You'll walk about 110,000 miles in a lifetime. Are your feet and ankles up for it?
- 80% of Americans will experience foot problems at some point in their lives. They each pack in 26 bones, 33 joints, and 100+ muscles, tendons, and ligaments.
- Ankles take more weight-bearing force than any other joint in the body. No wonder they're also the most commonly injured joint!
Orthopedic surgeons Robert Kulwin, MD, and Jeffrey Wu, MD, teamed up with physical medicine and rehabilitation specialist Travis McClain, DO, RMSK, to help you “Step Away from Foot and Ankle Pain." Here are the key takeaways.
Common Causes of Foot, Heel and Ankle Pain
Your feet and ankles are the body's natural shock absorbers. They keep us moving, provide support, and keep us balanced. Daily wear and tear, and even genetics, can lead to all kinds of aches and injuries.
Arthritis is one of the most common causes of foot and ankle pain. The cartilage that cushions the joints wears down, leading to swelling, tenderness, and stiffness in the joints. “Inflammatory arthritis such as gout, rheumatoid arthritis and psoriatic arthritis most commonly affect the feet," says Dr. Wu.
“The number one form of arthritis affecting the foot is hallux rigidus which causes pain and stiffness in the metatarsophalangeal (MTP) joint of the big toes," continues Dr. Wu. “The biggest complaint with hallux rigidus is that the joint doesn't bend as much, so squatting, doing pushups or yoga, or wearing high heels, can cause pain."
While osteoarthritis is the more common form of arthritis leading to hip and knee replacements, post-traumatic - or post-injury - arthritis is the most common reason for ankle fusion or replacements, adds Dr. Kulwin.
Adult Flat Foot Deformity or posterior tibial tendonitis, affects the large tendon that runs down the inside of your ankle towards the arch of the foot. “It can wear out," says Dr. Wu. “This is what people are talking about when they say their arches have fallen or collapsed. Usually, the foot looks like it's turning out."
The posterior tibial tendon is responsible for pushing off with the foot or going up and down on the toes. “If you are trying to go up and down on one foot, you're going to have pain," says Dr. Wu.
Achilles Tendinosis and Tendonitis are common forms of heel pain that can be caused by a sudden injury or repetitive motion over time.
“One in 8 people over 50 have had some type of heel pain and half say it's disabling," says Dr. Kulwin. “Overuse, muscular tightness, certain antibiotics, and some autoimmune disorders can cause a thickening of the Achilles tendon known as Achilles tendinosis. Often these symptoms can be worse with activity or just first thing in the morning."
Insertional Achilles Tendonitis is a painful bump on the back of the heel, sometimes called “pump bump" as it affects many women who wear high heels, due to calf muscle tightness and overuse.
Plantar Fasciitis is an inflammation of the thick band of tissue that connects the heel to the ball of the foot. “Plantar fasciitis is the most common cause of heel pain that I see," says Dr. Kulwin. “The pain is more forward in the heel and is usually from repetitive micro trauma at the origin of the plantar fascia. Often, we will see a bone spur on an X-ray, but it's not the bone spur that causes the pain. The pain is really from a very tight calf muscle."
“Think of your foot as a bow with a bow string," says Dr. Kulwin. “When your calf is tight and you're trying to walk, you put more weight on the front of the foot and each step repeatedly stretches an already overly tight gastrocnemius, one of the two muscles that go into the Achilles tendon."
Fat Pad Atrophy is a painful condition on the bottom of the foot often confused with plantar fasciitis. It is usually caused by loss of padding under the heel, either from aging or genetics. It can also be caused by too many steroidal injections for plantar fasciitis. “This type of pain is all the time, unlike plantar fasciitis where it's usually painful first thing in the morning and then gets better," says Dr. Kulwin.
Stress Fractures can impact weight-bearing bones in the feet and ankles. Pain in the middle of the heel may indicate a stress fracture. This pain usually gets worse throughout the day. “I see this more often in female patients, because osteopenia and osteoporosis are more common in women. I also see this caused by repetitive impact, such as long distance running," says Dr. Kulwin.
Care typically starts with non-surgical treatment
“We start with conservative management," says Dr. Kulwin, “such as oral anti-inflammatory drugs like Ibuprofen or Naproxen." In some cases, immobilization can allow the rest needed to reduce inflammation and pain. In the case of rheumatoid arthritis, treatment usually starts with disease modifying medications.
Injections are another option, using steroids, gel or orthobiologics. Dr. McClain uses ultrasound to guide injections and for additional studies of the anatomy of the foot or ankle. “Guided ultrasound injections make sure we know exactly where we are going with the injection," says Dr. McClain. “It's much more accurate than palpitation guided injections. That's important because you have a lot of joints, blood vessels and nerves, all crossing over each other in a very small space in the feet and ankles. Ultrasound ensures we don't contact structures like bone that could potentially cause more pain."
Dr. McClain is also passionate about PRP or platelet-rich plasma injections. Plasma is a component of your blood that contains proteins that help blood to clot and support cell growth. “When applied in the right cases, there is potential benefit to it," says Dr. McClain. “We're taking your own platelets, your own growth factors, and we're re-injecting it at a very high dose into a location where we're trying to stimulate a profound healing response. This can also be very helpful in areas where we do not want to use steroid injections like the Achilles tendon."
The downside to PRP is that there is no standardization or regulation, so the quality of the equipment and the physician is very important, warns Dr. McClain. PRP is also not typically covered by insurance, so it can be expensive.
Orthotics, Devices, and Shoes
Custom orthotics can support the foot and provide a more rigid support for the toes. A steel shank known as a Turf Toe plate makes your shoe stiffer, so there's less bending of the foot and toes. A gentle heel lift and a walking boot can ease heel pain, as can gel heel cups and padded house slippers when you aren't wearing shoes at home. Devices such as lace up ankle braces or an Arizona brace are used to protect and support the ankle. Braces provide rigid fixation to keep the ankle from moving and the bones from grinding against each other, further worsening arthritis.
Shoes with a good fit, low heels and supportive arches are best. “Shoes with rocker bottoms allow your foot to roll through the shoe instead of your ankle," Dr. Kulwin says. “This is especially helpful for those with hallux rigidis, midfoot arthritis, plantar fasciitis, or limited movement in the ankle due to arthritis."
Women should be careful about the amount of time spent in high heels. The downward slope of a high heel can shift your weight to the wrong place – the ball of your foot – and misalign your entire skeleton, potentially stressing your hips, legs and back, too. Thin heels also increase the risk of ankle injuries. If you are going to wear high heels, it's important to limit the amount of time spent wearing them, and to stretch your feet and legs regularly.
Stretching and Physical Therapy
In fact, stretching is also recommended for heel pain caused by a tight Achilles tendon, insertional Achilles tendonitis, or plantar fasciitis, as is physical therapy. Dry needling has been shown to reduce the pain of insertional Achilles tendonitis.
Changing how you move and perform certain tasks can help foot and ankle pain, says Dr. Wu. “Instead of squatting to garden, use a low stool and try to keep your feet flat or limit how much you bend your toes." Low impact activities, like bike riding instead of running, also put less stress on feet and ankles.
Weight loss can reduce stress on feet and ankles. Obesity nearly doubles the odds of a patient having a severe ankle fracture, according to research published in a recent issue of the Journal of Foot & Ankle Surgery. “The less you weigh, the less stress goes through that arthritic joint," says Dr. Kulwin.
When should someone consider surgery? “When you have a worsening deformity or pain that's limiting your function and you've tried everything else, then it may be time to look at surgery," says Dr. Wu.
Cheilectomy is a procedure to clean out the MTP joint or remove the bone spur caused by hallux rigidus that can provide relief and allow more motion in the toe with less pain. “Unfortunately, it won't cure the arthritis," says Dr. Wu, “so at some point you might still need a second procedure called arthrodesis, where we fuse the two bones of the MTP joint. Most patients can do anything after having the big toe joint fused, even running or jogging, though some pushups or yoga poses may need modification. The limitations are you can't wear high heels."
“With adult flat foot, usually we try to correct or improve the architecture of the foot," says Dr. Wu. “Sometimes that involves moving a tendon or we may do an osteotomy where we cut the bone and shift it to recreate the arch. If you start to get worsening deformities or arthritis, then we may have to fuse the joints."
With Achilles tendinosis, physical therapy, boot immobilization and sometimes a heel lift, are about 80% effective. Steroids should be avoided, as they can cause the Achilles tendon to rupture. “If there is a substantial amount of tendinosis or more than 50% of the tendon has gone bad, then a tendon transfer – bringing in anther tendon - can help," says Dr. Kulwin.
“For insertional Achilles tendonitis, if stretching, therapy and orthotics fail, we can do surgery to remove the back of the heel and bring the tendon back down," continues Dr. Kulwin.
“Ninety-five percent of plantar fasciitis cases resolve with non- surgical treatment. As a last resort, we can do a plantar fascial release where we make a small incision in the back of the leg and release the tendon that's tight. Most people are better in 6 – 8 weeks," says Dr. Kulwin.
Stress fractures rarely require surgery. Typically, patients can do protected weight bearing for 6 – 8 weeks, wearing a walking boot.
For mild to moderate narrowing of the ankle joint, or a mechanical block to motion like a bone spur, a cheilectomy or debridement may be performed to remove the bone spur. “This may be appropriate for patients who still have some good cartilage in place and limited pain, or limited motion, while doing certain activities like walking up hill."
A relatively new procedure called a joint distraction arthroplasty stretches the ankle joint and uses a hinged external fixator to hold the ankle in this position for a period of time. “This reduces pressure while still allowing some compression of the joint fluid," says Dr. Kulwin, “which we know feeds the cartilage and subchondral bone, allowing the damaged joint to heal."
“An advantage to distraction arthroplasty is that no bridges are burned. If the results aren't satisfactory, a subsequent fusion or replacement can still be done," adds Dr. Kulwin.
“Beyond these joint sparing procedures, we still have two options to improve the ankle joint," continues Dr. Kulwin. “The first is arthrodesis or ankle fusion and it's actually a really good surgery. When you watch someone who has had an ankle fusion walk, it's hard to tell which side was fused. All that really changes is the length of your stride."
Fusion can be a good option for those with neuropathy in their feet, a history of a bad fracture that got infected, or for someone whose job requires high impact activity. One downside, however, is that adjacent joints may compensate for the limited motion of the ankle joint. “When a joint starts working in a way it wasn't designed for, it tends to get a little worn down, leading to arthritis in those joints," says Dr. Kulwin, “but most patients who get arthritis in those adjacent joints are asymptomatic. The bigger worry with a fusion is a non-union, so we do everything we can to avoid that."
The next option is ankle replacement. “In the past 10 -15 years, we've developed a really good ankle replacement," says Dr. Kulwin. “The advantage of an ankle replacement is that it preserves motion and gait and protects the adjacent joints."
“There are two main kinds of implants that we use that have really good long-term data. The first is a lower profile implant, almost a joint resurfacing type of procedure, that is good for patients who may be less active and have good bone stock. If it fails down the road, which about 1 in 20 do by 10 years, then you've got a lot of room left to do a revision."
“The second type of implant is known as the 'in bone' and this is a very stable implant because the stem goes up into the tibia," continues Dr. Kulwin. “This is good for patients who either don't have great bone quality from prior fractures or who have fusions adjacent to the implant or who had to have a deformity corrected. This is the implant I tend to use."
Many people ask if fusion and ankle replacement is better, says Dr. Kulwin. “There are a limited number of patients who do well with either, but mostly it's which is most appropriate given the other things that are going on. Ask your surgeon and don't be afraid to get a second opinion. If anyone tells you that you don't need a second opinion, that's when you need to get a second opinion."