Ankle and Foot Pain

Ankle and foot together form a complex and tough structure of many small bones for weight-bearing and balancing. Various strong ligaments bind these bones together. With many small joints involved, it has adequate flexibility too. Ankle and foot pain is a frequent problem, although many sufferers do not consult doctors for various reasons. Pain can arise from joints and bones and structures around joints such as ligaments and tendons. Pain on the upward or downward movement of the ankle originates from the ankle joint. The ankle is tender all around its circumference and may be swollen. Other problems in this region are heel pain, forefoot pain, and midfoot pain.

Some important conditions causing pain in the ankle and foot are as follows:

  1. Flat feet: Flattening of the long arch of the foot can be congenital or acquired. A flat foot can be hypermobile (flattens on weight-bearing) or rigid. Faulty weight-bearing, improper footwear, unaccustomed physical activity, and weight gain usually cause pain in a flat foot. Inner sole and heel of footwear tend to wear off early. Soft silicone arch supports help in relieving mild to moderate pain, whereas severe pain requires harder wedges. These need to be obtained from an occupational therapist. It is necessary to opt for regular use of properly fitting shoes, and high heels must be avoided. Pain killers may be used as and when required. Regular exercises for strengthening the intrinsic muscles of the feet are also essential.
  2. Ankle sprain: Sprained ankle is a common injury that usually occurs due to excess strain during the inwardly turned position of the foot. Severe pain is associated with swelling is located on the outer side and front of the ankle. Weight-bearing may not be possible. Pain on the inner side of the ankle indicates a high-impact injury. X-ray must be obtained to rule out a possible fracture. Treatment consists of rest, elevation, icepacks, and pain killers. Physical therapy must be followed as soon as the pain subsides. Inadequate treatment leads to an unstable ankle later in life.
  3. Achilles tendonitis: Calf muscles, which move the foot downwards, turn into a strong Achilles tendon attached to the back of our heel bone. Overuse of calf muscles (athletes, dancers) or faulty footwear leads to swelling and pain of this tendon. The pain is aggravated by pulling the foot upwards. Ultrasound examination confirms the diagnosis. Treatment consists of rest (a splint may also be used), avoiding provocative activities, and pain killers. A heel raise is advisable. Local steroid injection must be avoided as it can cause rupture of the tendon. Tendon rupture is often a sudden event with a popping sound followed by difficulty in walking or in standing on the toes. Tendon rupture requires early surgery.
  4. Pain around the ankle: Various tendons, ligaments, and nerves lie near the ankle and cause pain around it. Tendon dysfunction usually results from repetitive use. Pain occurs on the outer (Peroneus tendon) or inner (Tibialis posterior tendon) side of the back of the ankle on the passive and active movement of the ankle. Rest, pain killers, and physical therapy form standard treatment. Local glucocorticoid injections and surgery is advised in nonresponsive cases. Various conditions can entrap the posterior tibial nerve below the inner side of the ankle in the tarsal tunnel. This entrapment is associated with pain and numbness on forcible up stretching of toes. Activity modification, pain killers, appropriate footwear is the routine treatment. Surgery may be required in nonresponsive cases.
  5. Plantar fasciitis: Plantar fascia stretches like a bow-string from the heel bone to the front foot and helps maintain the longitudinal arch of the foot. Plantar fasciitis is common in people with flat feet, older individuals, and obese persons. Prolonged standing and excessive walking in certain occupations (including sportspeople) can also lead to plantar fasciitis. Inappropriate shoes and improper training in athletes aggravate pain. Heel pain on weight-bearing – particularly after a period of rest – is an important feature of plantar fasciitis. Pain in the feet makes walking difficult on getting up in the mornings. Pain diminishes on walking. Pain can also occur on prolonged standing, especially on hard surfaces. Clawing of toes reduces pain to some extent. An X-Ray may show a bony overgrowth near the heel bone (calcaneal spur) though this spur is not a cause for pain. Treatment consists of hot fomentation, pain killers, weight reduction, heel pads, and exercises. Avoid walking barefoot or wearing slippers. Ultrasonic heat and local glucocorticoid injection may be helpful in some cases.
  6. Retrocalcaneal bursitis: A bursa (fluid-filled sac) lies between the Achilles tendon and heel bone. Swelling of this bursa leads to pain at the back of the heel on downward movement of toes. Bursitis can be associated with tendonitis. Ultrasound or MRI examination may be required to confirm the diagnosis. Treatment consists of rest, heel raise, heat, and pain killers.
  7. Fat Pad Atrophy: Heel is covered with specialized fat to absorb fat. This fat reduces with age and in other conditions. Standing and activities on hard surfaces aggravate central heel pain. In severe cases, the underlying bone may be palpable. Treatment consists of proper shoes with soft heel cups.
  8. Metatarsal pain and fractures: Five slender metatarsal bones extend from midfoot to the base of respective toes. Pain in one or many metatarsal areas (metatarsalgia) can be due to joint stress, swelling of bursas, or adjoining structures and fractures. Metatarsal stress fractures can be due to high impact (long-distance running) or low impact (weak bones – osteoporosis) and cause localized swelling and pain in the forefoot while standing or walking. Treatment consists of rest and immobilization (below-knee plaster cast).
  9. Morton's neuroma: Tissues around interdigital nerves swell, giving rise to a soft tissue mass and cause burning dull pain between the digits. The condition is usually unilateral and occurs between the third and fourth toes. Removal of shoes and foot massage relieve whereas high heels and tight shoes increase the pain. Treatment consists of weight reduction, appropriate footwear with metatarsal support, local glucocorticoid injections, and surgery (in resistant cases).
  10. Deformities of great and other toes: Toes may get deviated outside (valgus) or inside (varus) due to degenerative arthritis or repetitive injury (dancing). Weight-bearing causes a dull ache at the base of the toe. This pain increases on barefoot walking or on wearing high heels. Moreover, simultaneous nerve entrapment may cause numbness or burning of the toe. Movements may be restricted or absent. These complaints are most common in the great toe. Hammertoe (claw-like) is a typically shaped deformity due to arthritis. Painful corn or callus (bunion – bursitis) develops beneath such deformity and adds to the pain. Custom shoes and other orthotic appliances should be used in these conditions. Surgery may be required in nonresponsive cases.
  11. Complex Regional Pain: A difficult condition to treat, complex regional pain starts as burning or piercing pain in the foot and extends towards the leg and thigh. This pain may be associated with warmth, redness, and sweating. Late changes include weakness, contractures, and tremors.
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