Let’s dive into a discussion about common issues of the foot and ankle, and more specifically, the acute and chronic issues.
Acute injuries of the foot and ankle
Acute pain of any kind is usually caused by a specific event and results in immediate and severe pain. For the foot and ankle, acute injuries could be in the form of a sprained ankle or foot, a strained muscle in the foot or ankle, or a fracture. Most of these are considered “rolling” injuries where the foot and ankle are over rotated. If a break occurs, which you will most certainly be aware of, and it is located near a joint space of your foot an ankle, it is critical to address that injury right away.
Straining of the foot and ankle is damage to the ligaments, the structures in the body that connect bone to bone. The ankle ligament connects the tibia and fibula of the leg to the talus and foot bone. There are 28 bones in the foot and numerous joints and ligament that can strained as well, although that is less common since the muscles of the foot are so small.
With a strain, you won’t be able to put any weight onto the injured foot. A strain of the foot ankle is usually an injury of a tendon that goes across the ankle on either the outside or inside, top or back. Obviously, that means there are quite a few variations of a strain that can occur.
A lot of times with a strain, you will hear a pop or feel a pop followed by pain, bruising, and swelling. For example, the Achilles tendon in the foot and ankle, the largest of the tendons, may rupture without you even noticing. A rupture usually occurs due to a forceful event such as coming down from a jump, trying to push a car, taking off into a sprint, or any sort of event where your heel is being forced to the ground but your calf is contracting.
With an Achilles rupture, patients often feel as if they were just kicked in the back of the heel, but when they turn around, no one is there. Patients will also feel a small little gap in their Achilles. This injury needs to be seen as soon as possible. There are options for non-operative treatment, but only if the injury is treated appropriately and in a quick manner.
There are many other acute injuries that could be discussed, but the common denominator of them is their need to be treated promptly. The timeline for appropriate surgical treatment is two weeks, sometimes sooner depending on the severe of the injury.
Chronic injuries of the foot and ankle
Chronic injuries of the foot and ankle are those that nag people day-in and day-out. Achilles tendonitis has several different variations. Pain can appear in the calf, along the Achilles mid-substance, or right path insertion point of the heel bone. Pain at the Achilles mid-substance is usually a warning sign that your may have an impending rupture. Listen to that pain carefully and avoid activities that cause flare ups. I usually require an MRI to determine the extent of the tendonitis and to determine the appropriate treatment course for each individual.
The most effective non-operative treatment for Achilles tendonitis is activity modification. Avoiding the activities that cause pain sounds easy enough, but unfortunately, a lot of people state that walking is a cause of their pain.
We can try some other non-op remedies such as a heel lift you placed in your shoe and eccentric strengthening with a physical therapist, which is simply lowering of the hell slowly to the ground to strengthen and stretch the Achilles tendon.
You should also consider adjusting your footwear. You need to ask yourself
- How old are your shoes?
- Are your shoes worn out?
- Is it the right shoe for you?
- What activities are you doing in the shoe?
Moving down the line of conservative treatment options, we could try a series of platelet-rich-plasma injections which studies have shown offer some benefit. I do not use corticosteroid injections in tendons as they could lead to an increased risk in rupturing.
If nothing is working, your should consult a physician about surgical treatment. Surgery will correct the problem, but afterwards you will need to protect your Achilles for a period of roughly three months.
Arthritis, impingement, tendonitis
When looking at arthritis, there are several types and reasons for its occurrence. These include
- Post-traumatic arthritis
- Rheumatoid arthritis
Arthritis can lead to joint deformity if left untreated. If you are having pain and symptoms, you should be seen quickly because procedures such as ankle replacement or ankle fusion may need to be considered.
Impingement and laxity are more sports related issues and occur more frequently in active individuals. If you feel as if your ankle is constantly on the brink of rolling over, or if you’re making a sharp cut, and you don’t trust your ankle, you should see someone. There are great procedures that can fix this issue and help you avoid adding other injuries such as a severe ankle sprain on top of the impingement.
Tendonitis of the ankle involves a lot of the same treatment options that we discussed with Achilles tendonitis.
- Activity modification
- Shoe inserts
- Physical therapy
- Over-the-counter anti-inflammatories
Prescription strength medication can be prescribed if necessary and corticosteroid injections may be a treatment option for you as well. Surgical treatment should be explored if the above options are not working, and an MRI should be obtained to determine what exactly the issue is.
A very common issue I see in the heel of the foot is plantar fasciitis which can be severe enough to be crippling. Many patients find even just walking or getting up after a prolonged period of sitting can be excruciatingly painful.
Treatment options include stretching, and tons of great and detailed stretching exercises can be found on the American Orthopedic Foot and Ankle Society’s website. Other treatment options include shoe inserts and night splints or night socks. Night socks are a device that you leave on your feet overnight to keep your foot stretched out so it does not contract. One of the reasons pain will be so severe in the morning is due to the contracting down of the foot overnight, and when you step on it you’re really just stretching it out, causing micro-tears. I usually recommend patients try out the Strasbourg sock.
Heel pads and ice packs may also help alleviate some pain. Formal physical therapy can be explored, and if you’ve had a couple months of physical therapy with little improvement, we can try a steroid injection at that point. These injections do a fantastic job of resolving the symptoms for at least a period time. Relief can be long lasting, but occasionally we may have to repeat a shot after about 12 weeks.
Surgical options do exist, but again, these are always last resort after we try more conservative options.
- High arches or pes calvis
- Flat feet or pes planus
Foot deformities are something we want to prevent from progression, and we can do that through shoe inserts or orthotics. Surgical options for these are quite extensive, and so the recovery can be intense. If we can prevent a foot deformity from occurring in the first place, then hopefully we can prevent patients from having to through those extensive surgical procedures.
Bunions can range from mild to severe in their pain levels. I usually recommend patients buy shoes that don’t rub against them, especially for milder cases. Surgery can fix bunions, but there are risks of complications. If a shoe with a wider toe box if sufficient, then I would suggest avoiding surgery.
Common in active people, neuromas are a nerve that is a little prominent and is being pinched usually by a couple of bones in the foot. It is typically located right around the middle toe, and you might feel some numbness or shooting pains going up or down your foot.
It could be related to walking barefoot or running. Again, I suggest shoe modification. A neuroma pad can be placed into your shoes that will help spread the metatarsal heads apart so they don’t pinch on that nerve. Injections are also a viable option. If none of that is working, a surgical excision can be performed.
Frequently asked questions
When is ankle replacement your best option, and who are good candidates for ankle replacement?
Ankle replacement over the last 20 years has come a long way. The designs we have today are excellently engineered and offer great relief for patients.
Good candidates for total ankle replacement should have a body mass index lower than 25 and age over 65. The patient should be active but not into extreme activities. Anyone who walks, hikes, plays tennis or golf are good candidates. People with previous infections in the ankle and anybody with a large ankle deformity are not good candidates.
When going to receive an ankle replacement, one thing I counsel people about is that you should expect within 10 years to require another procedure of some sort to either clean up the bone bone spurs that have formed or to fill in some areas that the bone has eroded with bone grafting. The ankle replacements themselves last around 18-20 years, but after that point you may need to start replacing some components.
Ankle fusion is another procedure that has a similar success rate to the ankle replacement. Unlike the ankle replacement, once the ankle fusion is performed, no other future procedures should be expected.
With an onset of help pain, should I stop exercise walking?
Once your develop heel pain, the first question you should ask yourself is, “am I wearing the right shoe?” You need to make sure that the shoes aren’t too old, aren’t worn out, and are appropriate for the activities you do.
Activity modification is usually what I recommend first. You can combine activity modification with anti-inflammatories and begin some stretching exercises to try and subside the symptoms before they get out of control.
Switch up your exercises. Try biking or elliptical training for instance. If symptoms aren’t getting better after about four weeks, I would make an appointment with your physician and consider starting formal physical therapy sessions.
What can be done about a broken ankle that never fully healed?
A lot of things could going on here. There could be a malunion where the bone heals but not in the correct position, or it could be a non-union where the bone never healed. That can be painful if the ligaments are damaged which is very common. If the ligaments are causing instability, that could be the source of your pain.
There’s a lot that we can do. Depending on how bad the malunion is, we can fix that by literally going in and breaking the ankle again and then fixing it correctly. For a non-union, we can fix that surgically as well.