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Foot and ankle problems- part 2

In the second of two articles, rheumatologist Dr Phillip Helliwell and colleagues look at common problems of the rearfoot

In the second of two articles, rheumatologist Dr Phillip Helliwell and colleagues look at common problems of the rearfoot

The most common heel and ankle problems encountered in primary care are: pain at the back of the heel and Achilles tendon pain, ankle sprain and instability, plantar fasciitis and flat foot deformity and tibialis posterior dysfunction.

A lot of simple advice can be given but – like problems involving the forefoot – these conditions encompass a huge spectrum of disability and pathology. If simple measures fail then seek help from a podiatrist, physiotherapist or musculoskeletal doctor. Reliable internet-based advice and simple patient leaflets are also available (see box).

Pain at back of the heel and Achilles tendon pain

Pain around the posterior heel has four main causes:

• Achilles paratendonitis – by far the most common and due largely to mechanical factors. A typical history is someone who has just completed a 25-mile hike in boots that haven't been worn for four years. In other cases the patient may have severe hyperpronation – or flat foot deformity. But beware the elderly patient on steroids or recent courses of a quinolone antibiotic such as ciprofloxacin which can cause tendonitis and partial or complete rupture.

• Haglunds ‘one' – due to bony prominence on posterior superior aspect of heel. This may present with persistent Achilles pain proximal to the insertion and associated with the posterior superior aspect of calcaneum. MRI scanning shows high signal at this point.

•Haglunds ‘two' – "pump bumps" – due to bony prominence on posterior lateral aspect of heel. Pump bump is primarily bony but may have an adventitious bursa overlying it.

•Achilles insertional tendonitis which is primarily seen in spondyloarthropathy (such as reactive arthritis, psoriatic arthritis and ankylosing spondylitis). Pain and swelling are found at the point of insertion of the tendon, rather than the substance of the Achilles proximal to the insertion. This may be associated with other features such as back pain and stiffness, dactylitis and skin disease.

Ankle sprain and instability

Inversion sprains around the ankle are common both in and out of sport. Most sprains are minor but the severest can result in ligamentous rupture and osteochondral defects in the articular surface of the talus and the tibia.

The most important risk factor for sprain is a previous sprain so adequate treatment of a first sprain is very important.

Most sprains go to A&E and have an X-ray. Often, they also receive inappropriate advice on early management (see below). Investigations are rarely of help initially.

Treatments

• For the acute injury RICE (rest, ice, compression and elevation) is recommended, but only until the initial swelling has subsided. Early mobilisation is important.

• Getting the patient up and about is important in preventing long-term disability.

• When the ankle swelling and bruising has settled an active rehabilitation programme should be given. If available this should be done through physiotherapy. If not advise on proprioceptive and muscle-strengthening exercises. People can make a ‘wobble board' from a piece of 2cm thick (45cm square) wood or mdf and a suitable base, such as a wooden door knob. Alternatively they can be bought – for example at www.physiosupplies.com

• In the rehabilitation phase patients will often feel instability in the ankle. The strength and balance training outlined above will help this. Some people require additional help with in-shoe orthotics and ankle braces (the latter can be bought at sports shops and some chemists).

• Sports people who have recurrent ankle sprains should be encouraged to do wobble board training intensively as there is evidence that this can prevent recurrence. Some sports people also find that taping their ankle prior to activity also helps.

• The more severe sprains are associated with ligament rupture, avulsion injury (at the base of the fifth metatarsal) and osteochondral injuries. For sprained ankles that do not recover these factors should be considered. In these cases imaging is required and, in some cases, a surgical solution is necessary.

Plantar fasciitis

Pain in the plantar fascia region (deep to the heel pad) is a common foot problem that arises from repeated trauma to the fascia and attachment. The symptoms include discomfort along the fascia which is aggravated by weight bearing and painful at the origin of the fascia.

It is often characterised by a focal tenderness at the attachment on initial weight bearing after rest, particularly when getting out of bed. This pain generally dissipates within half an hour or so. Aetiological factors include:

• A sudden increase in activity, worn/inappropriate footwear, overweight (particularly rapid weight gain such as with pregnancy), occupational activities (such as those where the toes are extended such as squatting) and poor foot mechanics, including rigid foot types and over pronated (flat) feet.

• It is a common sporting injury and is often associated with changes in running surfaces, training protocols or footwear.

• As it often occurs with systemic inflammatory arthritis (particularly ankylosing spondylitis and other seronegative arthritides such as psoriatic arthritis), it is important to consider the possibility of systemic disease.

General therapeutic advice for plantar fasciitis includes:

• Identify likely causative factors (including weight reduction, inappropriate footwear, training errors) and treat.

• NSAIDs are the most common form first-line treatment by GPs.

• Taping offers good, short-term symptom relief.

• Stretching exercises can also help plantar fasciitis – see Common Foot Problems on the Arthritis Research Campaign website

• Orthotic devices can help in the short-term resolution of pain, although their long-term benefit is not clear. These can be custom made (expensive if done privately) or bought ‘off the shelf' at chemists.

• Steroid injection may also have a short-term benefit, although usually considered only with intractable pain.

Flat foot deformity and tibialis posterior dysfunction

Flat foot deformity is common and occurs in about a quarter of the population. It has been associated with plantar fasciitis, Achilles tendon pain, ‘shin splints' and even osteoarthritis of the knee. Tibialis posterior dysfunction (TPD) is the most common cause of acquired flatfoot deformity in otherwise healthy adults.

General presentation of TPD:

• Pain and swelling of the medial ankle and instep.

• Be suspicious of a progressive flat foot deformity. Commonly an insidious onset though a specific eversion injury to ankle may be described.

• May be overweight, middle aged and recently undertaken a higher level of activity than normal. Common in runners and hikers.

• May be pain, no heel inversion or an inability to perform a single heel raise.

• Pain on palpation along the course of the tendon, particularly behind the medial malleolus and at the navicular enthesis. Pain on resisted ankle inversion.

• Often a unilateral presentation but 70% will have a contralateral flat foot, suggesting the symptomatic foot was probably flat to start with.

• Ultrasound or MRI may be appropriate to assess extent of soft tissue damage.

Treatment

• Early recognition is crucial to optimise treatment outcomes.

• Emphasise the progressive nature of the pathology for treatment compliance.

• Control pain and inflammation.

• Stabilise joint with hiking boot, tape, orthoses, brace, cast. Refer to podiatry.

• Tendon rehabilitation, if still functioning. Refer to physiotherapy.

• Surgery. Tendon debridement or transfer, with corrective osteotomy. Arthrodesis if fixed deformity or degenerative changes.

Patient advice

What to do:

• Ask about any recent changes in physical activity or new footwear

• Inspect the footwear for abnormal wear and look at the foot both in shoe and bare foot (standing and sitting)

• Consider referral for orthotics to correct any foot deformity (especially over-pronation)

• Physiotherapists and podiatrists can advise on exercises and taping for rehabilitation

What not to do:

• Inject steroids into the substance of the Achilles tendon

• Inject steroids directly through the heel pad into the plantar fascia (both these manoeuvres may cause subsequent rupture of the ligament or tendon)

• Disregard the potential of quinolone antibiotics (such as ciprofloxacin) to cause tendonitis and tendon rupture

• Rest the patient for too long after a sprain – wait for initial swelling to subside (usually a few days maximum)

Web-based information

• For advice about exercises see theArthritis Research Campaign website where you will find ‘Hands On' (information for health professionals). February 2004 Number 2: Plantar fasciitis and heel pain. October 2006 Number 10 Common foot disorders

• The British Orthopaedic Foot and Ankle Society has patient information

• Patients could also be directed to the website of the Society of Chiropodists and Podiatrists

British Footwear Association

• There is useful information on US-based site www.footphysicians.com

Dr Philip Helliwell is consultant rheumatologist at the Academic Unit of Musculoskeletal and Rehabilitation Medicine, University of Leeds.

This article was co-written by Heidi Davys, Ann-Maree Keenan, Anthony Redmond, Carl Ferguson, Lee Short and Brian Welsh.

Competing interests: None declared

Flat foot deformity occurs in about a quarter of the population Flat foot deformity occurs in about a quarter of the population

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