Foot & Ankle
Anatomy and Function of the Foot and Ankle
The foot is an anatomical marvel in terms of its strength, flexibility and functional design. It is able to support the weight of our entire body. With every step we take, the foot must absorb a tremendous amount of force and stress. On an average day, walking can bring a force equal to several hundred tons of pressure to bear on our feet. The foot and ankle contribute largely to our balance and proprioception, which is how we subconsciously perceive our body's position and movements. Uneven surfaces can be a challenge for individuals with foot and ankle conditions. The ankle joint is comprised of the tibia and fibula (lower leg bones), and the calcaneus (heel) and talus (foot bone). This joint allows movement in all directions. In addition to the bones, there are several ligaments within the ankle joint that provide stability. There are a total of 26 small bones in the foot, along with 33 joints and a network of more than 100 muscles, tendons and ligaments that work together to allow movement and stabilize our arches.
The arches of the foot are created by ligaments and are supported by a large area of connective tissue called fascia spanning the bottom of the foot. The plantar fascia is a long, thin ligament that lies directly under the skin, connecting the heel to the front of the foot. The Achilles tendon connects our calf muscles to the heel bone and comes into play when we walk, run and jump. It is the largest tendon in the human body. When everything is healthy, the foot and ankle should be comfortably able to rotate in a circle in both a clockwise and counterclockwise direction. The midfoot should have the flexibility to roll in and out of each walking stride. The ankle and foot joints are responsible for providing a full range of motion for walking, running, pivoting and jumping.
Foot and Ankle Conditions and Treatment Options
Both the Achilles tendon and the plantar fascia are susceptible to injury from overuse or strain.
One of the most common ankle injuries is an ankle sprain, in which one or more of these ligaments is stretched, partially torn or completely torn. Another common source of foot and ankle pain is arthritis.
Osteoarthritis, rheumatoid arthritis, and traumatic arthritis are the most common forms of this disease. Osteoarthritis is an age-related “wear and tear” type of arthritis, where cartilage wears away over time resulting in bone-on-bone contact, bulges and bone spurs. Rheumatoid arthritis is an autoimmune disease in which the synovial membrane becomes inflamed or thickened. This chronic inflammation often begins in the feet and ankles and tends to be symmetrical. Post-traumatic arthritis can follow an injury to the foot or ankle. The condition may develop after trauma such as a fracture, severe sprain or ligament tears.
Chronic ankle instability is a condition characterized by a recurring “giving way” of the outer (lateral) side of the ankle. This condition often develops after repeated ankle sprains. Usually the “giving way” occurs while walking or doing other activities, but it can also happen when you’re just standing. Many athletes, as well as others, suffer from chronic ankle instability.
People with chronic ankle instability often experience; a repeated turning of the ankle, persistent discomfort and swelling, pain or tenderness, feeling wobbly or unstable in the ankle.
Ankle instability usually develops following an ankle sprain that has not adequately healed or completely rehabilitated. When you sprain your ankle, the connective tissues (ligaments) are stretched or torn. The ability to balance is often affected. Proper rehabilitation is needed to strengthen the muscles around the ankle and “retrain” the tissues within the ankle that affect balance. Failure to do so may result in repeated ankle sprains. Each new sprain leads to further weakening of the ligaments, perpetuating and increasing instability.
Non-surgical treatments include physical therapy, bracing, and medications can reduce inflammation, strengthen the ankle, improve range of motion and retrain your muscles. In some cases, surgery will be needed to repair or reconstruct damaged ligaments. Your surgeon will evaluate your individual case when deciding which procedure is best for you. The length of your recovery time will vary, depending on the procedure or procedures involved.
A bunion, also known as hallux valgus, is a bony prominence at the base of the big toe, which often results in pain, redness and rubbing in footwear. The first metatarsal bone abnormally angles outward towards the other foot from its joint in the midfoot. A bunion can change the shape of your foot, make it difficult for you to find shoes that fit correctly and worsen the symptoms if left untreated.
Triple arthodesis is used to address many types of foot deformity and pain. This procedure fuses three joints in the back of the foot.
Triple arthrodesis is indicated for severe arthritis, instability or deformity that cannot be controlled with nonsurgical approaches. Other conditions, such as severe flatfoot, abnormal connections between bones, excessively high arches and joint instability due to neuromuscular disease, can also warrant treatment with fusion. Surgeons try to avoid fusions, but sometimes pain and deformity are so severe that this procedure offers the best chance of producing a less painful foot with better alignment. Fusions often improve stability and allow for easier standing and walking. The triple arthrodesis is a time-tested, durable procedure.
Patients who are still growing are not ideal candidates as they may develop additional deformity as they grow. Patients who use tobacco, have an active infection or have poor healing potential are at higher risk for complications. Nonsurgical measures such as bracing and anti-inflammatories should be attempted first. If another surgical procedure that leaves the joint intact can achieve the same goal, this is preferred over a fusion.
Subtalar (ankle) arthroscopy is a surgical procedure performed to treat pain caused by problems of the subtalar joint in the ankle. The surgery is minimally invasive, performed through small incisions, by using a viewing instrument called an arthroscope. An arthroscope is a thin long tube with a camera attached, which helps your surgeon clearly view the surgical site on a monitor. Arthroscopy can be used to diagnose and treat different disorders of the ankle joint. The list of problems that can be treated with this technology is constantly evolving and includes:
Ankle arthritis: Ankle fusion is a treatment option appropriate for many patients with end-stage ankle arthritis. Ankle arthroscopy offers a minimally invasive way to perform ankle fusion. Results can be equal to or better than open techniques.
Ankle fractures: Ankle arthroscopy may be used along with open techniques of fracture repair. This can help to ensure normal alignment of bone and cartilage. It may also be used during ankle fracture repair to look for cartilage injuries inside the ankle.
Ankle instability: Ligaments of the ankle can become stretched out, which can lead to a feeling that the ankle gives way. These ligaments can be tightened with surgery. Arthroscopic techniques may be an option for this problem.
Anterior ankle impingement (also referred to as athlete’s ankle or footballer’s ankle): Ankle impingement occurs when bone or soft tissue at the front of the ankle joint becomes inflamed. Symptoms include ankle pain and swelling. This can limit the ability to bend the ankle up. Walking uphill is often painful. Osteophytes (bone spurs) can be seen on X-ray. Arthroscopy can be used to shave away inflamed tissues and bone spurs.
Arthrofibrosis: Scar tissue can form within the ankle. This can lead to a painful and stiff joint. This is known as arthrofibrosis. Ankle arthroscopy can be used to identify the scar tissue and remove it.
Infection: Infection the joint space cannot be treated with antibiotics alone. It often requires an urgent surgery to wash out the joint. This can be done with arthroscopy.
Loose bodies: Cartilage, bone and scar tissue can become free floating in the joint and form what is referred to as loose bodies. Loose bodies can be painful and can cause problems such as clicking and catching. Locking of the ankle joint may occur. Ankle arthroscopy can be used to find and remove the loose bodies.
Osteochondral defect (OCD): These are areas of damaged cartilage and bone in the ankle joint. OCDs are usually caused by injuries to the ankle such as fractures and sprains. Common symptoms include ankle pain and swelling. Patients may complain of catching or clicking in the ankle. The diagnosis is made with a combination of a physical exam and imaging studies. Imaging may include X-rays, MRI or CT scan. The treatment is based on the size, location and stability of the OCD. The patient’s symptoms and activity demands are also considered. Surgery often consists of scraping away the damaged cartilage and drilling small holes in the bone to promote healing. Bone grafting and cartilage transplant procedures can also be performed.
Posterior ankle impingement: This occurs when the soft tissue at the back of the ankle becomes inflamed. Pointing the foot down can be painful. This overuse syndrome occurs commonly in dancers. It can be associated with an extra bone called an os trigonum. The problem tissue can be removed with arthroscopy.
Synovitis: The soft tissue lining of the ankle joint (synovial tissue) can become inflamed. This causes pain and swelling. It can be caused by injury and overuse. Inflammatory arthritis (rheumatoid arthritis) and osteoarthritis can also cause synovitis. Ankle arthroscopy can be used to surgically remove inflamed tissue that does not respond to nonsurgical treatment.
Unexplained ankle symptoms: Occasionally patients develop symptoms that cannot be explained by other diagnostic techniques. Arthroscopy provides the opportunity to look directly into the joint. The surgeon can then identify problems that may be treated with surgery.
Total Ankle Arthroplasty (Ankle Joint Replacement)
Total Ankle Arthroplasty (Ankle Joint Replacement) is considered in patients that experience ankle pain and decreased function from arthritis after trying conservative management. Conservative management includes anti-inflammatory medication, bracing, physical therapy, activity modification and pain medication. Patients with rheumatoid arthritis, osteoarthritis and post traumatic arthritis are usually good candidates for ankle joint replacement procedures. Other patients that should be considered are those that need but do not want a fusion-type procedure that would eliminate the motion at the ankle joint.
Patients with significant deformity or dead bone in the ankle, or those with infection, neuropathy, inadequate leg function, poor blood flow or inadequate soft tissues may not be good candidates for this procedure.