Musculoskeletal conditions of the foot and ankle: Assessments and treatment options

doi:10.1016/j.berh.2012.05.009

Best Practice & Research Clinical Rheumatology

Volume 26, Issue 3, June 2012, Pages 345-368

https://doi.org/10.1016/j.berh.2012.05.009 Get rights and content

Musculoskeletal conditions of the foot and ankle are an important public health challenge due to their increasing incidence combined with their substantial negative impact on patients' quality of life. Non-pharmacological treatments serve as the first line of treatment and are frequently used for patients with musculoskeletal conditions of the foot and ankle. This review provides a summary of the assessments and non-invasive treatment options based upon available evidence.

Recent studies show that individuals with foot and ankle pain have multiple co-existing impairments in alignment, motion, load distribution and muscle performance that may be evident in static and/or dynamic tasks. In addition, both clinical and epidemiological studies support the inter-dependence between the foot and proximal joints. For instance, aberrant foot structure has been linked to foot osteoarthritis (OA), as well as OA and pain at the knee and hip. Most recently, advances in motion capture technology and plantar load distribution measurement offer opportunities for precise dynamic assessments of the foot and ankle.

In individuals with musculoskeletal conditions of the foot and ankle, the chief objectives of treatment are to afford pain relief, restore mechanics (alignment, motion and/or load distribution) and return the patient to their desired level of activity participation. Given that most patients present with multiple impairments, combinational therapies that target foot-specific as well as global impairments have shown promising results. In particular, in individuals with rheumatoid arthritis and other rheumatic diseases, comprehensive rehabilitation strategies including early detection, foot-based interventions (such as orthoses) and wellness-based approaches for physical activity and self-management have been successful.

While significant improvements have been made in the last decade to the assessment and treatment of foot and ankle conditions, few randomised clinical trials specifically have investigated patients with foot or ankle conditions to provide global insights into this area. Consequently, current recommendations vary based upon the scope of studies presented in this review as well as the strength of studies. This review indicates a need for more in-depth investigations into the components of assessment and treatment options for foot and ankle musculoskeletal conditions.

Section snippets

Introduction and purpose

Foot and ankle conditions are major public health problems, and with the increasing numbers of older adults in the population, the burden of these problems will escalate. In persons with rheumatoid arthritis (RA), these conditions are about double the rates observed in the general population. Yet, foot and ankle conditions have thus far received minimal attention by rheumatology professionals. Compared to non-invasive corrections for joint malalignment at the knee and hip, very little work has

Overview

Foot pain has emerged as a significant clinical and public health challenge due to its high prevalence and substantial negative impact on physical function and quality of life. Foot pain affects 20–37% of community-dwelling adults 45 years and older [1], *[2], [3]. In older adults without disabling foot pain at baseline, 8.1% reported it at a 3-year follow-up [4]. Individuals with foot pain experience significant physical disability *[2], [5], have difficulty with activities of daily living [6]

Overview

Approximately 15% of middle-age and older adults have experienced ankle pain in the last month [3] and 10% of older adults show radiographic signs of ankle OA [106]. Ankle pain and dysfunction are significant contributors to poor health outcomes with ageing, such as reduced physical function [107], [108], [109], balance [107] and gait speed [109], [110] as well as increased disability [108] and fall risk [7].

The ankle joint complex, defined as the talocrural and subtalar joints [111],

Regional interdependence of the foot and ankle

Lower extremity function during most weight-bearing activities of daily living occurs in a closed kinematic chain, and consequently may be interdependent (e.g., [238], [239]). This regional interdependence may be evident during assessment, and may offer valuable strategies for intervention. For instance, clinical studies indicate that ankle and foot mechanics may be related. In terms of assessment, limited ankle dorsiflexion (equinus deformity) has been noted in individuals with heel pain

Conclusions

This review presented our current understanding of assessments and non-invasive, non-pharmacologic treatment options for musculoskeletal conditions of the ankle and foot. Recent studies show that individuals with foot and ankle pain have multiple co-existing impairments in alignment, motion, load distribution and muscle performance. Consequently, a comprehensive assessment of the foot and ankle should include patients' self-reported outcomes and measures of alignment, motion, strength and

Role of funding source

Drs. Rao and Riskowski were supported by American College of Rheumatology REF Research Scientist Development Awards. Dr. Riskowski was also supported by the NIH's National Institute of Arthritis and Musculoskeletal and Skin Diseases (R01-AR047853) and National Institute of Aging (T32-AG023480). Dr. Hannan was supported by the NIH's National Institute of Arthritis and Musculoskeletal and Skin Diseases (R01-AR047853 and R01-AR060492) as well as from the National Institute of Aging (R01-AG026316).

Conflicts of interest

The authors have no conflicts of interest to declare.

Acknowledgements

The authors acknowledge the helpful assistance and comments from Thomas Hagedorn at Hebrew SeniorLife, Boston, MA.

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Citation Excerpt :
Foot and ankle disorders are one of the most common reasons why patients seek medical care [1,2].
Population-based register data could be used to improve our knowledge of patients surgically treated for foot and ankle disorders. The quality register Swefoot was recently created to collect surgical and patient-reported data of foot and ankle surgery. This manuscript aims to describe the development and current use of the register.
The development of Swefoot started in 2014 and currently, data on 16 different diagnoses are collected in 49 units performing foot and ankle surgery. Registrations are performed by the surgeon and the patient.
Between 2014 and 2020 approximately 20,000 surgical procedures have been registered. 75.1% of the registered patients were women, 9.3% were smokers, 9.3% had a concomitant rheumatoid disease, and 18.4% a BMI larger than 30 kg/m²_.
The Swefoot is a unique national register for foot and ankle surgery. It is by now possible to present demographic, surgical, and outcome parameters based on Swefoot.
Clinical Examination of the Foot and Ankle
2022, Foot and Ankle Biomechanics
This chapter outlines the components of a methodical examination of the foot and ankle to elucidate the reasoning behind the selected modules and their value in reaching an accurate diagnosis while examining the foot and ankle. Components of the physical examination include demographics, vital signs, patient history, assessment of pain, visual observation/inspection, lower extremity alignment, radiographic examination, range of motion/flexibility/joint mobility, muscle strength, sensory testing, circulation, foot and ankle specific testing, footwear examination, and functional assessment. Finally, a consideration of future biomechanical research is presented.
Neurological Foot Pathology
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This chapter provides an overview of pathologies involving neurological mechanisms affecting foot and ankle biomechanics including stroke, cerebral palsy, toe walking, peripheral neuropathy, foot drop, tarsal tunnel syndrome, Morton’s neuroma, Charcot foot, Charcot-Marie-Tooth disease, Friedreich’s ataxia, and poliomyelitis. A brief literature summary of their etiology, impact on biomechanics, and treatment is included. Each section discusses the variations in biomechanics, gait, and neuromuscular anatomy that might occur with each pathology as it relates to the foot and ankle. The implications on quality of life and potential rehabilitative outcomes are reported. A variety of treatments (standard of care, in research, novel developments) for each pathology are described along with brief discussions on the efficacies of each treatment.
Heavy load carrying and musculoskeletal health: An exploratory study of biomechanical risk factors among sand miners in Pokhara, Kaski District, Nepal
2021, International Journal of Industrial Ergonomics
Trends in urbanization contribute to the growing global demand for raw construction materials. The health effects of load carrying among occupational groups that mine and carry sand and stone used for construction of roads and buildings remains poorly understood.
We conducted an exploratory cross-sectional study among a convenience sample of sand miners working at an excavation site on the Seti River in Pokhara, Nepal. Load carrying weight, duration, and frequency were used to categorize miners as having “low” or “high” load-carrying exposures. Musculoskeletal disorders (MSDs) were identified using self-reported symptoms of moderate to severe musculoskeletal pain, as well as physical examinations.
The average loads carried by female and male sand miners weighed 66 kg and 87 kg, respectively. Among all participants (N = 42), 45% reported moderate to severe musculoskeletal pain in at least one body region and 16 (38%) had MSDs identified using specified case criteria. The prevalence of MSDs was lower among miners carrying, on average, heavier loads compared to those carrying lighter loads (OR = 0.18; 95% CI: 0.04, 0.7), possibly indicative of the healthy worker survival effect. Miners carrying loads for longer durations had higher odds of MSDs compared with those carrying for shorter durations.
This study has provided data on the extraordinary loads carried by sand miners in Nepal and preliminary evidence of health impacts associated with these loads. However, larger epidemiologic studies are needed to justify action to protect the health and safety of these unrecognized and understudied groups.
The effect of a 12-week custom foot orthotic intervention on muscle size and muscle activity of the intrinsic foot muscle of young adults during gait termination
2020, Clinical Biomechanics
The tissue stress theory is commonly used to prescribe foot orthoses, however the mechanisms of foot orthoses are not understood well. The effect foot orthotics have on the plantar intrinsic muscles remains unclear. The study was designed to assess changes in muscle size and activity of the intrinsic muscles of individuals with pes planus after wearing custom-made foot orthotics for 12-weeks.
Eighteen young adults with pes planus were allocated by stratified sampling into the orthotic group (n = 9) or control group (n = 9). Ultrasonography measured the cross-sectional area of the flexor digitorum brevis, abductor digiti minimi, and abductor hallucis at baseline, 6 and 12-weeks. Subsequently, participants completed an unexpected gait termination protocol (12 of 50 trials unexpected) and average electromyography magnitude was recorded.
After 12-weeks the orthotic group cross-sectional area significantly decreased by 9.6% (P < .001) for the flexor digitorum brevis, 17.1% for abductor digiti minimi (P < .001) and 17.4% for abductor hallucis (P < .001). There were no significant differences of muscle activity magnitude for the intrinsic muscles.
The short-term use of custom-made foot orthoses created a decrease in muscle size of the flexor digitorium brevis, abductor digiti minimi and abductor hallucis plantar intrinsic muscles but had no effect on muscle activity. Clinically, these results help to understand the adaptations that are created when foot orthoses are supporting a pes planus foot structure when reducing plantar pressures. These findings may help enhance the prescription of foot orthoses by adding a strength program to prevent disuse atrophy of these muscles.
Electromyographic Activity of Hip Musculature During Functional Exercises in Participants With and Without Chronic Ankle Instability
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The main objective of the present study was to investigate the electromyographic (EMG) activity of gluteus medius (Gmed) and gluteus maximus (Gmax) muscles during functional exercises in subjects with chronic ankle instability (CAI) vs healthy controls.
Seventeen subjects (age, 24.4 ± 2.03 years) with CAI and 17 healthy controls (age, 24.6 ± 2.57 years) were recruited for the present study. For all participants, after testing maximum voluntary isometric contraction of the Gmed and Gmax muscle, EMG activity of these muscles was recorded during functional exercises, such as the Y Balance Test and the single-leg squat with and without Swiss ball.
EMG activity of Gmed and Gmax was found to be significantly (P < .05) reduced during all functional exercises in subjects with CAI when compared with healthy controls. No significant differences (P > .05) were observed in the EMG activity of both muscles across different functional exercises.
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5Musculoskeletal conditions of the foot and ankle: Assessments and treatment options

Section snippets

Introduction and purpose

Overview

Overview

Regional interdependence of the foot and ankle

Conclusions

Role of funding source

Conflicts of interest

Acknowledgements

Pain

Osteoarthritis and cartilage / OARS, Osteoarthritis Research Society

Archives of Physical Medicine and Rehabilitation

Gait and Posture

Gait and Posture

Archives of Physical Medicine and Rehabilitation

J Biomech

Gait and Posture

Gait and Posture

Gait Posture

Gait Posture

Gait and Posture

Arch Phys Med Rehabil

Manual therapy

Prevalence of foot and ankle conditions in a multiethnic community sample of older adults

American Journal of Epidemiology

Association of foot symptoms with self-reported and performance-based measures of physical function: The Johnston County osteoarthritis project

Arthritis Care and Research

Onset and persistence of disabling foot pain in community-dwelling older adults over a 3-year period: a prospective cohort study

Journals of Gerontology. Series A, Biological Sciences and Medical Sciences

Are foot disorders associated with functional limitation and disability among community-dwelling older adults?

Journal of Aging and Health

Foot pain and disability in older persons: an epidemiologic survey

Journal of the American Geriatrics Society

Foot and ankle risk factors for falls in older people: a prospective study

Journals of Gerontology. Series A, Biological Sciences and Medical Sciences

Impact of hallux valgus severity on general and foot-specific health-related quality of life

Arthritis Care and Research

Cross-sectional analysis of foot function, functional ability, and health-related quality of life in older people with disabling foot pain

Arthritis Care and Research

Foot pain: is current or past shoewear a factor?

Arthritis and Rheumatism

Arthritis, foot pain and shoe wear: current musculoskeletal research on feet

Current Opinion in Rheumatology

Footwear characteristics and foot problems in older people

Gerontology

The interaction of ‘occupant factors’ on the lower extremity fractures in frontal collision of motor vehicle crashes based on a level I trauma center

Journal of Trauma

A mechanism of injury to the forefoot in car crashes

Traffic Inj Prev

Foot fractures in restrained front seat car occupants: a long-term study over twenty-three years

Journal of Orthopaedic Trauma

Foot pain in rheumatoid arthritis prevalence, risk factors and management: an epidemiological study

Clinical Rheumatology

Foot pain, impairment and disability in patients with acute gout flares; a prospective observational study

Arthritis Care and Research

An ultrasonographic study of metatarsophalangeal joint pain: synovitis, structural pathology and their relationship to symptoms and function

Annals of the Rheumatic Diseases

Factors associated with foot pain severity and foot-related disability in individuals with first metatarsophalangeal joint OA

Rheumatology

Theoretical model and Rasch analysis to develop a revised Foot Function Index

Foot and Ankle International

Evidence of validity for the Foot and Ankle Ability Measure (FAAM)

Foot and Ankle International

A systematic review of instruments measuring foot function, foot pain, and foot-related disability in patients with rheumatoid arthritis

Arthritis and Rheumatism

Measures of Foot Function, Foot Health, and Foot Pain

Arthritis Care and Research

The Lower Extremity Functional Scale (LEFS): scale development, measurement properties, and clinical application. North American Orthopaedic Rehabilitation Research Network

Physical Therapy

Manual physical therapy and exercise versus electrophysical agents and exercise in the management of plantar heel pain: a multicenter randomized clinical trial

Journal of Orthopaedic and Sports Physical Therapy

Reliability and validity of current physical examination techniques of the foot and ankle

Journal of the American Podiatric Medical Association

Structural factors associated with hallux limitus/rigidus: a systematic review of case control studies

Journal of Orthopaedic and Sports Physical Therapy

Reliability of standard foot radiographic measurements

Foot and Ankle International

Validity of 3 clinical techniques for the measurement of static foot posture in older people

Journal of Orthopaedic and Sports Physical Therapy

5
Musculoskeletal conditions of the foot and ankle: Assessments and treatment options