Foot & Ankle 101

There is not one body part that when it is hurting, everything else starts to hurt. The foot and ankle are no different. In a lot of ways, having foot or ankle pain limits our ability to do one simple thing – walk. Walking is key to daily movement and once we start to compensate due to pain, the whole system can get out of whack. What first comes to mind with the foot and the ankle are ankle sprains. Only about 50% of ankle sprains seek medical consultation and are the most common ankle and sport related injury (1). In the most recent study (2016), 27% of ankle sprains occurred under 18 years, 40% between 18-35 years, 18% in 36-49 years, and 15% in those older than 49 years (1). Additionally, 40% of ankle sprains are sport related with the most common sports being indoor and court sports such as volley ball and basketball (1). Ankle sprains do occur in field sports but at lower rates (1). Recurrent ankle sprains and the diagnosis of Chronic Ankle Instability are most common with athletes and female athletes, both high school and collegiate, having significant higher prevalence (1). According to Minton (2023) the three most common foot and ankle conditions outside of sprains are: Achilles tendinopathy, plantar fasciitis, and Morton’s neuroma. Out of the three, Achilles tendinopathy is the most successful to treat overall because the tendon responds to proper loading strategies (2). For plantar fasciitis at least 1 million patients present with plantar heel pain and even after 15 years up to 44% of patients continue to have pain (2, 8). Morton’s neuroma is more difficult with 30% not responding to conservative treatments (2). With the foot and the ankle there are several key injuries that physical therapy can help with: lateral and medial ankle sprains, chronic ankle instability, Achilles tendinopathy, and plantar fasciitis.

Lateral ankle sprains are common. Ankle stability is provided by the anterior talofibular ligament (ATFL), posterior talofibular ligament (PTFL) and the calcaneofibular ligament (2, 3). Once there is an injury the goals are to 1) limit the degree of the injury, 2) restore range of motion, balance, and strength, 3) increase agility and endurance and 4) facilitate return to sports (3, 4). When we look at this process, even if the individual injured is not very active, restoration of agility and endurance is essential because the ankle needs the ability to take on advanced forces. Often physical therapy and rehabilitation stop after phase 2 because insurance dictates the individual is functional. Are they? As noted in our Peace & Love blog post, treatment of an acute ankle sprain is early weight bearing and range of motion exercises (4). We are here to guide you through this process to treat ankle sprains with the utmost care and researched practices.

Medial ankle sprains are less common than lateral ankle sprains. The sprain occurs due to an injury to the deltoid ligament and/or the spring ligament (5) when the foot is excessively moved outward with force or even a significant force applied from the outside to the inside of the ankle. The same rules apply to a medial ankle sprain as lateral ankle sprains for rehabilitation using the four steps mentioned above.

Chronic ankle instability is a term used to describe consistent reinjury of the ankle ligaments, even to the point where some ligaments may be completely torn. This occurs with the person who states: “I am always rolling my ankles.” The goal for physical therapy here is no different than the goals listed above, with a lot on emphasis on normal range of motion, balance control, and improving the muscular aid to stability.

Achilles tendiopathy – includes Achilles tendinitis and Achilles tendinosis – is generally associated with a sudden increase in activity but overall causation remains unclear (6). The most recent summary by van der Vlist et al (2018) discovered 9 risk factors for developing Achilles tendinopathy: 1) prior tendinopathy or fracture, 2) use of ofloxacin (quinolone) antibiotics, 3) an increased time between heart transplantation and initiation of quinolone treatment for infectious disease, 4) moderate alcohol use, 5) training during cold weather, 6) decreased isokinetic plantar flexor strength, 7) abnormal gait pattern with decreased forward progression of propulsion, 8) more pressure on the lateral side of the plantar surface of the foot while running, and 9) creatinine clearance of <60 mL/min in heart transplant patients. These factors can possibly increase Achilles tendon issues. Treatment for Achilles tendinopathy consists of one very important factor – exercise (7). New insoles, heel lifts, taping, ultrasound and shockwave therapy do not have enough evidence to support using those tools to properly treat the tendon (6, 7). Dry needling specific to the Achilles tendon is currently being researched by the American Academy of Manipulative Therapy (AAMT) with positive outcomes for treatment based on the raw data. We have and implement these protocols and they have very good outcomes though the research is ongoing.

Plantar Fasciitis is heel pain with the first step out of bed that tends to decrease with more activity, but increases again with low activity. The most tender spot is pain on the underside (plantar) aspect of the heel toward the inner aspect of the heel. This condition occurs most commonly in later life, 45-64 years with the risk factors that include being overweight, prolonged standing, Achilles tendon injuries, and limited range of motion (8, 9). Chronic stages of plantar fasiciitis, greater than 3 months to years, can develop with painful bone spurs, improper thickening on tendons and soft tissues, and even numbness (9). Numbness around the heel, not associated with lower back symptoms or neuropathy, is termed Baxter’s Impingement which is much more difficult to treat due to very limited research. Treatment for plantar fasciitis is focused on restoration of active range of motion, improve muscular, tendon, and soft tissue length, and improving foot and ankle strength.

When we tear a ligament or a tendon, the conversation of “Should I have a surgery or not” comes up. The answer is, how much pain are you having? When there is minimal to no pain, a surgery may not be required. Certain ruptures like an Achilles rupture may or may not require surgery based on the surgeon. If there is significant pain, an inability to walk, and loss of function, a surgery is probably needed. We would recommend in either case a conversation with an orthopedic foot and ankle specialist.

At the SHOP, we develop plans and routines to help with foot and ankle in Springfield, MO. We believe in our treatments and implement them throughout our practice to help you achieve decreased pain, improved mobility, and enhanced ability to do the things you love.

If you live in Springfield, MO and the surrounding area, let The SHOP help treat your foot and ankle pain. Do you want to learn more or get started with treatment?

References:

1. Martin RL, Davenport TE, Fraser JJ, et al. Ankle Stability and Movement Coordination Impairments: Lateral Ankle Ligament Sprains Revision 2021. Journal of Orthopaedic & Sports Physical Therapy. 2021;51(4):CPG1-CPG80. doi:https://doi.org/10.2519/jospt.2021.0302

2. Minton Truitt Cooper. Common Painful Foot and Ankle Conditions. JAMA. 2023;330(23):2285-2285. doi:https://doi.org/10.1001/jama.2023.23906

3. Dhillon MS, Patel S, Baburaj V. Ankle Sprain and Chronic Lateral Ankle Instability. Foot and Ankle Clinics. Published online February 2023. doi:https://doi.org/10.1016/j.fcl.2022.12.006

4. Marín Fermín T, Al-Dolaymi AA, D’Hooghe P. Acute Ankle Sprain in Elite Athletes. Foot and Ankle Clinics. 2023;28(2). doi:https://doi.org/10.1016/j.fcl.2022.12.007

5. Pflüger P, Valderrabano V. Sprain of the Medial Ankle Ligament Complex. Foot and Ankle Clinics. Published online March 2023. doi:https://doi.org/10.1016/j.fcl.2023.01.009

6. Chimenti RL, Neville C, Houck J, Cuddeford T, Carreira D, Martin RL. Achilles Pain, Stiffness, and Muscle Power Deficits: Midportion Achilles Tendinopathy Revision – 2024. Journal of Orthopaedic & Sports Physical Therapy. 2024;54(12):CPG1-CPG32. doi:https://doi.org/10.2519/jospt.2024.0302

7. van der Vlist AC, Breda SJ, Oei EHG, Verhaar JAN, de Vos RJ. Clinical risk factors for Achilles tendinopathy: a systematic review. British Journal of Sports Medicine. 2019;53(21):1352-1361. doi:https://doi.org/10.1136/bjsports-2018-099991

8. Voelker R. What Is Plantar Fasciitis? JAMA. Published online September 5, 2024. doi:https://doi.org/10.1001/jama.2024.9505

9. Anas Mohammed Alhakami, Reem Abdullah Babkair, Sahely A, Shibili Nuhmani. Effectiveness of therapeutic ultrasound on reducing pain intensity and functional disability in patients with plantar fasciitis: a systematic review of randomised controlled trials. PeerJ. 2024;12:e17147-e17147. doi:https://doi.org/10.7717/peerj.17147