Your foot and ankle pain explained

Don’t let aching feet and ankles stop you from your favorite activities.

If you have lived with years of foot and/or ankle discomfort, you most likely have become more sedentary, postponing important physical activities that have both physical and psychological benefit. Many of these conditions can be treated medically with simple, conservative measures. Others have surgical solutions that can ultimately yield an enhanced quality of life.

Below are some common complaints I hear and what I advise:

“It feels like there’s an icepick in my heel.” 

If you have plantar fasciitis, you may experience intense pain at the undersurface of the heel, usually associated with extreme stiffness in the morning and after an extended period of sitting. The plantar fascia is a tendon sheath that runs along the undersurface of the foot. It is commonly associated with inflexibility of the Achilles tendon and flat arches. Sometimes increased activity will bring on a flare – sometimes it occurs with no apparent reason.

While this condition is quite painful and inconvenient, it usually resolves over time with a course of ice, rest, anti-inflammatory medications like ibuprofen and physical therapy. Stretching the heel cord, or Achilles, is the mainstay of treatment. Cushioned gel heel cups provide considerable relief, and cortisone injections are sometimes utilized if the condition persists for several months, despite treatment. Surgery is reserved for refractory cases.

“My Achilles is so tight – it might tear.”

The largest tendon in the body, the Achilles tendon, is a common site of inflammation. It connects the muscles in your lower leg to the heel bone and is commonly aggravated by athletic activity. Sometimes the culprit is overuse, but degenerative changes can also play a role.

You may experience pain in the back of the heel and often a painful “bump.” Tightness in the heel cords or Achilles plays a significant role – it can be associated with flatter arches or the overall loss in flexibility that tends to occur naturally as we age.

Conservative measures like ice, anti-inflammatory medications and, particularly, stretching can be helpful in alleviating symptoms. The condition can become chronic, and a period of immobilization in a walking boot can sometimes calm the tendon to the point that physical therapy is more effective. I sometimes operate for treatment of prolonged cases that fail to respond to these other treatments.

“My big toe is killing me.”

Arthritis at the joint of great toe or first metatarsal phalangeal joint is the most common site of arthritis in the foot. Chronic stress on the joint from certain anatomy of the foot that places excessive force on the joint or injury from running or other sports can damage the cartilage. You may develop painful, bony spurs at the top of the joint and roughening of the two articular surfaces. The toe becomes inflexible, and every step is associated with pain.

I frequently recommend simple measures like avoiding high heels and purchasing shoes with a wider toe box. Ice and anti-inflammatory medication can also reduce symptoms. Patients tend to be more comfortable in a shoe with a rigid sole. If symptoms persist, surgery is an option. If the degeneration is not particularly severe, a more minimal surgery can be done to remove the offending bone spurs.

“Every step hurts.”

When standing, walking or running, the three bones that make up the ankle joint provide support, shock absorption and balance. There is another joint beneath the true ankle joint that provides for the side to side motion of the ankle that is essential in enabling us to adjust our gait on uneven surfaces. These joints are typically covered by a smooth, slippery articular cartilage surface that provides for easy, fluid motion. Sometimes from trauma but, more commonly, through wear and tear, the cartilaginous surface starts to wear or become roughened, and abrasive osteoarthritic surfaces are the result. Patients come to see me distressed, as each step is associated with the pain of the two rough surfaces colliding.

Arthritis of the foot and ankle can present in a variety of ways. My patients often complain of tenderness at the ankle joint along with warmth or swelling. Early morning pain is often worse as is the aftermath of extended standing or walking. Nonsurgical therapy varies from anti-inflammatory medication like ibuprofen to bracing and inserts for shoes which support and help to minimize pain. Periodic cortisone injections can help keep pain under control.

If degenerative changes are severe enough and fail to respond to conservative therapies, my patients and I have a discussion about surgery. For arthritis of the ankle, or tibiotalar joint, two surgical options exist – a total ankle replacement or a fusion. The most appropriate surgery depends on a variety of factors which I review carefully with patients during a pre-operative consultation.

A fusion, or arthrodesis, fuses the bones of the joint completely, making one bone out of two. The goal is to decrease pain by eliminating motion in the arthritic joint. I remove the damaged cartilage in surgery and then use pins, plates and screws to fix the joint in a permanent position. This is usually a successful and durable solution to the problem. An important factor to consider is the extended period of non weight-bearing activity required after surgery to facilitate successful fusing of the two bony surfaces.

For some patients, a total ankle arthroplasty (TAA or ankle replacement) is a good surgical choice. With a TAA, the damaged cartilage is removed and the bone is prepped – a new metal and plastic joint is implanted – effectively replacing the joint. While TAA is an excellent solution for a painful, arthritic ankle joint, the life-span of the implant must be considered. Current implants last about 20 years, and the joint does not respond well to demands such as running or jumping – generally making TAA a poor choice for a younger patient. I typically perform ankle replacement surgery in older, less physically active, arthritic patients with appropriate indications for surgery.

Life is too short to struggle with nagging, chronic foot and ankle pain that makes each step a burden. Consider the options and take needed action to put some spring in your step.

Dr. Gregory G. Caronis, is a board-certified orthopedic surgeon at Advocate Health Care