Your foot and ankle pain explained

With the warmer days of summer here, don’t let the activities you looked forward to all year get spoiled by a problem many people face – aching feet and ankles. It’s hard to be active and healthy when pain is a constant.

With a board-certified specialty in disorders of the foot and ankle, I see many patients who have lived with years of discomfort that plagues both recreational and daily activities. The patient becomes 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 my associated advice:

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

This common complaint presents to my office several times each week, if not daily. A patient complains of intense pain at the undersurface of the heel, usually associated with extreme stiffness in the morning and after an extended period of sitting. We call this “start-up” pain, and it is a hallmark of a condition called plantar fasciitis. 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 – in nearly 20 years of practice, I’ve operated on only a handful of patients.

“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. Patients hobble into my office with pain and swelling in the base of their heel and a concern about rupturing the tendon due to pain and tightness. They point to the back of the heel as being the source of their trouble, and there is 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”

Patients frequently come to see me when pain at the base of the great toe causes walking or athletic activity to be painful. Arthritis at the joint of great toe or first metatarsal phalangeal joint is the most common site of arthritis in the foot. The bones of the foot and great toe are generally covered with a smooth cartilaginous surface. 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 – often with the development of 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. In advanced cases, I perform a fusion to encourage the two surfaces to grow together. Patients usually have fairly limited range of motion at that point, and they trade a minimal increase in stiffness with pain relief as the two rough, arthritic surfaces are no longer rubbing together.

“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 with Advocate Medical Group Orthopedics.