There are several conditions that are related to the tendons located at the back of the foot: 1) Insertional Achilles Tendonitis, which affects the lower portion of the heel, 2) Non-Insertional Achilles Tendonitis, which is a fibrous degeneration with a thickening of the tendon and generally occurs in the middle of the tendon, and 3) Peroneal Tendonitis, which affects the side of the foot and causes the tendons to swell and become painful. With all of these conditions, the pain is debilitating and can affect walking and standing. Ankle sprains are another common cause of foot pain that can lead to muscle or tendon damage and chronic pain. A sprain is an elongation or tearing of the ligaments caused by an unnatural twisting force. This causes pain, bruising, swelling and in serious cases instability of the ankle. Like tendonitis, ankle sprains are most painful when walking or standing and can affect daily activities. Due to the fact that ankle and foot pain can become chronic and can effectively slow you down, it is important to find out the cause of the pain and the correct form of treatment.
People of all ages are susceptible to foot pain, and those who are physically active are even more likely to suffer from the symptoms. Whether the pain is in the arch, heel, or the sides of the foot, it can affect your daily routine to the point where your activities may change. Tendonitis is an inflammation or irritation of a tendon, a thick cord that attaches bone to muscle. If you have tendonitis, you know that it is a problem that can be very painful. Tendonitis is caused by a series of tears in the connective tissue surrounding the muscle and the tendon. When the tears occur, the body’s natural response is inflammation and if further tearing occurs without proper healing, the tissue becomes degenerative. This can cause the tendon to not function properly, and can cause pain.
Understanding Foot Pain and Tendonitis
Pain is an obvious symptom of injury in the overall foot region. Whether it is a chronic condition such as plantar fasciitis or following an acute injury such as with an ankle sprain, an in-depth understanding of the pain mechanism is essential in treating foot pain. For example, heel pain is frequently caused by inflammation of the insertion of the plantar fascia on the inferior aspect of the calcaneus. This condition can occur in isolation but recent evidence has shown it is generally an impact injury to the foot which triggers the onset of plantar fasciitis. Tendonitis and symptomatic arthritis injuries generally occur when the intensity of the injuring force is above a certain threshold, producing an inflammatory response in the tendon or joint. Alternatively, a severe twisting injury to the ankle may partially or completely tear a ligament which should be evidenced by pain and joint instability. A traumatic incident such as a stress fracture or muscle rupture will have an obvious mechanism of injury usually involving a specific event. Understanding the mechanism and event of the injury will give clues to the severity of what has occurred. An example would be a runner who has gradually worsened pain in the midfoot region, with no recollection of a specific injury, suspecting a stress fracture. Finally, pain involving referred pain from nerve compression or radicular pain from the lower back can be more difficult to diagnose and the cause of the pain may be a distance from where the symptoms are felt.
Common Causes of Foot and Ankle Pain
In general, tendonitis can occur through injury or repetitive movements. This is certainly the case when it comes to the causes of foot pain and tendonitis. These include: – Injury, where the high stresses and impact that the foot and ankle must endure during sports or from a simple misjudgment in stepping off a curb can lead to the stretching or tearing of the tendon. Once a tendon is damaged, the forces upon it may cause the tendon to become thickened, and in some cases, produce a painful lump on the side of the ankle; this is known as a tendon lump or tendon nodule. – Biomechanical issues, for instance, individuals with abnormal arches of the foot or flat feet have more stretching and twisting within the tendon. This can cause an uneven force of weight bearing and result in increased damage to the tendon. This uneven weight distribution can also be due to poor footwear, i.e., high heels often result in increased pressure on the ball of the foot and will subsequently increase the stress on the toe tendons. – Repetitive movement, particularly those of a non-ergonomic nature, can put excessive load on the tendon responsible for that action. For example, posterior tibial tendonitis is caused by the overuse of the tibialis posterior muscle in an attempt to stabilize the arch of the foot. This can occur in activities involving lots of walking or in sports involving pushing off the inside of the foot, such as skiing.
The Importance of Seeking Treatment
Delaying treatment, or avoiding it altogether, can cause a mild case of tendonitis to become severe with lengthened healing times. This can lead to more chronic problems such as tendonosis and increased risk of re-injury. Seeking a professional diagnosis and follow-up treatment with a therapist can aid in the reduction of pain and swelling. This can be done with modalities such as ultrasound and iontophoresis. The therapist can also work on a stretching protocol and eccentric strengthening of the affected musculature. In more severe cases of tendonitis where a significant amount of functional strength has been lost, a period of immobilization or use of a walking boot may be necessary. By seeking professional treatment for ankle pain and tendonitis, you are taking an active step in preventing prolonged damage to the affected tissues which could result in a need for surgical intervention.
Home Remedies for Foot Pain
Home remedies are indeed very helpful to cure foot pain. Most of these remedies can be easily done in the comfort of your home without the need for medications. On how to reduce foot pain, it starts with resting and elevation. This is very useful to help reduce the pain and swelling. Try to rest and put your foot in a comfortable position by elevating it. You can put some pillows or anything soft to support your foot. Lie down for a while and do this as often as possible. This simple action is considered as one of the most effective ways that can be done to help reducing both pain and swelling on tendonitis and ankle pain. Another method can also be done to reduce foot pain tendonitis treatment is by applying ice packs on the affected area. Ice packs are proven to have the ability to cool the affected area and relieve the pain. Try to do this with the rest and elevation. Roll a frozen ice pack or ice cubes in a towel and put it on the affected area. Do this for 15-20 minutes and keep doing it 3-4 times a day. Do not forget to combine it with rest and elevation on the bed. It’s also wise to reduce the amount of walking when doing this step. If possible, take time off from work to stay at home. This will be helpful to prevent the pain from becoming more severe.
Rest and Elevation
During the acute phase of pain and/or swelling, any rest is good rest. Take a load off your feet and relax without feeling guilty. If possible, don’t put any weight on the affected foot. Immobilization of the foot may be a good way to do this. You can use a splint or a brace if necessary. If there is an extrinsic factor contributing to the tendinitis, this would be a good time to get rid of it in an effort to reduce inflammation (i.e. get new, better fitting shoes). Short-term use of crutches might be needed to avoid further stress on the tendon. With a severe injury, a cast or walking boot may be necessary. Following active rest, foot elevation is probably the most effective way to reduce inflammation of the tendon. Try to keep your foot above your heart whenever possible. Using a pillow to prop up your foot should become second nature. Rest and elevation are also the most effective means of pain relief available. Compared to anti-inflammatory modalities, rest and elevation do not incur any risk of side effects and are equally effective at reducing pain and returning normal function to the affected area. While these ideal conditions are rarely met in the modern world, even adding an hour of extra quiet time with the foot elevated to your daily routine can be beneficial. Easier said than done for many people given work, family, and daily chores often take priority over musculoskeletal health, however, promoting understanding for the necessity of rest and elevation is important for anyone suffering from foot tendon pain.
Applying Ice Packs
Ice pack that is applied to the area for a 20-minute session is effective in reducing the inflammation and pain caused by tendonitis. One should be cautious to avoid applying ice directly to the skin as it may cause an ice burn, using a thin towel between the ice pack and the skin should prevent this. There are many types of commercially available ice packs, the most convenient and effective ones being flexible when frozen to enable ease when shaping to the foot and ankle. An alternative is to freeze ice in a paper or foam cup and then use the top of the cup as a handle to rub over the affected area. This has the added advantage of the ice massage enabling decreased pain and improvement of the injured tendon’s ability to stretch. It is important to keep in mind that if symptoms do not improve or worsen after the ice treatment, it is best to consult a physician to consider that there may be a possibility of a more serious injury. Overall, the regular use of an ice pack has proven to be one of the more influential treatments in reducing pain associated with tendonitis and ankle pain, as well as aiding in the prevention of further injuries.
Gentle Stretching Exercises
Stretch 3: Plantar Fascia Stretch. This is the best one for plantar fasciitis. Cross the leg with the affected foot over the other knee. Grab the base of the toes on the sore foot and pull back towards the shin until you feel a stretch in the bottom of the foot/heel. The top of the foot should rest against the crossed leg.
Stretch 2: Calf stretch. Stand facing a wall with your hands on the wall at about eye level. Put one leg back with the toe facing the wall. Keep the heel on the ground and lean towards the wall. You should feel a stretch in the back of your leg without the heel leaving the ground. If the heel is coming off the ground move the foot further from the wall.
Stretch 1: Towel Stretch. Loop a towel around your foot where your toes and ball of the foot are holding the ends of the towel in each hand. Keep your knee straight and the leg with the towel around it hanging off the edge of a bed or a chair. Pull back on the towel and move your foot towards you. You should feel a stretch on the bottom of your foot and/or the back of your lower leg. If you feel the stretch in the calf you can try to do this with the knee bent. This will also stretch the calf more.
Ankle Pumps (Neutral Foot): This exercise is easy but effective for increasing blood flow and circulation to the foot and ankle and also works the calf muscle. Sit in a chair straight up with your foot flat on the floor. Begin by moving your foot at the ankle towards you as if you are trying to bring your toes to your knee. Return to the starting position and then move your foot at the ankle away from you as if you are trying to point your toes down. Repeat this motion in a slow and controlled manner. Each up and down motion is considered a repetition. You should perform 30 repetitions.
Gentle stretching exercises for your tendonitis or ankle pain can help to promote healing and flexibility in the surrounding tendons and muscles. The key with stretching is to avoid any pain. You should feel a gentle pull from the stretch but no pain. If you feel pain, you are pushing the stretch too hard. Hold each stretch for 20-30 seconds and repeat each stretch 5 times. Do not bounce while stretching. This can cause small tears in the muscle which will lead to more scar tissue build up and further decreased muscle flexibility. A good time to stretch is after a light warm up or after a hot pack has been applied to the area. This can help to decrease the stiffness in the area and allow for a better stretch.
Over-the-Counter Pain Relievers
Complete Healing of Tendonitis: General time frames for the 3 stages of tendonitis are: 1. Pain with activity, no pain at rest – It may take 6 weeks to 2 months of modified rest to improve this condition. 2. Pain with activity and at rest, no functional loss – It may take 3-4 months to achieve a full pain-free state with this condition. 3. Pain with activity, some loss of function, swelling – Although the duration for this condition is very limited through completely resting the ankle, it can take 4-6 months to achieve a full pain-free state and performance.
In summary, the healthiest way to treat tendonitis symptoms is to reduce or eliminate the activity causing the problem. This may mean reducing the volume or frequency of high impact running or jumping type activities. During this time, alternative activities such as swimming or cycling can be used to maintain cardiovascular fitness while allowing the tendonitis to heal. Although, if the pain is too intensive and hinders any sort of comfortable movement or activity, complete rest along with the treatments previously discussed may be the only option. Step one should be to see a doctor to get a correct diagnosis on the pain and an appropriate treatment plan.
Over-the-counter pain relieving drugs (such as aspirin, ibuprofen, and Aleve) are easy to obtain and very cost-effective. All aspects of swelling, pain, and discomfort are reduced and/or eradicated with the use of these medications. Make sure to read and follow the directions on the labels unless directed by a doctor. As well, consult the doctor prior to using these if you have any allergies, medical issues, or are currently using other medications, as there may be complications or adverse effects. This form of treatment is beneficial on an as-needed basis, such as before/after a rigorous, higher impact sized activity. Unfortunately, these drugs do not fix the problem, they only mask the pain.
Singapore’s Approach to Foot and Ankle Pain
The mainstay of foot pain treatment has always been education and empowerment. Foot and ankle pain affect a person’s mobility and function, and by learning about the condition and its treatment, many patients will experience improvement in their condition. There are many resources accessible to Singaporeans. These range from public education programs on television, radio, newspapers and magazines, to health talks and screenings in the polyclinics (government-run primary healthcare clinics) or public forums in community centres. Health information on foot and ankle conditions is also available on the internet, though it is always good to verify the source and accuracy of the information. On this note, the Foot Care Program provides reliable information in a non-complex language for better understanding. This website is one of the initiatives developed by the Diabetic Education Committee, which is made up of a multidisciplinary healthcare team. This website is not only useful for diabetic patients but also anyone who has foot problems, diabetic or non-diabetic. This is complemented by tools such as the “orthoses-prescription-guide” for doctors, which provide an evidence-based approach to treating foot and ankle conditions.
In terms of managing foot and ankle pain, Singapore has a relatively comprehensive approach. This ranges from self-management with information provided by foot doctors and other healthcare professionals, to seeking assistance in professional foot care services.
Overview of Singapore’s Healthcare System
Singapore’s healthcare system is one of the best comprehensive healthcare systems. It is made up of a combination of public, private, and voluntary healthcare providers. In terms of public health, there are a number of government clinics, polyclinics, public hospitals, and specialty centers that are designed to deliver quality, accessible, and affordable healthcare services. These providers are subsidized to a varying extent, either through direct government subsidies or by subsidies on medications and means testing patients. High subsidy levels are available for the treatment of chronic diseases in the form of a Chronic Disease Management Program, a good example of the availability of foot and ankle treatment within the public sector. Subsidized public sector healthcare is highly available for permanent residents and Singaporeans and also available to non-Singaporeans. However, the availability of such care is based on the individual’s residential status, and policies do frequently change, affecting the subsidies and eligibility for care. Medisave is a national savings scheme that helps citizens put aside part of their income into their Medisave account to meet their future personal or immediate medical expenses. Medishield is a form of medical insurance that covers large hospitalization bills and selected expensive outpatient treatments. Both schemes of Medisave and Medishield show the importance of encouraging self-reliance and taking individual responsibility for one’s healthcare in a practical and cost-effective way. This is reflected further by the Medifund scheme, which was established to help needy patients who are unable to pay for their medical expenses despite Medisave/Medishield. This is a last resort for those who do not have family support and cannot pay for their medical bills. Beyond this, there are also a number of other concession cards and schemes, so it is fair to say the public will be able to access a wide range of healthcare services at a subsidized rate at various entry points.
Availability of Foot Pain Treatment Options
The next form of treatment is to seek some form of professional help to obtain a specific diagnosis of the problem and receive guidance on further treatment. This may be from a General Practitioner although for foot and ankle problems a doctor from the associated discipline; orthopaedics or rheumatology, may be more appropriate. At the GP level, the patient may be referred to a physiotherapist for a program of exercise therapy, iontophoresis, or soft tissue treatment. Advice and treatment from a health professional represents a span of options based on the severity of the condition and the health beliefs of the individual. At a surface level, it has been suggested that severe conditions and those of the older population are more likely to be treated with conservative measures due to associated risks of surgical intervention.
Self-help begins with the use of the PRICE principle (protection, rest, ice, compression, elevation), and taking NSAIDs to reduce pain and inflammation. This initial step aims to reduce inflammation and mechanical stress on the tissues which are the main reasons for pain and loss of function. Changing one’s footwear or taping the affected limb or joint to limit excessive motion, which may be causing or contributing to the problem, is also considered a self-help measure, as is a reduction in any weight-bearing activity which aggravates the symptoms. This initial suite of measures represents early “treatment” of foot pain, although they are merely the general measures used to control pain and inflammation from any injury and may not specifically target the problem in the foot and ankle.
In Singapore, options for foot ankle pain treatment at home represent a variety of potential remedies. As with any healthcare problem, the availability of options begins with self-help and progresses through a graduating scale of alternative options. “Treatment” itself can be any measure taken to reduce foot pain or inflammation. This article will try to provide a brief overview of the options.
Accessing Professional Help in Singapore
Public hospitals in Singapore have various specialist doctors who deal with foot and ankle problems. They would be based in the orthopaedic or the department of general surgery. A little known, but very effective way to access these doctors is through the polyclinics. Patients may visit the polyclinic and get a referral to see an orthopaedic specialist at a public hospital. This specialist will be experienced in dealing with tendonitis, ankle pain and various other foot and ankle problems. A referral would also mean that the fees for seeing a specialist at a public hospital would be much less than seeing a private doctor. An added advantage of being under a specialist in a public hospital is that if conditions are more serious and require surgery, the patient would be immediately referred to the same specialist at the same hospital. This is unlike being under a private doctor who may refer a patient to a different specialist at a different hospital. This would usually mean delays in getting treatment due to the need to get a new referral and transfer medical records to the new hospital.
Professional Treatments for Foot Pain
Custom orthotics and footwear Orthotics and arch supports are commonly used to treat tendonitis as they can help correct faulty foot mechanics, which are thought to contribute to the development of the condition. A study on custom orthotic intervention in patients with posterior tibial tendon dysfunction found that it increased function, decreased pain, and improved the quality of life for patients over a 64-week period. This form of orthotic was no more effective than a prefabricated arch support but did show the benefits of support intervention. In comparison to orthotics, a study of patients with Achilles tendonitis found that using high motion control shoes to support the ankle and hindfoot was more effective at reducing pain and stiffness than a traditional shoe of equivalent price. This suggests that not all forms of footwear intervention are as effective or more effective than standard forms of treatment for tendonitis.
Physical therapy is an integral part of treatment for tendonitis. Its exact role is still undefined due to the variety of treatments available and the lack of evidence showing that any one treatment is better than others. One study has shown that eccentric strengthening exercises of the plantar flexors provide good short-term pain relief and reduction in the severity of symptoms. This was, however, only on a small sample of patients and more evidence is required. The benefit of specific types of physical therapy, such as ultrasound therapy or extracorporeal shock wave therapy, is also not proven. In time and with more evidence-based research, it is likely that specific physical therapy regimes will be developed for the treatment of different types of tendonitis.
Physical Therapy and Rehabilitation
Rehabilitation will be a key element in the treatment of many foot and ankle problems. In some cases, it will begin as early as the first few days after an injury or surgery. For some conditions, it will be a part of the overall treatment plan and begin when the pain subsides. The type of rehabilitation will vary depending on the specific problem. A well-thought-out rehabilitation plan will include: – Flexibility exercises will be done for tight muscles and tendons. – Strengthening exercises will be given for weak muscles. This is important for restoring proper function. – Balance and proprioception exercises are used in many different conditions ranging from an ankle sprain to chronic problems like foot drop. Coordination is a complex skill that will take a long time to restore even with intense exercise. This will be an important factor in developing a regimen for your particular condition. – Functional training may be the most important element in the rehabilitation plan. The goal is to return to your prior level of activity or, in some cases, to allow you to do a specific activity for the first time. This will require simulating the activity in a safe environment and eventually increasing the intensity to the level needed to perform the activity. If there was an athletic activity prior to the injury/surgery, it may be necessary to coordinate care with a coach or athletic trainer for a specific or modified training program.
Custom Orthotics and Footwear
Braces are another form of orthoses that can be used for posterior tibial tendon dysfunction. A study by Nimmappa et al. (2012) showed that a specifically designed ankle-foot orthosis improved the clinical signs and symptoms in adult patients. AFOs are used primarily to slow the progression of the disease and avoid the need for surgical intervention. This can be done by reducing the load on the involved limb. Using an AFO can be used to better control your motion, limit or prevent joint movement, and transfer load through the limb. The AFO protects the involved joint and any surrounding structures. A study conducted by Mootanah et al. (2008) among lower leg muscle forces in patients with PTTD concluded that transfer of the load through the limb provided by an AFO could significantly decrease and redistribute forces acting on the foot and ankle complex.
Orthoses are now more effective and comfortable than ever before. The term orthoses includes insoles, heel cushions, and custom-made braces. Research has shown that custom-made insoles provided significant pain relief for patients suffering from posterior tibial tendon dysfunction. The patients also noticed that the insoles decreased the progression of deformities that are commonly associated with posterior tibial tendon dysfunction. In some cases, it also delayed the need for surgical intervention. A study conducted by Ha et al. (2005) observed patients with stage I and II posterior tibial tendon dysfunction and noted that custom-made insoles enhanced the function of the foot and reduced pain severity. Insoles are now made of a soft, cushioned material providing more comfort and impact shock absorption. This material will tend to deform with use. How much the insole then changes shape can have a direct effect on its ability to reduce pain. Custom-made insoles can be expensive and time-consuming, but they are made specifically for your foot and can be made to accommodate any bony deformities that may have been caused by the condition.
Corticosteroid Injections
Re-injection in patients for the same tendon problem can at first be done if there is some slight benefit from the first injection, but this injection is not as effective as the first and should not be repeated more than once. If there is no benefit from an injection, it should not be repeated. It is important to note that corticosteroid injections are most effective when the tendon has a reactive or early disrepair stage of tendinopathy but can be detrimental for the degenerative or late disrepair stage and could result in a rupture of the tendon in this later stage. Corticosteroid injections are more ideal for patients wanting quick pain relief for a recent tendon injury, as this has a more likelihood of reaction to the drug.
Different types of anabolic steroids (testosterone, nandrolone, Trenbolone) are known to affect tendons negatively in athletes by increasing collagen synthesis but decreasing the tensile strength of the newly formed tendon. However, corticosteroids are gaining increasing popularity for the treatment of many tendon conditions. A corticosteroid is injected along with a local anesthetic into the degenerative area of the tendon, either guided by ultrasound or palpation. A corticosteroid injection is thought to decrease the cell and vessel response to injury or tissue damage, which is the assumed cause of pain in chronic tendinosis. A corticosteroid injection should have a rapid and powerful effect in decreasing pain and has been suggested as a first line of treatment for tendinosis. There is quite a lot of variation between individuals in the clinical response to a corticosteroid injection. Some people experience a marked reduction of pain and improvement in function, whereas others do not experience significant benefit. On average, it seems that approximately 60-70% of patients will respond well. The pain-relieving effect of the anesthetic typically only lasts for a few hours, and it could return for up to 24 hours only to disappear and still could be pain-free. The corticosteroid, however, usually takes 24-72 hours to have any significant effect on the pain. Once the pain has improved, the patient will still need to be careful with the tendon for up to 2-3 weeks, as the corticosteroid is also reducing the strength of the tendon. This is why it is important that the patient is doing eccentric strengthening exercises and gradually increasing the load on the tendon so it can take the corticosteroid-induced reductions in strength and fully recover. The effectiveness of a corticosteroid injection has been shown quite clearly for conditions such as lateral epicondylalgia (tennis elbow) and gluteal tendinopathy (greater trochanteric pain).
Surgical Intervention
The most common but more major operation is the Evans (or Lateral transfer calcaneal osteotomy). This approach involves making a cut in the heel bone. This effectively moves the heel bone to a position where the tendon has better leverage to lift the arch. Once the bone is in a new position, it is held in place with a screw. Following this, the patient is put into a below knee cast or walking boot for 6 weeks.
Static reconstruction involves repairing the damaged tendon. It is then augmented with a ligament from the inner side of the foot to give it extra support. This sometimes involves a transfer of the tendon running the big toe to improve clenching of the foot, in order to improve stability in that part of the foot.
Surgical correction is not a common treatment for tibialis posterior tendon dysfunction. It is usually only considered if long-standing adult acquired flatfoot has not improved after a reasonable period of time with a range of non-surgical treatments. It is also needed to treat a ruptured tibialis posterior tendon, but this is usually a different style of operation.