual Therapy, 8(3), 130–140.

2. Woolf, C.J. (2011). Central sensitization: implications for the diagnosis and treatment of pain. Pain, 152(3), S2–S15.

3. Neumann, D.A. (2017). Kinesiology of the Musculoskeletal System, 3rd ed. Elsevier.

4. Rabin, A. et al. (2014). Restricted ankle dorsiflexion increases plantar pressures. Journal of Orthopaedic & Sports Physical Therapy, 44(6), 418–426.

5. Powers, C.M. (2010). The influence of abnormal hip mechanics on lower extremity injury. Journal of Orthopaedic & Sports Physical Therapy, 40(2), 42–51.

6. Cote, K.P. et al. (2005). Effects of pronated and supinated foot postures on postural stability. Journal of Athletic Training, 40(1), 41–46.

7. Perry, J. & Burnfield, J.M. (2010). Gait Analysis: Normal and Pathological Function, 2nd ed. SLACK Incorporated.

8. Hertel, J. et al. (2006). Influence of foot position on balance. Journal of Athletic Training, 41(1), 42–48.

9. McKeon, P.O. et al. (2015). The foot core system: a new paradigm. British Journal of Sports Medicine, 49(5), 290.

10. Kelly, L.A. et al. (2014). Intrinsic foot muscles and arch support. Journal of Anatomy, 225(3), 296–305.

11. Jaffri, A.H. et al. (2023). Intrinsic foot muscle training and functional outcomes. Journal of Athletic Training, 58(11–12), 941–951.