Foot and Ankle Pain

 

Foot and Ankle Pain, What is it?

Foot and ankle pain can have many different causes.  Most people are familiar with the more common reasons, including sprains, fractures, or arthritis. In fact, ankle sprains account for 85% of all reported ankle injuries[1]; however, there are many other reasons for foot and ankle pain. Understanding the complexity of the design of the foot and ankle will help explain the various reasons why it is so common.

The position of the feet builds the alignment of the knees, hips, pelvis, and low back. With the occurrence of any abnormal or compensatory movements within the feet, other structures throughout the lower half of the body are affected. When someone experiences low back, hip or knee pain, a health care provider will often assess the feet to determine if they are contributing.

The foot is perfectly designed for function. The foot, including the ankle, has 26 bones, 33 joints, 19 muscles, and 107 ligaments. Bones form the structure of the foot and can withstand quite a bit of force and weight. When one bone meets another bone, together they form a joint.

Ligaments are a tough fibrous tissue that connects bone to bone. The purpose of the ligament is to hold the bones together throughout the movement. Muscles attach to bones by tendons. When a muscle contracts and relaxes, it pulls on the tendon which in turn pulls on the bone causing movement.

The basic bone and joint anatomy of the foot:

  • Forefoot
    • Bones
      • Five distal phalanges
      • Four middle phalanges (no middle bone in the big toe)
      • Five Proximal phalanges
      • Five metatarsal bones
    • Joints
      • The great toe interphalangeal (IP) joint – between the proximal and distal interphalangeal bones (no middle interphalangeal bone)
      • Distal interphalangeal joint (DIP) – between the middle and distal phalanx of each toe
      • Proximal interphalangeal joint (PIP) – between the proximal and middle phalanx of each toe
      • Metatarsal phalangeal joint (MTP) – between the metatarsal and proximal interphalangeal bones
    • Midfoot
      • Bones
        • 1 Cuboid-line up with the 4th and 5th metatarsal
        • 3 Cuneiform (medial, middle, and lateral)-line up with the 1st, 2nd, and 3rd metatarsal
        • 1 Navicular-sits lateral to cuboid bone and proximal to the three cuneiform bones
      • Joints
        • Tarso-metatarsal joint (Lis Franc joint)-encapsulates all the bones in the midfoot
        • Midtarsal joint (Chopart)-includes the talonavicular joint (talus and navicular bones) and calcaneocuboid joint (calcaneus and cuboid bones)
      • Hindfoot
        • Bones
          • 1 Talus
          • 1 Calcaneus
        • Joints
          • Tibiotalar joint (Ankle joint)-where the tibia (bone in leg) joins with talus bone; transfers forces of leg to ankle
          • Subtalar joint (Agility joint)-where the talus and calcaneus join; 3 surfaces of the joint which allow for most of the ankle movement

There are many tendons and ligaments within the foot to help with stability and movement. Two major soft tissue structures are quite well known, the Achille’s tendon and the plantar fascia, which is sometimes called the plantar ligament.

As previously mentioned, tendons attach muscle to bone. The Achille’s tendon is the largest and strongest tendon in the body. The tendon extends from two calf muscles (gastrocnemius and soleus) and attaches to the heel (calcaneus).

An injury to this tendon is quite painful and takes a long time to heal. It has little blood supply which slows the healing process. Its main function is propulsion, or pushing off the ground.

The plantar fascia is commonly injured and a frequent source of pain.  Pain in this area is commonly called plantar fasciitis. This ligament also lacks blood supply which means it can be stubborn in healing. It extends from the heel (calcaneus) and attaches to each of the five metatarsal heads and proximal phalanges of the toes. It covers most the bottom of the foot. Supporting the arch of the foot and stabilizing the foot bones and joints are its main purposes.

This basic understanding of the foot anatomy is important to understanding how foot and ankle pain occurs. Any bone, ligament, or tendon within the foot can get injured and therefore cause pain. If not managed early enough, foot pain develops into weight shifting, gait changes, and puts stress on other structures of the body.

What causes foot and ankle pain?

A few common causes of foot and ankle pain are:

  • Bunions
  • “Flat feet,” or poor or flattened arches
  • Instability after an injury
  • Hammer toes
  • High arch in the foot
  • Landing on the heel after a fall or jump
  • Poor or unsupportive footwear
  • Poor care of toenails
  • Rolling the ankle
  • Running or walking, especially while wearing improper footwear, on uneven surfaces, or for extended periods of time
  • Scar tissue development after an injury
  • Stubbing a toe
  • Tripping and falling
  • Trauma, like a car accident

The following are the common conditions associated with foot and ankle pain:

  • Arthritis
  • Achille’s tendon tendinitis (tendon is inflamed)
  • Achille’s tendon rupture (tendon tears away from the bone)
  • Avulsion fracture (ligament or tendon injury breaks off a part of the bone)
  • Bursitis (inflamed bursa sac)
  • Congenital deformity
  • Fracture (broken bone)
  • Infection
  • Nerve injury
  • Plantar fasciitis
  • Sciatica
  • Sprain (injured ligaments)
  • Strain (injured muscle or tendon)
  • Tarsal Tunnel Syndrome (impinged nerve at the ankle)

Symptoms of Foot and Ankle Pain

Symptoms will vary widely depending on the issue. Some conditions and injuries, like an ankle sprain and ankle fracture, have similar symptoms.  Someone who is experiencing foot or ankle pain would benefit from medical attention for proper diagnosis and treatment.

A few of the more common foot and ankle symptoms include:

  • Bruising
  • Difficulty walking
  • Dull ache
  • Redness
  • Sharp pain
  • Stiffness
  • Swelling
  • Warmth to touch
  • Weakness

How is foot and ankle pain diagnosed?

How a diagnosis is made varies on the injury. Some injuries may require immediate attention. For a traumatic event like a fall, especially if accompanied by severe pain or a noticeable deformity, getting immediate care by a medical provider is advised.

In cases where fractures, nerve impingements, severe sprains, arthritis, or infections are suspected, a physician may order an X-Ray or MRI (magnetic resonance imagining). He or she will look at the foot structure including the soft tissue, bones, and in some cases, the nerves. Images are often used to support what the medical provider already suspects after a physical exam.

 

If there is no evidence of deformity or has been no trauma, a PT is a good starting point.  The PT will complete a physical exam of the foot.  He or she will start by reviewing the medical history including talking about the onset of symptoms. Also, he or she will assess the range of motion, strength, tenderness, and observe the color and any swelling.  If the patient can bear weight, the PT will assess the pattern of movement when walking. Based on the cumulative information, most foot and ankle pain symptoms can be diagnosed.  If a PT feels the findings of the patient’s foot and ankle require additional assessment, the PT will communicate with a medical provider and send the patient on for further referral.

Treatment of Foot and Ankle Pain

With the following symptoms, immediate medical attention is needed:

  • Deformity
  • Inability to weight bear
  • Open wound
  • Progressive pain
  • Redness
  • Sharp, stabbing pain that doesn’t go away
  • Warmth

With symptoms of slow onset, and no traumatic event, there may be some instances where managing the foot or ankle pain can be handled without medical care.  With a minor sprain or strain, often applying ice with gentle compression as well as rest and foot elevation is sufficient. In some cases, wearing an ankle support (brace or splint) is helpful, but is not always necessary.

For the more severe cases of foot or ankle pain, medical attention may be needed.  Significant bruising, difficulty walking, swelling, and intense pain require medical attention. A PT can assess the foot and ankle pain and establish as customized treatment plan based on the patient’s individual clinical findings.

The initial goals of PT are to reduce swelling, manage pain symptoms, provide training on an assistive device as needed (crutches, canes, or walkers) to reduce weightbearing, and possibly immobilize the foot/ankle with a brace. Once those symptoms have improved, the PT will work with the patient on recovering range of motion, strength, and eventually functional activities.

Treatment will vary greatly depending on the injury and condition. In some cases, surgery may be needed. If this is the case, your physician will provide you all the details of the risks and recovery for the recommendation.

Next Steps

Early intervention for foot and ankle pain is important to managing foot and ankle conditions conservatively. The sooner symptoms are addressed, the more likely conservative care will help.

All states have direct access to a physical therapist, meaning patients can go directly to a physical therapist without a physician order.  Each state has different guidelines, however, and can be found on the American Physical Therapy Association’s website Physical Therapy Direct Access By State.

Find A Clinic will help locate a PT that has top national rankings for treating foot and ankle pain.

[1] http://www.healthline.com/symptom/ankle-pain

 

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