The feet and ankles are an extremely complex structure and many common problems can occur in this area. Indeed around 1 in 5 of all people will suffer from foot and ankle pain in their lifetime. As feet and ankles bear the full body weight and cushion all impact when walking, running, and jumping it is not surprising that injuries arise.
The feet and ankles are more complicated than we think. The feet are actually made up of 26 different bones and more than 33 joints arranged in columns and arches that vary in both stiffness and flexibility. There are 3 different parts to the structure- the back of the foot (hind foot) which is made up of the heel bone and the ankle (talus).They are joined together by joints which allow the foot to move from side to side. The ankle bone is joined to leg bones at the ankle joint which acts like a hinge allowing the foot to bend up and down.
The middle of the foot (midfoot) is made up of 5 tarsal bones which form the arch of the foot. Tarsal bones are connected to the front and back of the foot by muscles and the arch ligament (the plantar fascia). They also act as the shock absorbers when walking and running.
The front of the foot (forefoot) is made up of toe bones which are connected to 5 long bones by joints. The forefoot takes on half of the body’s weight. Muscles in the lower leg are attached to bones in the feet by tendons which control movement. The heel bone is connected to the calf muscles by the Achilles’ tendon, which is the most important tendon for movement and where injury can often occur.
Foot and ankle pain; Both foot and ankle injuries are common especially in sports persons or people who lead active lifestyles, however there are other causes that can lead to pain and damage. Pain can occur in the ankle joint itself, the heels, toe, sole and ball of the foot. Symptoms can include swelling, bruising, sharp pain between the heel and the arch of the foot, and pain when standing on tip-toes. One of the main issues in any ankle/foot injury is that if left untreated it can have a knock on effect in other parts of the foot. For example if an ankle is sprained and damage is caused to the ligaments which hold the bones of the joint together, other stressors are put through other joints in the foot as the walking gait is forced to change.
Pain can mean that weight cannot be put through the foot and the shape and mechanics of the joint can actually change.
There are several causes of foot and ankle pain. One of the most common is arthritis.
Arthritis damages the joints and causes pain and significant inflammation. In the UK alone, more than 10 million people have arthritis or suffer from similar conditions that affect the joints.
Arthritis in the ankle doesn’t gain as much attention as other joints in the body but it can take a significant toll on mobility and quality of life. Arthritis in the ankle can lead to pain, swelling, deformity, and instability in the ankle joint. Arthritis here affects the tibiotalar joint, which forms between the shin bone and ankle bone and 70% of arthritis in feet and ankles are caused by previous injury.
There are differing kinds of arthritis that affect the foot and ankle. Osteoarthritis is a degenerative joint disease where the cartilage that cushions the ends of the joint wears away gradually due to wear and tear. Injury can damage the cartilage directly or change how the ankle joint works leading to deterioration over time. Post traumatic arthritis develops in the foot as a result of injury e.g a sprain, fracture, or dislocation that can lead to premature deterioration of the joint. Rheumatoid arthritis is a chronic inflammatory disease where the bodies immune system attacks itself. Standing and basic walking becomes uncomfortable.
Achilles tendinopathy and tendonitis is a common overuse injury resulting in repetitive injury to the Achilles’ tendon, the band of tissue at the back of the lower leg which connects the calf to the heel bone. It causes pain and stiffness to the back of the heel and means there is an inability to move freely or play sports. This is a common injury for those who play racquet sports, football, and run. Age can also be a factor as the tendon becomes less flexible over time and less able to cope with movement. Other causes include weight, genetics, and existing medical conditions such as high blood pressure and cholesterol.
Peroneal tendinopathy is common in athletes and runners and causes pain and swelling to the back of the foot and the outside of the lower leg. It can also be caused if you have a muscular imbalance or a high foot arch.
Other causes of ankle pain include Plantar fasciitis – where you have pain on the bottom of your foot and around your heel, bursitis – fluid filled sacs which become inflamed, bunions, tarsal tunnel syndrome, fracture, ligament injury and ankle instability.
When surgery is an option;
If an ankle is fractured or arthritis interferes with its function and causes pain which cannot be controlled by traditional medication, surgery is an option.
Fracture repair is the most common reason for ankle surgery. A fracture can range from a clean break to a break that means the bone is left in small pieces. The exact procedure will depend on which bone is broken and how severely. Surgery may include the placement of metal plates and screws to hold the bones in place as they heal.
Total ankle replacement- ankle replacement is far less common than a hip or knee replacement. In this procedure, damaged cartilage and bone are removed and replaced with new metal or plastic joint surfaces to restore the joints function. During ankle replacement, the surgeon makes an incision in the front of the ankle , removes the damaged bone and joint cartilage, reshapes the involved bones and attaches the parts of the artificial joint. The surgeon creates a bone graft between the end of the fibula and places screws through the two bones to support and stabilise the ankle. This procedure helps preserve joint motion. Ideally patients will have good bone quality and normal tendons and ligaments. This surgery will help patients who have existing arthritis in smaller joints which would be further worsened by loss of ankle joint motion. The surgery, however, can have mixed results as risks include implant failures and is not ideal for people who have deformity or prior infections that have lead to the joint damage. The ankle joint, also because of the load going through the foot, and the amount of stress placed on it, doesn’t always fare well for the implant as they are not as good as natural bone. The surgery will preserve movement in the ankle joint but outcomes for a replacement for a weight bearing, poorly supported joint like the ankle needs a lot of surgical expertise in the operating theatre.
Ankle arthroscopy is a minimally invasive surgery performed by inserting a lighted scope and narrow instruments through small incisions in the skin of the ankles. Surgeons may use this procedure to remove pieces of cartilage or bone debris from the joint space or to evaluate and repair a damaged ligament. Ankle arthroscopic repair is helpful in the early stages of arthritis in the ankle and for those with limited ankle arthritis but it is often ineffective in advanced ankle arthritis as because when a significant amount of cartilage has worn away, the procedure will not help the joint.
Ankle fusion is for end stage ankle arthritis. This procedure involves surgically removing the surfaces of the joint affected by arthritis and joining the bones with plates and screws until they grow together or fuse. While the procedure leaves the ankle with permanent pain relief, it means that the ankle is left with no up and down or side to side movement at all.
The surgery is ideal for those with excessive bone loss, poor ligaments, poor bone quality, or a previous infection. It isn’t always a good option for everyone as sometimes the bones don’t heal and join together and arthritis can be developed in the adjacent joints of the ankle and foot from increased stress after surgery. The patient will be pain free but not be expected to walk the same again.
Ankle distraction arthroplasty – this procedure uses an external fixation or frame which is assembled around the lower leg and foot and surgically attached with pins and wires. The frame pulls the damaged joint surfaces apart and in return allows cartilage lost from arthritis to regenerate through the body’s natural healing process. This helps to preserve the joint and bone rather than replace it.
Surgery risks and recovery include infection, bleeding, nerve damage, skin complications, blood clots, fat embolism, and bone misalignment. After surgery it can take up to 3-6 months for the foot to feel better but recovery will depend on the complexity of the operation. With minor surgery and simple fractures patients can be back on their feet within 4 to 8 weeks but with major surgery it may take up to a year for the swelling to go away and for movement to improve. After an ankle replacement it may not be possible to return to running or other sporting activities at all.
What are the other alternatives to surgery – ankle arthritis doesn’t have a cure but there are many alternative treatments that can help which can help relieve pain and improve function.
Medication are important parts of treatment – they can help slow bone loss and relieve inflammation. Steroid injections into the ankle joint can help relieve inflammation, analgesics can help with pain relief, and topical creams are good for helping with pain. Lifestyle changes can help such as exercise and healthy eating, icing, physical therapy and supportive devices can also help.
Many of these injuries such as arthritis, plantar fasciitis, Achilles tendinopathy, peroneal tendon pain and ligament injury can be treated with stem cell therapy – AMPP – activated mesenchymal pericyte and plasma using Lipogems® technology and PRP therapy.
PRP is an effective and well researched procedure which provides a great alternative to ankle surgery. Treatment is administered via an injection, 2-6, performed at weekly intervals and patients see improvements within 4- 6 weeks. It is a safe treatment option which uses a concentrated dosage of platelets prepared from the patient’s own blood to repair the damaged cartilage, tendons, ligaments, muscles and bones in the ankle. Activated mesenchymal pericyte plasma injections uses the bodies own adipose (fat cells) to treat the pain and inflammation immediately. The procedure takes an hour with a minimal recovery time of 3 hours. This is a minimally invasive procedure and can also be used after surgery to help aid in healing. Early results show an improvement for 75% of all patients undergoing treatment. Stem cell therapy offers a much shorter recovery time and proposes less risks than conventional surgery and also means that the patient is often up and walking the same day. A patient who had suffered from two broken legs which resulted in extreme pressure and ankle pain underwent Lipogems® treatment on both ankles and 6 months later could walk further than before and was no longer awoke at night with terrible pain.
“Anyone with painful ankles should consider Lipogems®. I’m feeling very positive now about things and much happier. It means that I don’t have to have major surgery which is not without risks so Lipogems® is a much better option!” Patient testimonial.