Ankle and Foot Pain

Ankle and foot together form a complex and tough structure made up 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 common problem although many sufferers do not consult doctors for various reasons. Pain can arise from joints and bones as well as from structures around joints such as ligaments and tendons. Pain on upward or downward movement of ankle originates from 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 are as follows:

  1. Flat feet Flattening of long arch of foot can be congenital or acquired. Flat foot can be hyper mobile (flattens on weight bearing) or rigid. Faulty weight bearing, improper foot wear, 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 silicon arch supports help in relieving mild to moderate pain whereas severe pain requires harder wedges. These must be obtained from an occupational therapist. One must opt for regular use of proper fitting shoes and high heels must be avoided. Pain killers may be used as and when required. Regular exercises for strengthening of intrinsic muscles of feet are also essential.
  2. Ankle sprain Sprained is a very common injury which usually occurs due to excess strain during inward position of sole. Severe pain is associated with swelling is located on the outer side and front of ankle. Weight bearing may not be possible. Pain on inner side of ankle indicates a high impact injury. X-ray must be obtained to rule out possible fracture. Treatment consists of rest, elevation, ice-packs and pain killers. Physical therapy must be followed as soon as pain subsides. Inadequate treatment leads to unstable ankle later in life.
  3. Achilles tendonitis Calf muscles, which move the foot downwards, turn into strong Achilles tendon attached to the back of our heel bone. Overuse of calf muscles (athletes, dancers) or faulty footwear lead to swelling of this tendon leading to pain. Pain is aggravated by pulling the foot upwards. Ultrasound examination confirms the diagnosis. Treatment consists of rest (a splint may also be used), avoidance of provocative activities and pain killers. A heel raise is advisable. Local steroid injection must be avoided as it can cause rupture of tendon. Tendon rupture is often a sudden event with a popping sound followed by difficulty in walking or in standing on toes. Tendon rupture requires early surgery.
  4. Pain around ankle Various tendons, ligaments and nerves lie near ankle and cause pain around ankle. Tendon dysfunction usually results from repetitive use. Pain occurs on outer (Peroneus tendon) or inner (Tibialis posterior tendon) side of the back of ankle on passive as well as active movement of ankle. Rest, pain killers and physical therapy form standard treatment. Local glucocorticoid injections and surgery is advised in nonresponsive cases. Various conditions can entrap posterior tibial nerve below the inner side of ankle in the tarsal tunnel. This is associated with pain and numbness on forcible up stretching of toes. Activity modification, pain killers, appropriate foot wear is the routine treatment. Surgery may be required in nonresponsive cases.
  5. Plantar fasciitis Plantar fascia stretches like a bow-string from heel bone to front foot and helps maintaining the longitudinal arch of foot. Plantar fasciitis is common in people with flat feet as well as in older individuals and obese people. Prolonged standing and excessive walking in certain occupations (sportsmen too) can also lead to plantar fasciitis. Flexible soled 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 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. X-Ray may show a bony overgrowth near 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 useful in some cases.
  6. Retrocalcaneal bursitis A bursa (fluid filled sac) lies between Achilles tendon and heel bone. Swelling of this bursa leads to pain at the back of heel on downward movement of toes. Bursitis can be associated with tendonitis. Ultrasound or MRI examination may be required to confirm diagnosis. Treatment consists of rest, heel raise, heat and pain killers.
  7. Fat Pad Atrophy Heel is covered with a specialized fat to absorb fat. This fat reduces with age and in other conditions. Central heel pain is aggravated by standing and activities on hard surface. Underlying bone may be palpable in severe cases. 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 of the 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 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 third and fourth toes. Removal of shoes and foot massage relieve whereas high heels and tight shoes increase 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 injury (dancing).Weight bearing causes dull ache at the base of the toe. Pain increases on barefoot walking or on wearing high heels. Concomitant 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. Hammer toe (claw like) is a typically shaped deformity due to arthritis. A 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 lancinations in foot and extends towards leg and thigh. This may be associated with warmth, redness and sweating. Late changes include weakness, contractures and tremors.
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