People who have lax ligaments or a history of trauma e.g. from twisting the foot, walking on uneven terrain or from a fall, are more prone to suffer from ankle sprains. Constant wear of high-heeled shoes can also increase the chances of having a sprain as the foot is less stable and can twist more easily. Sports that require side-to-side motion, e.g. football and tennis, also increases the chances of suffering an ankle sprain.
People with flat feet and high arched feet are also more likely to sprain their ankle, as the abnormal position of the joints of their feet destabilize the ankle, putting added pressure on the ankle ligaments. It is usually the weaker ligaments on the outside of the ankle that are sprained first.
A previous sprain usually leaves residual instability to the ankle, leading to recurrent sprains. In the acute phase, inflammation will be observed at the ankle area, that is, localised heat, redness, swelling and pain. The patient will feel like their weight is mostly on the outside of the ankle and the ankle is weak. Some may describe it as a feeling of the ankle ‘giving way’ during locomotion.
X Rays of the ankle are usually normal although bone spurs (abnormal bony outgrowths) are sometimes present.
Sprains may be resolved by a combination of the following treatments, depending on the severity of the sprain and the presence of an underlying biomechanical problem, lax ligaments or both.
Acute phase
• Icing immediately after a sprain. A contrast footbath may also be done.
• Bandaging and strapping.
• Elevation of the limb
• Resting.
Chronic phase
• Massaging the joint and trying to encourage ankle movement.
• Wearing an ankle guard to stabilize the ankle.
• The use of orthotics to try to attain some control over any biomechanical problem.
• Strengthening exercises especially for the outer leg muscles and the Achilles tendon.
• Heat or ultrasound
• Footwear changes.
Arch pain refers to pain in the inner longitudinal arch (ILA) of the foot. This is the curved area on the inner bottom part of the foot.
People with flat feet can experience pain in the arch because of overstretching or excessive movement of the plantar fascia. Flat foot results in an inward rolling of the causing increased mobility of the joints. This puts more stresses on the inner part of the foot especially on the plantar fascia, which may not be able to cope with the additional stretch expected of it. In severe cases, where there is total arch collapse, the stress on the plantar fascia is maximal. An aching or burning pain may be felt in the arch. This is sometimes accompanied by plantar fasciitis, a condition that causes pain on the bottom of the heel.
High arched individuals may also end up suffering from arch pain. This is because their feet tend to be more rigid and have little range of motion. Again, tension is placed on the plantar fascia (tightness) resulting in pain in the arch. Some people with high arched feet may have more mobile feet due to lax ligaments or co-existing biomechanical problems. In these cases, arch pain is experienced as well due to the excessive motion of the joint of the mid-foot, resulting in strain on the plantar fascia.
Usually, arch pain can be resolved with the use of orthotic therapy and footwear changes if the problem is biomechanical.
Tarsal Tunnel Syndrome occasionally results in pain in the arch as well. In these cases, it is only by addressing the condition that the arch pain can be settled.
Trauma, like stepping on an object when barefoot, wearing high-heeled shoes and so on, can also be the basis for arch pain. Rest and footwear changes can relief symptoms in these individuals.
Kohler’s Disease
This is an osteochondrosis affecting the navicular, a bone that forms part of the arch of the foot. It usually occurs in boys between the ages of 3 and 9.
Symptoms include:
• Pain and tenderness in the arch especially over the navicular.
• Patient may limp.
X Ray examination may be used to diagnose the condition.
Treatment is by orthotic therapy and adequate rest. Kohler’s Disease is self-limiting and should regress spontaneously.
Arthritis is defined as the inflammation of joints. The classical signs of inflammation includes pain, swelling, warmth, redness and loss of function or motion. There are various forms of arthritis but not all forms of arthritis will display all the classical signs of inflammation. Any systemic diseases causing degeneration in joint cartilages or synovial memebranes results in arthritis.
There are many forms of arthritis that can affect the lower limb. However, we shall only discuss the common forms of arthritis here:
1. Osteoarthritis (OA)
2. Rheumatoid arthritis (RA)
3. Ankylosing spondylitis (AS)
4. Psoriatic arthritis
5. Gouty arthritis
Osteoarthritis (OA)
This is a degenerative disease of the joint due to wear and tear of the articular cartilage. It can occur as a result of friction, trauma or abnormal loading of the joint. Occasionally, there may be bony growths or lipping around the joint. Incidence of OA increases with age and tends to affect ‘overworked’ joints.
Clinical features of OA:
1. Pain and tenderness around the joint.
2. The joint becomes stiff when it is rested for a while. Patient experiences restriction or crepitus (clicking sounds) upon movement.
3. Joint is cool with bony swellings/lumps.
4. Recognised on x-rays with decreased joint space and extra bony growths.
5. Symptoms get worse as the day progresses but can be relieved by rest.
Management of OA includes:
1. Physical therapy – hydrotherapy, ultrasound, heat and manipulation.
2. Joint rest – either with the use of orthotics or splints.
3. Pressure relief.
4. Footwear advice.
5. Painkillers.
6. Surgery.
Ankylosing Spondylitis (AS)
AS is the inflammation of the synovial joints most commonly affecting the spine, hips and shoulders. Males below thirty years of age are most susceptible. The inflammation process affects the joint capsules and attached ligaments and tendons.
Foot problems associated with AS includes Plantar fasciitis and Achilles tendinitis.
Management of AS includes:
1. Physiotherapy and hydrotherapy.
2. Foot orthoses or other insoles.
3. Non-steroidal anti-inflammatory drugs.
4. Painkillers.
Psoriatic arthritis
Psoriatic arthritis is arthritis associated with psoriasis. It affects 10% of the people with psoriasis. The joints most commonly affected are the distal joints of digits and the hip joint.
Clinical features of psoriatic arthritis includes:
1. Sausage shape appearance of digits due to inflammation of the synovial membrane of digital joints.
2. Joints are stiff in the morning.
3. Patient complains of fatigue.
4. Bony reabsorption of digits.
5. Nail may develop white spots, an uneven surface and become thicker.
Management of Psoriatic arthritis includes:
1. Physiotherapy and hydrotherapy.
2. Foot orthoses or other insoles.
3. Footwear and footcare advice.
4. Non-steroidal anti-inflammatory drugs.
5. Painkillers.
6. Disease-modifying anti-rheumatic drugs (DMARDS) eg. Gold salts, chlroquine.
Gouty Arthritis
This is caused by the deposition of sodium urate crystals in the joints. An abnormality in metabolism results in an overproduction of uric acid or decreased excretion of uric acid from the body. The excess uric acid in the blood and tissue fluids then precipitate to form sodium urate crytals. More males than females seem to be affected and they tend to be middle-aged in the upper social class. These patients usually present with similar family history.
Clinical features of a gout attack includes:
In a gouty arthritic joint, deposited sodium urate crystals (tophi) in the joint result in an inflammatory process and erosion of articular cartilage in the joint. This results in a deformed joint and white tophi may be seen through the skin. Tophi may obstruct joint motion which may be painful.
Management of Gout:
1. Anti-inflammatory drugs.
2. Drugs to reduce uric acid levels in blood.
3. Reduce weight
4. Reduce alcohol consumption.
5. Diet control.
6. Increase exercise and adopt a healthy lifestyle.
7. Foot orthoses or other insoles.
8. Footwear advice.
9. Surgical excision of bulky tophi or if infection may be a problem.