As we see, our foot is a really important part of our life, living in the present scenario with facilities and technologies. Common routine foot care sessions may enhance patient thinner and better by taking pressure off their joints and reduce the occurrence of skin or nail disorders. Basically, at every step, we are dependent on our foot. If anything happens, pain in any form, it’s really excruciating. Look into the following instances in our daily life, how these trivial foot pain makes changes to our lifestyle. An aged person in the family who is having foot pain due to age or some disease, the result of pain is restriction of movements. They can’t walk and eventually, it will make them bed-ridden. Imagine a housewife who is working a lot in the kitchen. Take the example of a ‘masala grinder’ that fell down and she got an injury in her leg. The pain from the injury will restrict her to bed, and her work will be interrupted. A sportsman may get foot pain with a simple event of an ankle twist during the play, and it may lead to the stoppage of his game for a while or he might keep on playing and get a bigger injury. That’s why foot pain and ankle pain should have clear management. If those persons having foot pain get good treatment with good management, it will make their recovery faster and it will avoid any more serious problems in the future. It’s an expectation of anyone who suffers from foot pain and ankle pain to have fast relief from it and be ready to do anything as before. But the fact is not all foot pain is recognized early and has proper treatment. Poor management of foot pain leads to chronic foot pain and more serious problems.
Overview of Foot Pain and Ankle Pain
Foot and ankle pain is a common problem. It can have an effect on everyday activities and can prevent you from taking part in the sports and hobbies which you enjoy. Simple everyday tasks such as walking can cause pain in the foot and ankle and can often be due to an overuse injury. Often foot and ankle pain has an insidious onset and can gradually get worse, affecting the quality of your life. This can result in increased anxiety regarding the problem as well as changing your mental attitude. In severe cases, it can lead to depression and a feeling of isolation from the inability to enjoy social events due to the pain and the limitations it imposes. Although there is a high incidence of acute trauma-related foot and ankle pain in active individuals, it has been shown that chronic pain is more disabling. This tends to affect older individuals who have a decreased bone density and an increased risk of soft tissue problems due to chronic diseases such as diabetes. Although the young active individuals may have a higher morbidity and time loss from work due to their injury, chronic pain in the older individual has a long-term effect on their quality of life. This will inevitably lead to a higher demand for effective management of foot and ankle pain in the future.
This section provides the reader with an overview of the commonly encountered problems of foot and ankle pain. The prevalence of these problems is highlighted, together with the effect it has on personal lifestyle and demand for healthcare. The anatomy of the foot and ankle complex is described to give the reader a better understanding of the problems they may encounter. This aids in the diagnostics and management of the problem, which can often be a complex issue. Often, understanding the problem is the first step to managing it effectively and preventing recurrence.
Importance of Effective Management
Pharmacological intervention comes in many forms. It may include simple analgesia for painful acute conditions or it may involve more complex regimes involving use of disease modifying anti-rheumatic drugs (DMARDs) or corticosteroid therapy for severe inflammatory conditions. It is therefore evident that foot and ankle pain is an important issue in many people’s lives and that effective management of such conditions is of paramount importance.
Management of foot and ankle pain comes in many forms. Often musculoskeletal pain in these areas is managed with physical techniques such as exercise or gait re-education. Often an individual’s choice of footwear can exacerbate foot pain or can be the primary cause of pain. This is particularly pertinent in those with inflammatory joint disorders such as rheumatoid arthritis. Occupational therapy is often utilized to advise on the most suitable footwear for an individual’s condition.
Most people at some point in their life will suffer from foot or ankle pain. The latest National Health and Nutrition Examination Survey reported that the prevalence of chronic, impairing foot pain in those over 50 years of age is approximately 29 percent. An additional 19 percent report pain in their ankles. Pain in these areas reduces an individual’s quality of life and increases disability. It has been shown to contribute to a decreased ability to carry out daily activities, to lower self-esteem, and an increased risk of falls in older adults. It is therefore imperative that any presenting foot or ankle pain is managed effectively in order to reduce associated symptoms and to limit negative impact on an individual’s overall health status.
Common Causes of Foot Pain
Morton’s Neuroma is the common name given to perineural fibrosis or nerve damage. This usually occurs in the 3rd interspace of the foot, caused by long-term nerve irritation from adjacent bones. The most common reason for Morton’s neuroma is biomechanical, which can lead to increased stress inside the foot. This stress can be due to excessive pronation, which results in the prolonged tension of the nerve, or overloading the forefoot in activities such as running or jumping. High heel shoes have also been attributed to be a cause of Morton’s neuroma, as the body’s full weight is forced onto the forefoot. Finally, trauma or excessive use of the foot in high-impact or pivoting activities can also cause neuroma of the nerve.
A bunion is a bony bump that forms on the joint at the base of your big toe. Bunions form when the big toe pushes and bends in towards the other toes. This changes the structure of the bones and joints of the foot, causing the joint of the big toe to stick out. Bunions can cause a change in weight distribution and force the big toe to drift across into the second toe. Although the exact cause of a bunion is unknown, the structural change is due to an imbalance of the pull of the muscles. This can be caused by poor foot function or mechanics (excessive rolling in of the foot), which is hereditary. Other people who suffer from arthritis can also develop a bunion due to altered joint movement.
Plantar fasciitis is one of the most common orthopedic complaints. The plantar fascia runs along the bottom of the foot, connecting the heel bone to the toes, and supports the arch of the foot. When this suffers trauma, the body’s natural response is to cause inflammation in the area. Many patients with plantar fasciitis have heel spurs, although they are rarely a source of pain. The cause of the inflammation is usually due to overpronation (rolling in of the foot), which causes a decrease in the shock absorption in the foot. Overstretching of the plantar fascia can also be caused by excessive loading or high-impact activities such as running and dancing. These situations can occur in patients who have increased their activity level, duration, or intensity without due progression.
Plantar Fasciitis
It may feel like a nodule or a lump in the back of the heel and cause pain when walking and in the morning. The area may be red, warm, and swollen. If the condition is left untreated and continued stress, it may develop into the rupture of the fibers in the tendon. This will cause acute pain and weakness in the Achilles. In much more severe cases, the pain will be debilitating, and the patient will require surgery.
Most cases of Achilles tendonitis can be experienced as a result of lack of flexibility with the calf and increasing age. More aggressive activities increase the amount of stress on the tendon and increase the probability of developing the disorder. With repetitive stress on the tendon, the body is unable to recover the damaged tissue, and it can develop into a serious injury.
Achilles tendinosis is an overuse injury of the Achilles tendon, the band of tissue that connects calf muscles at the back of the lower leg to your heel bone. The Achilles tendon enables walking by helping to raise the heel off the ground. It is one of the most commonly diagnosed problems of competitive and recreational athletes who sustain injuries, and it can be a problem among the general population.
Causes of pain at the back of the heel
Bunions
Bunions are a very common foot condition and are the result of deformity of the metatarsophalangeal (MTP) joint at the base of the big toe. A bunion develops when the bone or tissue at the MTP joint moves out of place, causing the big toe to be angled towards the other toes, resulting in the bony lump being visible on the joint. The bunion is a progressive deformity and will not go away on its own; some form of intervention or treatment is required to prevent further deformity or relieve any pain associated with the bunion. The visible bump is the only symptom of a bunion; however, some patients may experience pain, inflammation, redness, and soreness over the affected joint. As the bunion is a structural deformity, wearing tight, narrow, or high-heeled shoes will not cause the bunion; however, it can cause more pain and discomfort or accelerate the progression of the deformity. It is noted that around 30% of the population suffer from bunions; however, only a small percentage require surgical intervention to relieve pain, correct the deformity, and improve the quality of life.
2.3 Morton’s Neuroma
The name Morton’s Neuroma is misleading. This is not a tumor; it is a perineural fibrosis and nerve entrapment most commonly involving the third intermetatarsal nerve between the metatarsal heads. This condition is typically caused by shoes with an inadequate toe box in which the metatarsal heads are forced together in an exaggerated and unnatural manner. Women are 4-6 times more likely to develop this condition because of their preference for fashionably narrow-toed, high-heeled shoes. Direct trauma to the plantar forefoot can result in chemical neuritis and thickening of the adjacent perineural tissue. Patients with this condition will characteristically experience burning paresthesias in the involved interspace which radiates into the corresponding digits. These symptoms may be eased by removing the shoe and massaging the foot. As the condition progresses, the pain will become more severe and constant and may involve the entire forefoot and adjacent digits. Tinel’s sign will be positive over the affected interspace. In the early stages of this condition, the symptoms may be relieved by a period of rest or by padding the area and taping the involved toes together. However, in chronic cases, the pain will be unrelenting and the metatarsal pads will cause further compression of the metatarsal heads and will be contraindicated. Left untreated, this condition will result in permanent nerve damage and chronic lifelong pain. A forefoot radiograph in the AP view may show an intermetatarsal bursitis or a “dropped” metatarsal head sign. A diagnostic ultrasound and MRI may also be helpful in evaluating the extent of nerve damage and the exact location of the neuroma. Conservative care can be effective only in the early stages of this condition. This would include shoe modifications, metatarsal pad placement to splay the metatarsals or a felt ring on the symptomatic space to relieve pressure on the involved nerve. Custom orthotics with a metatarsal pad and a cutout to relieve pressure on the affected area have been very successful in treating this condition. A recent study has shown corticosteroid injection to be successful in providing a resolution of symptoms in 83% of cases. However, there is a high risk of nerve damage and prolonged symptoms if the injection is missed and given into the nerve itself. Metatarsal phalangeal and intermetatarsal neuromas can be very effectively treated surgically. This would involve a neurectomy of the affected nerve and in the case of the metatarsal neuroma, a decompression of the involved interspace. This procedure has a high success rate with a low incidence of complications and long postoperative rehabilitation is generally not necessary.
Common Causes of Ankle Pain
Achilles tendinopathy can cause pain at the back of the ankle or the sides of the heel. The Achilles tendon connects the calf muscles to the heel bone and is the most common site of acute and chronic ankle overuse injuries. Tendinopathy refers to a continuum of tendon damage, inflammation and pain. It is often a result of repetitive and excessive load on the tendon, which can cause the tendon to become strained or in some cases torn. In the case of Achilles tendinopathy there may be a history of recent increased activity. Pain may occur during or after activity, and stiffness in the morning is common with tendon pain of any sort. In severe cases of tendon disruption a sudden traumatic event such as pushing off to jump, or a stumble can cause a complete tendon tear. Complete tears of the Achilles tendon are most often seen in men aged 30-40 and are usually the result of the same tendon being weakened by previous minor injury. There is an increased risk of Achilles tendon injury in steroid users and those with certain medical conditions or taking specific types of medication. Behavioral factors such as wearing extremely high heels with an inflexible sole or inadequate foot support have also been associated with Achilles tendon injury. Recreational running, particularly in trainers which are old and worn and provide insufficient shock absorption, is another common cause of tendon injury in the general population.
A sprained ankle can occur when the foot twists or rolls beyond its normal range of movement, causing the ligaments to stretch beyond their normal capacity or even tear. The traditional sign of an ankle sprain is pain on the outer side of the ankle. This can vary in intensity from a mild discomfort to severe pain which limits walking. Swelling will often occur and can be quite marked, especially in the first 48 hours. This may cause stiffness around the ankle and sometimes bruising, due to the blood from the torn ligament vessels becoming trapped beneath the skin, discolouring it. In more severe ankle sprains, where essentially the ligament has been torn through, instability of the ankle can occur and the ankle may feel weak, making it difficult to bear weight. A complete ligament tear is often referred to as a ruptured ligament and can take significantly longer to heal. Treatment for ankle sprains varies depending on the severity of the sprain, for a mild ankle sprain it may be possible to manage the injury with PRICE therapy and a period of rest, to protect the ankle from further damage. This would typically involve the use of an ankle support or strapping to help provide stability to the injured ligament. When bearing weight and walking in the initial stages of the injury, the use of crutches may help to reduce impact on the ankle and prevent aggravation of the injury. Anti-inflammatory medication may help to reduce both pain and swelling. More severe ankle sprains will often require a longer period of rest and immobilisation of the ankle. In cases of a ruptured ligament, surgery may be required to repair the damage. Physiotherapy and exercises to improve range of movement and ankle strength are essential with all ankle sprains in order to minimise risk of re-injury and prevent the development of chronic ankle instability. This can also be due to inadequate rehabilitation of a previous ankle sprain. Ankle sprains and early management is an area that has been reviewed multiple times over the years in an attempt to further understand and improve treatment.
Sprained Ankle
A sprained ankle is one of the most common acute musculoskeletal injuries. It is estimated that approximately 23,000 Americans sprain their ankle each day. There are several generalized risk factors for spraining your ankle, such as a previous history of an ankle sprain, inversion-prone ankles (“weak ankles”), and engaging in an activity with a high risk for an ankle injury. Other factors include a higher body mass and wearing high-heeled shoes. A sprain, by definition, is a “stretch and/or tear of a ligament”. Ankle sprains are most often the result of the ankle inverting (rolling in). When this happens during an activity, such as when playing basketball, and the foot lands on another player’s foot, the natural reaction is for the foot to roll in and cause a sprain. At that point, there will be pain on the outside of the ankle, and depending on the severity of the sprain, there can be varying degrees of bruising and swelling. The typical guidelines for recovery are: Phase I (1-10 days post-injury): control inflammation and pain, maintain the best possible range of motion. Phase II (after inflammation and pain are steadily improving): increase range of motion, increase strength, increase proprioception. Phase III (functional progression): according to the level of the individual/athlete, prepare for return to work or sport with a focus on strength and proprioception. The occurrence of a second ankle sprain is a common occurrence for people if not properly rehabilitated from the first. It is important to wait until the ankle is at 80-90% strength and functional ability compared to the other ankle to reduce chances of re-injury.
Achilles Tendonitis
The final phase of rehabilitation can be viewed as a normal ankle rehabilitation program, using the clinical reasoning that led to the above statements.
In Achilles tendonitis, especially chronic cases, the use of a heel raise, both in the short term to reduce tension of the tendon, and the long term bilateral insoles often proves to be effective at reducing symptoms created from a loss of ankle, sub-talar, and midfoot function. This is closely followed with a focused rehabilitation program to re-establish normal joint range motion at both the ankle and the subtalar joint. This often leads to being able to progress to standard manual therapy and exercise prescription.
There is special concern if the patient has a total rupture of the tendon, as this often requires surgical repair. This is followed by a clinical strength evaluation to rate and record the improvements while giving a level of safe progression to the next stage.
A good full lower leg and ankle stretching program can be very effective at reversing the effects of a chronically tight Achilles tendon. This, along with improved flexibility in the hip and thigh areas, has been shown to reduce the overall risk of re-injury.
With Achilles tendonitis, there is often sudden increased pain in the back of the leg or the heel, and there may be thickening of the tendon. Pre-athletes in the acute phase or within 24 hours of an acute injury can help with the control of pain and swelling. This can be followed a few days later with more direct control of the inflammation, utilizing ultrasound or other electrotherapy modalities. Passive joint mobilization may help prevent some areas in the ankle motion loss without the irritability of more aggressive manual therapy techniques.
Achilles tendonitis is an overuse injury in which the tendon that attaches to the back of the heel is inflamed. It usually occurs as a result of a sudden increase in the intensity or frequency of exercise, sports participation, yard work, or other activities. Incorrect footwear can aggravate the condition, especially if the shoes have a rigid counter (the back portion of the shoe that surrounds the heel).
Osteoarthritis of the Ankle
Osteoarthritis in the ankle can have a significant impact on the physical and social aspects of life. It is said that OA is underdiagnosed, with the symptomatology in an ankle often being attributed to problems in other lower limb or foot joints. This is cause for concern as delay in diagnosis and targeted management of OA may lead to progression of the disease and secondary changes in gait pattern or deformity of the joint.
Symptoms of OA in the ankle include pain, stiffness, restricted movement, tenderness, and sometimes giving way. The pain is usually vague with mild to severe aching, occurring with different activities or weight bearing. It is often worse during and after use of the affected joint. The onset is usually gradual and intermittent at first and then progresses to a more persistent pain. This usually prompts medical attention. A moving or unstable joint, such as in more severe cases of OA and when there is ligament laxity, causes inflammation within the joint with resultant synovitis. This manifests as joint effusion with swelling and local warmth. The swollen and painful joint may lead to altered gait and walking pattern in order to avoid pain, which exacerbates OA in other joints and causes problems in soft tissues such as tendons and ligaments.
Osteoarthritis (OA) is a degenerative joint disease causing the cartilage that cushions the ends of bones in the joint to wear away, to then become roughened and thin. The damage to the cartilage lining, the formation of marginal osteophytes, and subchondral sclerosis leads to painful and stiff joints. The cause is unknown, but it is thought to be a result of mechanical stress on the joint and abnormal joint alignment. Primary osteoarthritis is considered to be ‘age-related’ and the wear and tear on the joint over the years. Secondary osteoarthritis is the result of a particular cause such as an injury or joint abnormality.
Effective Management Techniques
Electrophysical modalities include percutaneous techniques such as radiofrequency and shock wave therapy, and the more traditional modalities such as low-level laser, ultrasound, interferential, and TENS. A current systematic review and meta-analysis of the evidence for all modalities in the management of musculoskeletal soft tissue injuries indicates that there is little high-quality evidence supporting their use but that there is some evidence to support the use of low-level laser therapy and pulsed ultrasound for reducing pain in the sub-acute to chronic phases. The evidence for this is further discussed in the chapter by Alfred Gatt and colleagues.
Pain-relieving modalities can be categorized in a number of ways. Often, a superficial categorization is into pharmaceutical and physical therapies. In Chapter 1, Alfred Gatt describes the tools available for foot and ankle injection and the evidence base for these. Various local anesthetic and corticosteroid injections are commonly used in the management of foot and ankle conditions. Anesthetics provide temporary pain relief and are often used diagnostically to confirm a suspected pain source. Corticosteroids have both an acute membrane stabilizing effect and a longer-term inhibition of the inflammatory cascade. The type of injection, site, dosage, and frequency should be selected based on the medical condition and the pathophysiology involved. There is much to be learned in this field, as discussed by Hintermann and Valderrabano in the chapter ‘Tendinopathies’.
Chronic foot pain and ankle pain cannot be understood or managed in isolation. This book describes the structural and biomechanical features of the lower limb that are important to consider in the diagnosis, management, and prevention of chronic foot and ankle conditions.
Pain Relief Strategies
The treatment of chronic pain is complicated because there is no gold standard of treatment. The options are allopurinol, chronic NSAIDs, or colchicine. Otherwise, you try to treat the multiple clinicopathological manifestations. For example, treat chronic tophaceous gout. You use a urate-lowering method and then use colchicine for one year until the tophi resolves. Pseudogout and ACP are easier to treat, you just focus on the treatment of the underlying cause.
If it is acute pain, relief is relatively straightforward. Simple oral NSAIDs, oral colchicine, or oral corticosteroids are three options. Voltaren Rapid is an option, even if it is not approved for the indication in your country. Gout of a young person – is the only situation where you might prescribe oral corticosteroids for an acute inflammatory arthritis.
Research tells us that gout reaches its peak about 12 years after onset. This is an important statistic to know. It tells us that gout will not be a problem in younger patients unless other systemic illnesses are present.
This is very good information. Any given patient can have a mixture of these causes. You don’t need to guess which cause is the right one. You can just treat the pain and see what works.
Physical Therapy and Rehabilitation
The therapist’s important information processing helps him in applying methods and techniques of rehabilitation that are useful and applicable for treating the patient. The intake of a thorough history of the patient, injury, and his lifestyle into account helps in knowing the cause, kind, nature, and site of the injury. This provides insight into which treatment is best and helps in developing an accurate treatment plan. It gives a clear understanding and being goal-oriented about what he wants and expects. Having full knowledge of the pathology of the injury and treatment techniques helps in understanding what may work and what may not. Progressing to advanced techniques and being comparative of different techniques, knowing why and how they work, he moves to the most appropriate and finally selects the best. Giving the patient an understanding of therapy and progression, reassessment of the condition compared to the initial assessment, goal attainment indicating whether the goals have been achieved, and lastly, the follow-up. Anyhow, the rehabilitation concentrating on foot and ankle injuries uses the same basic principles but has certain modifications. This accounts for the unique environment in which the ankle and foot exist. The practice of techniques in a non-weighted and partial-weighted environment over three weeks, and partial weight-bearing and weight-bearing exercises, allows progression to the in situ and ultimately situ fire environment of the ankle. Static and dynamic balance training will be important, working at first on regaining ankle postural stability on a stable non-moving surface and progressing to the maintenance of functional mobility and stability during motion.
Orthotic Devices and Footwear
A current randomized controlled trial has examined the utilization of foot orthoses in the treatment of chronic first MTP joint torment. The osteoarthritis group was older and had greater disablement and foot pain intensity when compared with the rheumatoid group. Improvements in pain and disability parameters were seen in the rheumatoid group while the osteoarthritis group only improved in foot function movement. This may be attributed to the osteoarthritis group having more chronicity and structural abnormalities in their foot pain.
This area includes cultivating designed footwear and orthotic insoles. Investigation into the biomechanical purposes behind the foot and lower leg torment has advanced the utilization of remedial footwear and posture backing to decrease torment and incapacitate further movement of foot distortions. Orthotic insoles are planned to enhance the capacity of the foot and lower leg by adjusting the biomechanical arrangement and giving additional backing to tormented territories. Custom orthoses are costly but provide the best general alleviation of torment and improving foot function. A less expensive option is to utilize orthotic insoles given by the counter operators which have been shown to be effective in easing repeatable plantar foot torment. A significant issue with corrective footwear is the patient’s feeling that the shoes are unattractive and expensive. This can result in poor compliance of wearing the shoes which in turn reduces the effectiveness of the footwear. However, wearing the shoes at regularly scheduled times reduces foot torment and makes wearing corrective footwear more acceptable to the patient.
Surgical Interventions
The primary goal of surgery is to reduce pain and improve function. It will not guarantee that the foot will be pain-free, and there is a risk of prolonging the pain or a chance of infection. The individual will need to discuss these options with their surgeon and make a well-informed decision on the surgery. Another factor that one needs to consider is the time it takes to recover from the surgery. In some cases, it may take up to 4 to 6 months to be fully pain-free and able to return to full activity. This can be a major constraining issue for certain individuals, especially those with long-term disabilities.
Surgical interventions are a last resort for many patients with foot and ankle pain. The decision to have surgery is usually based on the amount of pain the patient is experiencing and the degree to which that pain impairs their quality of life. Surgery may be a course of action for treatment of the underlying cause of the pain as well as the pain itself. In some cases, the patient and physician may consider a surgical option on a condition that has failed other treatments.
