Pain is considered chronic when it has been present for more than 3 months. It can be characterized as intermittent or constant. Intermittent pain often has a high intensity and is generally more debilitating than a constant dull ache. The cause of pain can often be identified with damage to bone, joints, ligaments, tendons, or muscles. Identification of the pain generator is important in understanding the nature of the pain and planning treatments to improve pain and function. Individuals who have pain often have changes in their walking pattern to avoid positions that cause pain. It is well known that changes in gait can lead to further disability above and below the pain source. Muscle weakness and atrophy are also common in individuals with chronic foot and ankle pain. The pain itself, as well as periods of immobilization due to casting or bracing to improve pain from a certain condition, can lead to muscle changes. Limited joint motion is another result of pain and can be a source of pain in itself. Individuals often lose joint motion due to pain or muscle imbalance and never attempt to improve it because it does not hinder basic walking activities. Joint motion is important in many activities and without it, adjacent joints may overcompensate to perform activities they are not suited for. This can cause damage to those joints and result in pain in other areas of the lower extremity.
Chronic foot and ankle pain is a common problem that often results from damage to the complex structures of the foot and ankle. The pain may affect how an individual walks and may cause changes in gait to avoid pain. Muscle weakness, as well as limited joint motion in the foot and ankle, may also result from pain and may lead to further disability. When non-surgical and surgical treatments fail to resolve chronic foot and ankle pain, it is important to find other methods to cope with the pain and maintain function in the lower extremity. This paper reviews the nature of chronic foot and ankle pain, discusses the impact of pain on the lower extremity, and suggests coping strategies to improve functional outcomes.
Understanding Chronic Foot and Ankle Pain
Finally, there are times when chronic pain results from a bad experience with healthcare. This is often the case with fear-avoidance beliefs, and it is most common with the avoidance of activity due to pain. Activity and/or exercise are important for general health and have an effect on mental health and well-being. For pain with musculoskeletal origin, there is a belief that a single moderate to high-intensity session of exercise can increase pain and soreness, but this is not related to duration and is a short-term change. This can be explained to a patient, and with supervision, exercise could be an effective way of getting rid of chronic pain.
Osteoarthritis is a good example of a condition that causes acute and chronic foot pain. It is the most common type of joint disease, and it is estimated that 70% of people aged 70 or older will have some degree of osteoarthritis. It is characterized by degeneration of articular cartilage and changes to the bone underneath. This wear and tear of cartilage is usually painless. In the foot and ankle, the first metatarsophalangeal joint and the midfoot joints are most affected. Although wear and tear of these joints is painless, the changes in alignment or instability due to ligament damage can lead to acute pain with synovitis and chronic pain with the development of osteoarthritis in the joints. Changes in alignment and instability are mechanical factors, and it is important to understand what makes the pain worse and what eases it.
Intensity and duration of acute pain often lead to psychological problems such as depression or anxiety. These problems then lower the pain threshold and tolerance, thus increasing the frequency and duration of pain and creating a vicious cycle.
An understanding of how pain becomes chronic can help direct a treatment plan. Duration, intensity, and nature of pain are all factors to be considered. Pain frequency and duration are subject to change and are affected by intrinsic and extrinsic factors. Duration of pain is related to changes in the way genes are expressed, and this can lead to molecular and anatomical changes in the hypothalamus-pituitary-adrenal system, which can regulate pain and inflammation.
The first step in managing chronic pain is to identify its origin. This can be a complex process as the perception of pain in each individual is different, and there are many factors that affect it. Factors that have been identified for prolonging acute pain or causing chronic pain are depression, anxiety, fear-avoidance beliefs, prolonged NSAID use, various psychosocial factors, and/or the presence of other diseases or inflammatory arthropathies.
Chronic foot and ankle pain is a common but often unrecognized problem. Chronic pain differs from acute pain in that it can go on for months, years, or even a lifetime. It can result from a number of different injuries or systemic problems such as osteoarthritis, rheumatoid arthritis, neuropathy, or it may occur in the absence of trauma or a clear diagnosis. It is estimated that around 20% of the population can identify with having chronic foot and/or ankle pain.
Importance of Coping Strategies and Support
In order to minimize the negative impact of pain, it is important that individuals cultivate the belief that they can reduce the effect pain has on their quality of life. Pain catastrophizing is a negative mental set brought to bear during actual or anticipated painful experience and is characterized by three main elements: rumination, magnification, and feelings of helplessness. The perceived inability to control or decrease pain will lead to greater pain intensity and higher levels of psychological distress. Studies have shown that patients with pain catastrophizing are more likely to visit their health care professions, which contributes to greater health care costs compared with those who do not catastrophize. Individuals who feel unlike they are able to decrease or control their pain may benefit from cognitive therapy designed to increase their sense of self-efficacy in controlling pain as well as reducing feelings of helplessness. Self-efficacy has been related to less pain in some pain populations and is defined as the belief in one’s capabilities to organize and execute the courses of action required to manage prospective situations. Psychological flexibility has also been shown to be related to less pain and psychological distress in some chronic pain populations. This can be defined as the ability to stay in the present moment and consciously and effectively act in accordance with one’s deepest values despite current emotional experience. It is looking increasingly likely that acceptance based coping will be beneficial for those with chronic pain. This can be complex as it is not giving up which is associated with increased psychological distress, but giving up the struggle with the pain and learning to live a meaningful life despite it. This can be a long and drawn out process with many setbacks, but the ability to stay committed and take positive steps in the face of difficulty can result in a more meaningful and richer life.
Coping Strategies for Foot and Ankle Pain
Individuals with musculoskeletal pain disorders are often inspired to exercise and are frequently recommended specific exercise interventions by healthcare professionals. It is generally accepted that regular exercise is good for general health; being physically active is related to enhanced function and quality of life as well as good mental health. In the context of musculoskeletal pain, evidence exists to support the fact that exercise has beneficial effects on pain severity and related depression. This also seems to be true for people with foot and ankle pain. In an exploratory study comparing attitudes to, and use of exercise in older men with long-term pain from differing anatomical sites, foot pain sufferers expressed a strong belief in the effectiveness of exercise for improving pain and maintaining function. In an interview study of adults with rheumatoid arthritis, a common theme was the idea that exercise was beneficial for disease-specific symptoms in foot and ankle pain sufferers. This contrasted with other types of inflammatory arthropathy who felt that exercise exacerbated their condition. So, it seems that exercise may be an important strategy for people with musculoskeletal pain from the foot and/or ankle, in terms of improving symptoms and maintaining function. A variety of problems are encountered by foot and ankle pain sufferers when attempting to exercise. These may relate to the nature of the symptoms and functional limitations imposed by the pain, physiological changes causing deconditioning, and psychological obstacles to initiating activity. Such patients may be good candidates for referral to physiotherapists for exercise-based interventions.
Individuals adopting coping strategies for foot and ankle pain comprise a mix of problem-focused strategies such as task alteration, seeking coping, and emotion-focused strategies such as self-isolation. Exercise and physical therapy are amongst the most frequently used problem-focused coping strategies. Subjects adopt a variety of pain management techniques, often beginning with drugs from their own initiative. Assistive devices and the use of footwear are seldom reported in studies of coping strategies utilized by foot and ankle pain sufferers. There is evidence to suggest that the use of particular coping strategies is associated with both positive and negative outcomes for foot and ankle pain sufferers. This evidence is explored throughout the essay.
Physical Therapy and Exercise
Manual therapy encompasses joint mobilizations and manipulations to increase the available range at a specific joint. Soft tissue work may also be done to decrease muscle guarding and pain. Modalities are used to decrease inflammation and pain at a specific tissue. This may include ultrasound to increase tissue temperature, or electrical stimulation to override pain signals. Though the listed treatments can provide some pain relief, they are not the focus of physical therapy. Exercises are the main tool to remediate impairments and reach the set goals. This may include a series of strengthening exercises for a weak muscle, or retraining balance on a lower extremity with a functional progression from seating, to standing, to a dynamic environment.
Physical therapy is considered a mainstay in the treatment for any chronic disease that results in functional limitations. It focuses on remediating impairments and improving function. In the case of foot and ankle pain, a physical therapist will initially perform a complete biomechanical evaluation to determine the cause of the pain. This includes assessing posture, gait, footwear, and the lower extremity joints. Range of motion and strength will also be tested to determine if there are any deficits from the norm. From this information, a list of problems (i.e. impaired gait and decreased ankle strength) and potential goals will be made. A treatment plan is then developed consisting of manual therapy and modalities, and most importantly an exercise program.
Pain Management Techniques
Pharmacological treatments are a frequently used pain management technique. An evaluation of the evidence to support the use of these techniques in musculoskeletal injury management was conducted. Oral non-steroidal anti-inflammatory drugs (NSAIDs) were concluded to have a moderate level of evidence to support use in the management of musculoskeletal injuries. Topical NSAIDs, though not having as much research available, were also suggested for use in managing pain. Paracetamol, however, was not recommended due to a lack of evidence supporting use, and opioids were also discouraged due to a high risk of adverse events and insufficient evidence. Injection therapies were given mixed reviews. Corticosteroid was recommended for use in the management of plantar heel pain and lateral ankle pain, but discouraged in the treatment of osteoarthritis. Platelet Rich Plasma (PRP) was suggested for use in the management of tendinopathy and osteoarthritis but was given neutral recommendations in a variety of other conditions. There were, however, not many strong suggestions for or against most of the injection therapies due to a lack of research available. Lastly, biological treatments were given a mix of recommendations, but were generally suggested to have good outcomes with limited risks. The more commonly studied treatments, such as hyaluronic acid and autologous blood injections, had a moderate level of evidence to support use in the management of osteoarthritis, but conflicting recommendations and limited research in other conditions. The newer and less studied treatments such as growth factor and stem cell therapies were not given strong recommendations, but were suggested to have potentially good outcomes and minimal risk.
Assistive Devices and Orthotics
Orthotics are any device that is inserted into the shoe. This can include simple insoles purchased at a drugstore or custom-made devices provided by a podiatrist or orthotist. Studies have shown that shoe inserts can significantly decrease foot pain and improve function. Custom devices are designed for an individual’s specific foot abnormality or problem and can be very effective in reducing symptoms. A podiatrist can evaluate the patient for orthotics and can take a cast of the foot that is used to make a custom device. Insurance coverage for custom orthotics varies and can be quite limited.
When mobility is significantly impaired, assistive devices such as a cane, crutches, or a walker may be used. These devices reduce the amount of weight and stress on the foot and ankle and can improve mobility and decrease pain. They can also be useful when a patient is awaiting surgery. A physical or occupational therapist can recommend the most appropriate device and instruct the patient in its use. Devices are often used in the short term, but in cases of chronic arthritis, they may be necessary long term. Bracing is another option for those with chronic conditions, such as flatfoot, or for those recovering from a foot or ankle injury. Ankle foot orthoses, such as a Richie Brace, can provide rigid support for a flaccid or degenerative condition. More commonly, a simple ankle brace can add stability to a wobbly joint and prevent frequent sprains.
Support for Individuals with Foot and Ankle Pain
Living with chronic foot and ankle pain may render emotional well-being, including work on our mental health and improvement of depression and anxiety. This can also be accompanied by changes to the way we function in society or in the home.
For people in these situations, workers’ compensation or seeking new training and alternative employment opportunities may be possibilities to consider. If affected individuals are unable to work, consideration may be made to disability pensions or financial support from family members or friends. These types of options and changes in employment or financial support can be difficult and often stressful.
For people who suffer from pain in their feet and ankles, the chances are that they spend a lot of time on their feet at work. Those who have chronic foot pain and are unable to walk or stand for long periods of time understand the profound effect it can have on their employability and ability to earn money. Chronic foot and ankle pain is often a cause of job loss among individuals and can lead to financial stress and strain.
Dealing with and managing chronic foot and ankle pain is difficult at the best of times. This type of pain can be highly debilitating. Tasks such as walking to the shops, doing housework, or playing a game of sport can seem nearly impossible. Therefore, it is important to have measures in place to deal with these types of pain or to get relief from it.
Seeking Professional Help
Professional intervention is vital to manage the condition without it getting progressively worse and may involve several approaches such as off-loading painful areas of the foot with protective padding, footwear modifications, or strapping. A physiotherapist may assist with gait re-training and general conditioning exercises to improve muscle strength and flexibility to the foot and ankle. Orthotic therapy prescribed by a podiatrist or orthopaedic surgeon is often an effective method of treatment for many foot and ankle conditions. Guidance from dietitians and other health professionals can help individuals with systemic conditions that affect the foot such as gout or diabetes. In more severe cases of foot and ankle pain, surgery may be required and individuals will benefit from having an understanding of options available and what to expect from surgical intervention.
Individuals with chronic foot and ankle pain often seek the help of health professionals in order to manage their pain. This may involve seeking a variety of treatment options from different health professionals such as podiatrists, physiotherapists, occupational therapists, orthopaedic surgeons, general practitioners, and nurses. Effective treatment may also require referral to and collaboration with other health professionals such as rheumatologists, pain management specialists, or dietitians. Seeking care from a health professional can help individuals develop a better understanding of their condition, learn effective pain management strategies, and improve overall quality of life.
Support Groups and Online Communities
The internet is also a very accessible tool. 90% of adults with access to the internet have used it to find information about health. With the younger generation now growing up in a world surrounded by technology, the use of the internet for healthcare is predicted to just have the younger generations teach the older generations how to do the same thing.
Online communities are soon taking over as the main source of health information support. Websites such as patient.info and health unlocked have forums as well as conditions, treatment, and support information. Since the rise in technological advances, people now have access to reach a global community. Reaching a global community allows people to express their problems or experiences with people of all kinds of ethnicities and cultures. A study examining a sample of 69 Russian rheumatoid arthritis patients showed that in comparison to the present Russian society, it was much easier to maintain a relationship with a foreigner using the internet. This, in turn, would make global community support very effective.
Available in print and online is the Fibromyalgia Magazine. Subscription to the magazine allows access to support networks such as telephone coaching, email, and private sessions in Second Life. Members of a concurrent study using these technologies found a significant decrease in pain and increase in self-efficacy and mental health. This shows that support groups, no matter how informal the setting, can be of great advantage to people with chronic pain conditions.
Another group known as Stepping Stones meets in various London locations and is aimed at young people with arthritis aged 16-25 years. As the group meetings are informal, youthful, and there are often shared experiences such as educational or career difficulties, members of the group found that they all had an increase in self-confidence and the feelings of isolation and alienation were lost.
During the 1980s, Arthritis Care in the UK developed a network of self-help groups across the country. These groups offer patients the chance to meet others with arthritis, receive advice and information from guest speakers and health professionals, and take part in social or recreational activities. A study that interviewed patients after they joined the self-help groups throughout Canada concluded that the groups not only provided an understanding of arthritis and a source of information, but also improved the quality of communicative life, self-esteem, and confidence.
Support groups are groups of people that all have the same or similar problems. Members of the group share their experiences as well as practical advice that may aid pain management. People that engage in the help of support groups generally feel more in control of their conditions as well as obtain a greater understanding of their illnesses.
Family and Friends as a Source of Support
In cases where the patient is unable to fully care for themselves, relatives are an invaluable source of support for maintaining the household and attending to personal needs.
A healthy social life is an important part of this process. It may be helpful to plan out regular social activities with friends or relatives in an environment where the main focus will not be on the health condition (e.g. a hobby, sporting events, cinema, dining out). It is important to plan these activities around the limitations caused by the foot and ankle pain in order to make the most of them. For example, if arthritis makes it difficult to walk long distances, it would be best to find an event located close to parking and seating, such as the cinema or disabled seating at a sports match.
Many patients (and sometimes family members) find it helpful to set an agreed-upon time to discuss the condition and any changes that are being made to manage it. They also find it useful to preface this discussion with a general statement that the purpose is not to dwell on the negative impact of the condition, but to briefly discuss it in order to plan changes to more positive activities in the future. This is to avoid the pitfall of surrounding oneself with concerns about the health condition and how it is affecting one’s life.
This support primarily occurs in social and family situations. For those in a supportive environment, it may be easier to keep family members informed about the pain and the efforts that are being made to cope with it. They will be able to show understanding and are more likely to be encouraging. Those living alone may need to make a conscious effort to maintain good communication with family members.
