Do you really want to learn about foot and ankle pain? For many – no. Given the option, most people would rather not have foot or ankle pain and are just content with it going away on its own. But this is not reality, and only by understanding the true cause of the problem can it be effectively treated. Imagine trying to build a house without any knowledge of construction – it is dangerous because you don’t know what you’re working with. In the same sense, trying to treat an injury without any knowledge of its mechanism is dangerous. You may get lucky and it goes away, but more often, limiting the functional life of the injured area and at times causing more damage. Understanding the cause of the injury is the first step in preventing its recurrence.
Foot and ankle pain is a common complaint among adults, and at one time or another most of us will be affected by this condition. But it is also a largely ignored health problem, with people accepting the pain as a part of aging or their job. In reality, most foot and ankle pain does not go away on its own and will often get worse with time. The foot and ankle are very complex structures, and they are given little thought until there is a problem. A large majority of people will take notice when there is pain – when this occurs it is advisable to seek out the cause, as trying to push through the pain or “walk it off” generally makes the problem worse and more difficult to treat.
Definition of Foot and Ankle Pain
Arthritis-related pain is often associated with older patients and can occur in the joints between bones, making movements further damage or cause more pain to the area. Sometimes there is simply a very painful sensation that causes discomfort when weight-bearing or walking. This may be compounded with swelling to the joint area. Pain from overuse often results in damage to muscles, tendons, and ligaments around a joint. This pain can be sharp and intense and can be chronic. It may be diffuse or specific, and the exact location of the damage can be difficult to isolate. Pain to the rear side of the heel is often related to Achilles tendon damage, and pain to the side of the ankle may be related to damage of the peroneal tendons. Finally, pain to the mid and forefoot can result from many different conditions, and a thorough examination is generally required to diagnose the condition correctly. In some cases, the cause of the pain is easily determined and treated, and in others, it may be a long-term or recurring problem that is difficult to resolve.
Foot and ankle pain has been extensively researched to define. According to the International Association for the Study of Pain, pain is an unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage. Basically, pain is a way for your body to tell you that something is not right. It is the result of the body’s response to an injury to the tissues, whether the injury is acute or chronic. This includes sprains, strains, fractures, dislocations, breaks, and any other damage to the tissues. The pain may be immediate or develop over a period of time.
Importance of Understanding the Causes, Symptoms, and Treatment Options
The most common reason that people have for seeking healthcare of any sort is discomfort. Oftentimes, the discomfort of a musculoskeletal condition can be the difference in the choice to seek care. A patient with pain in one foot may decide to avoid putting weight on that side and ambulate with an abnormal gait pattern. This can lead to increased stress and likelihood of injury in other areas such as the knee, hip, or contralateral foot. For these reasons, it is important to have an understanding of the full extent of a condition and what treatment may be able to accomplish.
An example of this is the patient with posterior tibial tendon dysfunction who has acquired a flexible flatfoot on one side. This patient may fail to understand the mechanical derangement involving the loss of the medial longitudinal arch and think that the problem is just a weak ankle and that wearing an ankle brace support will be sufficient. In reality, an ankle brace is not likely to be a successful treatment choice for this condition. The patient has to understand the changes in the position of the foot joints and, at the same time, weigh the pain intensity and functional limitations against the option of surgery to reconstruct the normal alignment of the foot. For the latter patient, the knowledge of what a specific surgery can accomplish is vital.
Patients need to understand the cause of the foot and ankle discomfort to make an informed decision on treatment options. Patients have different reasons for seeking care for the pain, and each of these reasons may be important to the choice of treatment. Inaccurate diagnosis or self-diagnosis of the cause of a condition prior to consulting a physician often results in patients seeking treatment for conditions they may not have. Patients may have preconceived notions about their condition, considering a problem to be a greater or lesser concern than it actually is. They may understand the general cause of the condition but not know the specific anatomy involved. This can be important in understanding activities that should be avoided or the effects that the condition may have on a long-term basis.
Common Causes of Foot and Ankle Pain
Overuse and injuries Foot and ankle pain can be caused by a number of factors. These can include an injury, such as a sprain or a fracture, a medical condition such as arthritis, or it could be due to structural deformities. The most common cause of pain is a result of ankle sprains, which can affect all ages but is most common in young people. This is because an ankle sprain is often times a result of a sudden twist or injury. There are two different types of sprains which can occur: inversion/conversion sprains and high ankle sprains. The former is the most common and affects the outside of the ankle, resulting in inflammation or bruising of the foot. High ankle sprains are usually more severe and affect the ligaments joining the two lower leg bones together. This can lead to pain in the leg and is a condition which sometimes is misdiagnosed as a leg injury, making it extremely important that an MRI scan is carried out if pain in the lower leg exists after an injury.
Overuse and Injuries
Whether through a sport or activity, overuse is an example of an external cause of injury because the biochemical limits of a type of tissue are overwhelmed without allowing the appropriate time for repair. It occurs in the bones when they are repetitively loaded to the extent that new bone formation cannot occur quickly enough. This may result in a stress fracture. Muscles, ligaments, and tendons take on the majority of the load with most activity. When their strength is not in balance with the muscles around a joint, structural damage may occur. Common examples of this in the ankle are inversion sprains and fractures. When a ligament is stretched beyond its capacity, it does not revert elastically, thus becoming more susceptible to injury at that point and, in severe cases, resulting in joint instability. Tendons are often strained or ruptured partially or fully, resulting in pain, swelling, and in some cases, loss of function to a certain muscle group. Plantar fasciitis is an example of a condition resulting from overuse injury to the sole of the foot. The plantar fascia is a ligament-like tissue that supports the arch. Due to the high load the foot experiences with each step, the plantar fascia can become inflamed at the site of insertion to the heel, resulting in sharp pain to the sole of the foot and lower heel.
Arthritis and Joint Conditions
Tarsal tunnel syndrome is an entrapment of the posterior tibial nerve caused by an arthritic change in the tunnel. Symptoms are mainly pain and numbness in the sole of the foot and can often be relieved by medication and use of an orthotic.
Other forms of inflammatory arthritis may affect the foot and ankle, such as gout, ankylosing spondylitis, and systemic lupus. These systemic arthritic conditions often can be controlled through medication and sometimes diet.
Rheumatoid arthritis is a systemic condition that is best managed by a rheumatologist. It is due to an overactive immune system and causes inflammation of the joint lining (synovium). This can lead to severe damage of both cartilage and bone, causing joint deformity. The course of rheumatoid arthritis and the response to medication varies greatly between individuals.
Osteoarthritis is the most common type of arthritis. It is characterized by gradual wearing away of the cartilage of the joint. This may cause a deep, dull ache during activity, loss of range of motion of the joint, and joint swelling. Osteoarthritis can be localized to one joint or may be generalized in several joints throughout the body. High impact activity, repetitive microtrauma, or functional abnormality of the foot can lead to post-traumatic osteoarthritis. Although it might not be possible to avoid osteoarthritis, modifying activity, the use of orthotics, and taking anti-inflammatory medications often can prevent the symptoms of osteoarthritis and slow its progression.
About 10% of patients will develop foot and ankle symptoms as the first sign of arthritis. There are many types of arthritis, most of which can affect the foot and ankle. In many cases, arthritis may not be isolated to the foot and ankle. It is important to identify the exact cause and effects of the arthritis throughout the entire lower extremity.
Nerve Disorders and Neuropathy
A neuroma is a disorder involving a benign tumor on a nerve. The most common occurring neuroma for the foot is Morton’s neuroma, which develops between the third and fourth toes. The growth surrounding the nerve is the body’s response to the irritation, pressure, or injury to the nerve. This most often happens as a result of stress and irritation to the nerve, commonly from wearing tight-fitting shoes or other high-impact activities causing trauma to the area. Symptoms for a neuroma generally include pain on the ball of the foot, often described as having a pebble in the shoe. Many report the feeling of tingling or numbness in the toes, and some even say that the toes will burn. Measures for treating a neuroma may include changing the type of shoes worn, utilizing orthotics, cortisone injections, and in more severe cases, surgical removal of the growth on the nerve.
For the matter of understanding nerve disorders and neuropathy, I must say that nerve conditions are one of the more serious issues related to foot pain. The general public does not relate feet and ankle function to the nerve system, but in reality, there are many instances when nerves are the root of the problem. Nerves serve as the electrical wiring of the body and are responsible for sending messages to and from the brain. Sensory nerves send information such as touch or temperature from the brain to the body, while motor nerves send messages from the brain to the body that will initiate movement. If there is an interference with the relay of these messages, it can lead to an array of problems and complications with the feet. In normal scenarios, the nerve disturbance originates from a mistake in the signal along the way and usually not at the actual site of the symptom. A few instances of this type of error may involve the impulse being sent too slowly, too fast, or sending the wrong message.
Symptoms of Foot and Ankle Pain
Walking or standing for long periods of time can cause discomfort and pain for anyone, and foot and ankle pain is a common occurrence. Pain in the feet or ankles can cause alterations in gait (the way you walk), weakness, and decreased function of the involved limb. Often people have to sit or stop their activity due to pain. There are many causes of pain in the feet and ankles and sometimes it can be difficult to determine the exact cause. Any alteration of normal alignment of the two ends of a joint can cause arthritis in the joint. This can cause pain with weight bearing, stiffness and swelling in the joint, and in advanced stages can result in joint deformity. Nerve damage in the feet can be caused by peripheral neuropathy, or by a herniated disc in the low back. Depending on the location of the nerve damage, symptoms can vary from pain and swelling to a burning sensation and hot or cold intolerance. Chronic ankle instability and ankle fractures can often cause pain and sometimes a feeling of grinding from the ankle. The pain may be located at the outer side of the ankle in ankle instability, while ankle fractures may also have pain at the site of the fracture. Both of these conditions can also cause swelling and a feeling of joint weakness.
Pain and Discomfort
Categorizing types of pain can be very complex, but for the purpose of this article, pain can be broken down into two types: acute and chronic. Acute pain can be thought of as pain with a fast onset and short duration. An example of acute foot pain would be an ankle sprain. Chronic pain is pain with a slow onset and long duration. An example of chronic foot pain would be pain from rheumatoid arthritis. Pain can also be nociceptive or neuropathic. Nociceptive pain is the normal pain that occurs when the tissues are damaged. It is usually described as aching, sharp, or throbbing. It may be accompanied by physical damage such as a broken bone or evidence of tissue damage on medical imaging. Neuropathic pain is pain arising from the nervous system when the nervous system has sustained damage. The pain may take the form of shooting electrical pain, abnormal sensations, or pain from normally non-painful stimuli. An example of neuropathic foot pain would be a pinched nerve in the foot from a herniated disk in the back. Pain can also be referred from other areas, an important concept in accurate diagnosis. An example of referred foot pain would be gout, which is a form of arthritis where uric acid crystals are deposited in the joint, causing intense pain and inflammation. Uric acid crystals affecting the foot’s big toe joint can cause a sudden onset of severe pain in the big toe, with redness and swelling in the joint. This is similar to acute onset gout pain in the knee. With such a wide array of foot and ankle pain symptoms and causes, arriving at an accurate diagnosis can be quite difficult. To achieve an accurate diagnosis, it is crucial that the foot and ankle specialist conduct a thorough medical history and physical examination of the patient’s lower extremity. Medical history is important to identify the location, pattern, and possible causes of the pain. Duration and the type of pain are crucial factors, as well as the initial cause onset of the pain. Identifying the patient’s occupation and activity level is important too, as high-stress activities and certain types of occupations can predispose individuals to certain foot conditions. A past medical history of other systemic conditions is important as well, as there are many systemic diseases that can affect the foot and present with musculoskeletal pain.
Swelling and Inflammation
Arthritis and gout can also cause ankle swelling and often occur in older patients. Arthritic swelling may be quite pronounced, causing stiffness in the morning and after periods of rest. The range of motion of the ankle may become limited, and it may be difficult to bear weight on the affected limb. Gout is a metabolic condition resulting in inflammatory arthritis, and is caused by the accumulation of uric acid crystals in the joint. This will be extremely painful and result in rapid onset of swelling and inflammation. Uric acid is a waste product in the blood normally excreted in the urine, and is produced when chemical compounds called purines are broken down. High purine levels may occur as a result of a diet high in animal meat or can be caused by medical conditions such as kidney failure. Both arthritis and gout can be treated and managed, however they are generally chronic conditions that will never fully resolve, and will often recur.
Swelling of the ankle can be caused by many different conditions, with by far the most common being a sprain. A sprain occurs when the ligaments are twisted or turned in an awkward way, causing them to stretch or tear. The severity of the sprain will dictate the amount of swelling or stiffness that will be experienced, with more severe sprains causing an instantaneous reaction of swelling. Treatment of the sprained ankle is crucial, as the outcome will dictate the time required to return to full activity. Failure to apply adequate rehabilitation and treatment following a sprain may lead to a chronic instability of the ankle and recurrent sprains.
Limited Range of Motion
Range of motion can be affected by many of the conditions that cause foot or ankle pain and discomfort. If the pain is caused by an inflammatory condition such as arthritis or tendonitis, the body’s reaction to the inflammation will be to lay down additional bone in an attempt to heal the damaged joint. If the inflammation affects a joint, there can be destruction of the opposing cartilage surfaces, and the body will respond by laying down bone in an attempt to “stabilize” the joint. Unfortunately, this bone formation often creates more restriction and less motion in the joint while altering the normal mechanics and creating pain. Patients with rheumatoid arthritis can suffer damage to the joint and surrounding ligaments from the body’s immune response to the disease. Posterior tibialis tendonitis or dysfunction can lead to a flatfoot deformity which will limit the range of motion of the hindfoot and ankle, often in an adult acquired manner. Finally, conditions such as acute fractures or severe sprains can outright limit motion due to pain and instability in the involved bone or joint.
A limited range of motion in the foot and/or ankle is usually characterized by stiffness and difficulty in accomplishing the movements necessary for walking, running, or climbing. Range of motion is determined by the flexibility of the joints and surrounding muscles. The ability to move the foot and ankle through a full, pain-free range of motion is vital to proper function. Loss of motion of the hindfoot or the ankle can significantly alter one’s gait (the way they walk) and predispose them to developing problems in other joints of the lower extremity, like the knee or the hip. Loss of motion can be limited to one direction or plane of motion, or it can affect several movements of the foot and ankle. An example of this would be someone who has an ankle sprain that primarily affects the ligaments on the outside of the ankle. This person will often have pain and difficulty moving their ankle up and in, as this motion closes down the space between the two bones that the damaged ligaments connect.
Treatment Options for Foot and Ankle Pain
Physical therapy should be good for patients with chronic foot and ankle injuries. Systematic reviews on certain interventions for ankle sprains or chronic ankle instability showed that the interventions were effective in improving the principal outcome measure of the present study in both the short term and long term compared with other interventions or no intervention. Since there was some heterogeneity in the studies, it is difficult to make a precise prescription as to exactly what type of functional treatment is the most effective for physiotherapists or athletic trainers. However, the use of a variety of functional treatment techniques, from the early implementation of one leg balance training to later use of isokinetic exercises, continuous simulated joint stability re-injury, was effective in improving patient functional outcomes.
- Rest: You may need to use crutches until walking is not painful without them.
- Ice: For the first 48 hours after the injury, apply ice every two hours for 10-15 minutes. Remember not to use ice directly on the skin, but to wrap it in a cloth or towel to prevent frostbite.
- Compression: To reduce swelling, compress the ankle with an elastic bandage. Do not hinder blood flow by pulling the bandage too tightly.
- Elevation: To reduce swelling and pain, elevate the ankle above the level of the heart.
Rest, ice, compression, and elevation (R.I.C.E) is good for ankle and foot injuries. This treatment can help to reduce swelling and relieve pain. If you have an acute ankle injury, you can use the following R.I.C.E. treatment for the first 24 to 72 hours.
Rest, Ice, Compression, and Elevation (RICE)
Rest, ice, compression, and elevation (RICE) is good for individuals with ankle and foot pain resulting from sport or activity. RICE is used before continuing activity. Rest is the halting of painful activities and staying off the ankle or foot until pain has subsided. For severe injuries, this may include the use of crutches. Ice is the regular application of ice or a cold pack to the injury. It is used for 20-30 minutes, 3 times a day. Do not apply the ice directly to the skin. Compression is the application of a compression bandage often used in combination with elevation. It should be wrapped snug, but not so tight as to cut off circulation. Elevation is a particularly important, and often forgotten, element in sprained ankle rehabilitation. The ankle should be raised above the level of the heart for 2-3 hours a day. This can be done in 20-30 minute increments. This will help to minimize swelling and pooling of fluid in the injured area.
Physical Therapy and Rehabilitation
Rehabilitation after surgery is also very important. Depending on the type of surgery that is performed, a plan of care will be developed to help you limit pain and swelling, and improve your strength and motion. Therapy after surgery often lasts for several months to ensure the best outcome. This will also be a good time to discuss a possible change in footwear to further support the foot and/or accommodate for the surgery that was performed.
Physical therapy and rehabilitation are often a very effective method of treatment for most foot and ankle problems. They offer a wide variety of techniques which may increase the healing process, improve motion and strength, and most importantly, alleviate pain. Methods may consist of joint mobilization and manipulation, muscle strengthening and stretching, hot and cold pack therapy, ultrasound, and electrical stimulation. Your doctor may also recommend the use of custom orthotics or shoe inserts to support and improve the foot’s function. Your therapist will develop a plan of care that is specific to the problems that you are experiencing to help you reach your goals. It is important to keep open communication with your therapist and doctor. If at any time you do not feel comfortable with the treatment that is being performed, or you do not think it is helping, discuss this with your therapist or doctor to consider other alternatives.
Medications and Pain Management
Ibuprofen/NSAIDs: Taken in prescription strength form, or in a higher dose, ibuprofen and other NSAIDs are often effective in relieving pain and inflammation from conditions such as arthritis. This can be especially useful in the setting of a flare-up of pain in a specific condition. Caution should be taken in those at risk for NSAID-related gastrointestinal irritation or who have renal insufficiency, and the medication should be discontinued if any adverse effects are noted.
Analgesic medication: This group of medications includes acetaminophen and the NSAIDs (non-steroidal anti-inflammatory drugs) such as ibuprofen. These are some of the weakest pain medications, but are often sufficient to relieve mild to moderate pain from chronic conditions.
When pain from a foot and ankle condition is not adequately controlled by RICE and activity modification, the use of pain medications may be recommended. The type of medication prescribed will depend on the extent of the pain and the individual’s medical history. The listed medications are commonly prescribed.
Surgical Interventions
Triple Fusion or Hindfoot Fusion: These are more complex surgeries which involve the fusion of the three or four hindfoot joints together. This is usually performed on a patient with severe arthritis in the hindfoot and is aimed at pain relief.
Ankle Arthroscopy: This is a keyhole surgery technique for cleaning out damaged tissue and debris from the ankle joint.
Release of Tendon Contracture: If a patient develops a high arched foot later in life, it can become very painful and is usually associated with a tendon on the side of the foot/ankle tightening up.
There are many types of surgery for foot problems. For some severe problems involving deformity, several surgical procedures may be required to obtain correction. Here is a list of commonly used procedures:
A surgeon or podiatrist will select the best procedure for your problem. The aim is to correct the cause of your pain and improve the function of your foot. It is very important that you understand the procedure you are going to have and what it will involve. If you are unsure, ask your surgeon to explain again. Getting a second opinion is often a good idea if you are unsure about the recommended procedure.