Ankle-Foot Pain
From a diagnostic and treatment perspective, ankle-foot pain complaints can be broken into the hindfoot, midfoot and forefoot.
Many recurrent hindfoot ankle and foot complaints revolve around tendinopathy affecting the Achilles and posterior tibial/peroneal tendons.
They may represent degenerative changes which progress as we get older. Most present as some form of heel load-bearing pain which may include planter fasciitis.
Some localised swelling is frequently present. Underlying degenerative ankle and hindfoot changes are frequently coexistent.
Depending on the age of the patient and intensity of exercises, there are different presentations including Achilles tendinopathy, Achilles tendonosis and Achilles tendon tear. There may be combinations. These conditions are diagnosed clinically and on MRI/ultrasound. Treatments include offloading walking shoes, strapping support and physiotherapyorthotics. Local injection may or may not be appropriate depending on the diagnosis. Sometimes, surgery is necessary to decompress and repair of the tendon in continuity. Patients may have to then wear an loading brace for a few weeks.
Ankle joint instability is frequently related to sport and primarily affects the outer ankle, lateral ligaments. It is caused by an inversion ankle injury resulting in partial or full ligament tears. They are graded depending on the severity of ligament instability with associated crescent-shaped bruising and soft tissue swelling. Traditional treatments include initial RICE, ankle strapping/bracing and possible ligament repair such as the Broströms procedure. Late treatment may involve lateral ligament reconstruction sutures variation on the Evans procedure.
Ankle joint arthritis is relatively uncommon, is usually post-traumatic or part of a generalised arthritis. It presents with mechanical load-bearing pain and swelling. In the early stages, it is treated by ankle bracing, ankle arthroscopy and injection. In the later stages, ankle joint replacement or ankle fusion is indicated.
Midfoot complaints are centred on the Lisfranc or Chopart joint manifest as arthritis. Talonavicular arthritis may also occur. Subtalar joint arthritis is less common. Joint arthropathy will provoke localised load-bearing pain and restriction in movement. Diagnosis is made clinically supported by x-ray and MRI/CT. Orthotics supplemented by diagnostic injection and selective fusion usually is therapeutic.
Forefoot complaints centre around the big toe where one may develop a big toe bunion i.e. Hallux Valgus. Equally, some patients may develop joint arthritis, Hallux Rigidus ie degenerative big toe arthritis. Treatments may include local injection, orthotics and corrective big toe surgery such as Chevron/Aiken osteotomies and/or metatarsal toe joint replacement. Metatarsal joint fusion remains another option.
Forefoot transfer loading off the symptomatic big toe may result in metatarsalgia and Morton’s neuroma. It can be usually treated by orthotics and injection. Occasionally, surgery is indicated.
