How to stamp out foot and ankle pain

by Nathan Wei, MD, FACP, FACR

Nathan Wei is a nationally known board-certified rheumatologist and author of the Second Opinion Arthritis Treatment Kit. It's available exclusively at this website... not available in stores.

Click here: Second Opinion Arthritis Treatment Kit

The ankle and foot are, like the wrist and hand, a complex interaction of a number of bones, ligaments, muscles, and tendons. This complex contains 26 bones and 38 muscles!

The foot and ankle are responsible for three things: weight-bearing, locomotion, and stability. The ankle consists of the interaction of the tibia (the larger of the two lower leg bones), the talus, and the fibula (smaller of the two lower leg bones)

There are three major joints: the tibial-talar joint ; the subtalar joint ; and the talonavicular joint. While the fibula does not really contribute to the joint, it has a major role in providing support to the outside (lateral) part of the ankle by helping to anchor a complicated series of ligaments.

The ankle and foot is divided into three major sections: the hindfoot (the ankle); the midfoot (talonavicular joint and midtarsal bones); and the forefoot (the metatarsal phalangeal joints).

The arch of the foot consists of metatarsal bones and their supporting ligaments. The lowermost layer of ligaments is the plantar fascia.

Swelling of the ankle joint points usually indicates an inflammatory type of arthritis. Sometimes soft tissue swelling or edema (fluid accumulation) can also cause the ankle to swell. In some circumstances, a Baker's cyst in the knee or a blood clot in the calf can cause ankle swelling.

A common problem in the ankles of patients with rheumatoid arthritis is hindfoot valgus where the rear part of the foot turns out. This places a tremendous amount of stress on the hindfoot and on the tendons and ligaments of the medial ankle.

Heel pain in the rear of the heel is often due to Achilles tendonitis or bursitis. Rest, anti inflammatory drugs, padding, and physical therapy are helpful. Steroid injection is sometimes used but caution is needed because steroid injection predisposes the patient to developing Achilles tendon rupture.

A new procedure...percutaneous needle tenotomy with autologous tissue grafting using platelet-rich plasma (PRP) is a minimally invasive procedure that can help a patient avoid surgery and cure their tendonitis.

Pain in the bottom of the heel is often due to plantar fasciitis. This is a condition where the tissue in the bottom of the heel becomes inflamed. People with flat feet are predisposed to this. Orthotics may be helpful. In those cases where this does not work, glucocorticoid injection sometimes is used. Unfortuately, glucocorticoids thin the fat pad and can make the situation worse. Platelet-rich plasma is probably a more effective therapy. Recently, botulinum toxin (Botox) has been used with success. Rarely, surgery is required.

When the posterior tibial nerve is trapped along the medial (inside part of the ankle), numbness and tingling along with burning can be felt in the toes and the sole. This is called tarsal tunnel syndrome and may be treated with injection and splinting.

Midtarsal joint pain is felt in the area of the midfoot. Osteoarthritis is common in this location, as is gout.

Arthritis may also develop in the metatarsal joints. A patient will feel as if he or she is “walking on marbles.”

Osteoarthritis of the large toe leads to bunion formation where the big toe turns out.

Rheumatoid arthritis can present with swelling and pain involving the metatarsal phalangeal joints while gout often starts with pain and swelling in the first metatarsalphalangeal joint (big toe joint). Treatment of the systemic process is most important. Injection with glucocorticoid may be helpful symptomatically.

Another problem that develops in the foot is Morton’s neuroma, a benign nerve tumor. This is treated with steroid injection or prolotherapy. Patients who don’t respond to these procedures will often require surgery.

Hammer toes may occur with different types of arthritis. They can usually be treated with padding. Patients may also need surgery.

“Sausage toes” may occur in patients with psoriatic arthritis or Reiter’s disease. Systemic control of the disease and occasionally glucocorticoid injection are beneficial.

Laboratory tests are helpful in evaluating diagnoses of inflammatory arthritis.

X-rays are not that helpful. Magnetic resonance imaging is very useful, particularly with soft tissue problems. Recently, ultrasound has been used with some success.

As with other areas, surgery should be reserved for those patients who do not respond to more conservative measures.

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