This is the second part of our foot and ankle series. Arthritis in the foot and ankle. Is it hereditary? caused by being overweight? caused by trauma? Are you experiencing cracking and creakiness? Find out symptoms of gout on this episode, grades of ankle sprain, and other afflictions of the foot and ankle.
I’m going to kick us off with arthritis, as the foot and ankle are often sites for osteoarthritis, rheumatoid arthritis and gout.
I’ll quickly cover rheumatoid arthritis, which is an auto-immune disease, meaning that the body attacks itself.
Ankle sprains have a grading system, ranging from grade one, which is a slight stretching of the ligament with possible micro-tears, to grade two, where there is a partial tear of the ligament, to grade three, where there is a full rupture of the ligament, with no fibres touching.
Achilles tendon ruptures. As mentioned in the previous anatomy episode, the Achilles tendon is an extension of your gastrocnemius and soleus muscles and attaches into your calcaneus. It can become progressively weakened due to Achilles tendinitis, and or an overuse injury, as well as excessive and a long term steroid or steroid or medication use, which can also affect the structural integrity of the tendon, making it more susceptible to rupturing or in this case, the more common mechanism of injury so direct blow or injury to the ankle.
Dr Jacqueline Swiatlowski is a qualified chiropractor with over 6 years of experience. She has worked in a range of different environments including roles within the allied health industry, professional sporting clubs as well as in her own private practice. With a Master of Clinical Chiropractic from RMIT University as well as a number of additional qualifications, including Active Release Technique (ART), Animal Flow and a Certificate III & IV in Fitness from the Australian Institute of Personal Trainers, Jacqueline is an expert in movement restoration and chiropractic care. In the past she has worked alongside local athletes, including players from the Western Eagles Soccer Club, Melbourne City Soccer Club and the Coburg Lions Football Club. In her role at Jurmaine Health, Jacqueline’s main focus is treating patients and looking after their health. “Jacqueline is also a TRE provider now and can offer TRE treatments to patients.”
Episode 034: Foot and ankle part 2
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This is Jurmaine Health; the centre to help you achieve wellness in both your brain and body. We endeavour to encourage cross communication between health professionals for your health and wellbeing. We'll bring you topics on Functional Neurological Health, such as neuropsychology, neurobehaviour, neuromusculoskeletal, neurogastro, the embodied project, metabolism and microbiome, which are also some of the services that we provide.
Today's podcast is the second in our ankle and foot series, and will cover the most commonly seen injuries/issues relating to funnily enough, the ankle and foot!
Unfortunately, once again, I have no colleagues with me today, as one is away furthering her knowledge base, and the other is still recovering post surgery, so you'll be hearing my voice for the entire episode. Sorry guys!
So let's get this episode started, as we have a LOT to cover!
I'm going to kick us off with arthritis, as the foot and ankle are often sites for osteoarthritis, rheumatoid arthritis and gout.
I'll quickly cover rheumatoid arthritis, which is an auto-immune disease, meaning that the body attacks itself. The smaller joints of the body are often affected, in this case the ankles and feet, and the condition presents itself often symmetrically, with both sides being involved. People with RA may experience pain, swelling and heat in the area, decreased range of motion and increased stiffness, as well as weakness and fatigue during daily activities, especially walking stairs.
Next up, we have osteoarthritis, which is usually a gradual degeneration of the joint surfaces and/or the articular cartilage. Genetics may play a role in its development, as may excessive use of steroids or steroid medication, and obesity, as excess weight places the ankle and feet under greater load when performing daily activities, thus increasing the forces exerted on the joint cartilage, however previous trauma to the area is the more common predisposing cause of osteoarthritis of the ankles and feet. Previous ankle sprains are exactly the type of trauma that may predispose the ankles to osteoarthritis, as the instability in the area may cause further ankle sprains, only feeding the vicious cycle, if left untreated. Repetitive strain injuries can also accelerate the wear on joint surfaces. Most people will experience achiness and stiffness in the joints, with decreased range of motion, especially in the mornings. Crackling or creakiness in the foot and/or ankle may also be heard and felt, and there may be associated swelling (usually without heat), and if there is extensive osteoarthritis in the ankle or foot, there may be a change in size and/or deformity evident.
Last off the arthritis rank, we have gout. This is a common condition that primarily affects the hallux, your big toe! It's caused by an accumulation of uric acid crystals in the joint, when the kidneys can't eliminate them fast enough, and becomes a very painful, yes, I had that in capitals, condition, characterised by inflammation and swelling around the big toe joint. The area can be hot to touch, and when aggravated, may even make wearing a shoe, or shoes if on both feet, uncomfortable. Gout can come on as random attacks that last about a week and then settle down. If left untreated, the bouts can last longer, and the painless breaks between can decrease, and because of it's inflammatory nature, can cause permanent damage to the joint itself. Of course, in turn leading to problems higher up due to the now changed mechanics of the involved foot/feet! For the most part, this condition can be well managed by most through specific medications and lifestyle changes, where aggravating foods, drinks and habits are best avoided in order to prevent flare ups.
Moving past arthritis and onto ankle sprains. As mentioned in our previous episode on the anatomy of the foot and ankle, the most commonly sprained ligament is the anterior talofibular ligament, and it's most often damaged with inversion sprains (where you've rolled the ankle over the outside of your foot).
Ankle sprains have a grading system, ranging from grade one, which is a slight stretching of the ligament with possible micro-tears, to grade two, where there is a partial tear of the ligament, to grade three, where there is a full rupture of the ligament, with no fibres touching. Grades 1 and 2 can most often be treated with rest and specific exercise protocols involving stretching and strengthening exercises, as well as proprioceptive exercises of course. Grade 3 sprains may require surgical intervention, as the ankle has now lost significant integrity, and if not stabilised, may predispose the individual to recurrent ankle sprains and injuries, as well as predispose the joint to future osteoarthritis. This is especially true in those that lead lifestyles where they are often using their feet, be it for work or in their sporting choices. No matter what grade of sprain one has, but most definitely the case for grades 2 and 3, a comprehensive rehabilitation program is imperative, in order to strengthen the joint, prevent further injuries, and to help decrease the onset and severity of future arthritis.
As many of you know, we've worked with the Melbourne City Ballet Company for many years, and I can guarantee you, we have seen many ankle sprains over the years. Funnily enough, a common pattern with most of these injuries, was that they were NOT the first ankle sprain for each individual. Most of the dancers had previously suffered ankle sprains of various grades, and the impact of their previous rehab protocols, or lack thereof, is often apparent, as their presenting complaint of ankle/foot pain and stiffness is the result of previous poor management. This is also true for many of our footballers, soccer players and netballers, who also report similar issues, as well as instability in the ankles, and so their vicious cycle of ankle sprains repeats! Here I repeat once more the importance of a comprehensive rehabilitation program!
Before I let the topic of ankle sprains go, I'm going to rant for a bit about a pet peeve of mine relating to the imaging of ankles. I've mentioned this in our shoulder series, as it also features in the imaging of shoulders, but I'll repeat it here. We have many a times received imaging reports that state that there is an ankle impingement, not that this was something that we usually require imaging for, but we rarely get told WHAT the impinged tissues are! The part that would ACTUALLY be of some assistance to us! There is a reason as to why I told you all in the previous episode to Google the anatomy of the foot and ankle there are a LOT OF STRUCTURES in the area! Sorry, rant over! I'll stop digressing.
I'll go on a slight tangent with this next condition, as it's not the most common of injuries, BUT it's definitely worth mentioning if for nothing more than theatrical effect! I'm talking about Achilles ruptures!
As mentioned in the previous anatomy episode, the Achilles tendon is an extension of your gastrocnemius and soleus muscles, and attaches into your calcaneus (your heel). It can become progressively weakened due to Achilles tendonitis and/or an overuse injury, as well as excessive and/or long-term steroid or steroidal medication use, which can affect the structural integrity of the tendon, making it more susceptible to rupturing. OR, and the more common mechanisms of injury are direct injury or blow to the ankle, a heavy fall on the ankle, or a heavy step down, as frequently seen in footy when landing from a mark!
So when I say it's worth mentioning for theatrical effect, this relates to how people often describe the feeling of it rupturing as though they hear a loud pop or bang and as though someone has just slapped or kicked them directly in the area. For more theatrical effect, the person is also unable to walk on their toes, and will have a hole or space where there Achilles tendon should lie needless to say, this is a surgical job, where once again, an extensive rehabilitation program is imperative.
Going back to common presentations, we have compartment syndrome, as promised in the previous episode. Compartment syndromes can occur in other parts of the body, but as we're on the lower limb, we're going to stick with those that affect the lower leg, between your knee and ankle, but that can have effects into the foot/feet themselves.
There are 4 compartments in your lower leg, anterior, lateral, superficial posterior and deep posterior, all of which contain various muscles, nerves, veins, arteries, etc, depending on their location. Won't go into the full anatomy here, so if you'd like to see them more intensely, it's time for Mr Google again.
A compartment syndrome develops when there is swelling or bleeding within a compartment. As fascia doesn't stretch, this can cause increased pressure on the capillaries, nerves and muscles in the compartment, as the blood flow to muscles and nerve cells is disrupted, leading to possible damage to the tissues.
In acute compartment syndrome, this pressure must be surgically released immediately to prevent permanent damage, however, the more common type of compartment syndrome, and that one that I'll continue with is chronic exertional compartment syndrome. Something I think most of you may have experienced, or will experience, to some degree in your life. With chronic compartment syndrome, the pain and swelling is caused by exercise. It's most often seen in athletes that participate in activities with repetitive motions, especially in running, cycling, and jumping sports. Usually the pain is felt more significantly in the leg, and may have associated cramping, but the inability to gain full range of the ankle and foot is often also seen, as may be numbness into the ankle and foot and difficulty moving the foot, as previously mentioned as foot drop, where the nerve supply is disrupted due to the increased pressure on them. Rest and decreasing aggravating activities provides relief, as do exercises and manual treatments aimed at decreasing the pressure in the compartment.
This is where I apologise to anyone that has been previously treated by me for a compartment syndrome, as it's highly likely that dry needling may have featured sorry!
I've got one more common condition to finish off with, and one that I'm going to assume you all would've heard about, to various degrees yes, I'm talking about plantar fasciitis.
Quick anatomical recap, the plantar fascia is a thick fibrous band of tissues that extends from your calcaneus (heel) to your toes, and helps create the foots arch.
It's characterised by inflammation of the plantar fascia through overstretching it or overuse, and is commonly seen in sports that place a lot of stress on the heel bone, such as running, dance and aerobics.
The condition is often seen during pregnancy, due to the extra load of bub placing additional force through the ankles and feet, often also causing a dropped arch. As baby weight was just mentioned as a link, this is also applies to those that are overweight.
People who spend lots of time on their feet but don't have supportive shoes may also find themselves experiencing this condition.
Due to its attachment to the calcaneus (heel), heel spurs may also be found, and this will be a identified with some sort of imaging. Note, not all heel spurs are painful!
The pain is usually felt under the heel, may be dull or sharp, and the sole of the foot may ache or burn. Some people may also have a swollen heel. The pain is usually worse in the morning or after prolonged rest, especially after the first few steps, but also during or after intense activity.
This is another condition that is commonly seen amongst our ballet dancers, as they spend a lot of their time jumping on their toes, or doing pointe work. We have had success in the management of their symptoms through the use of night splints during their performing season.
Cortisone injections is probably what plantar fasciitis is most associated with, however this only masks the pain (at best), and surgical slicing of the plantar fascia is also a known treatment, especially in longstanding cases, and with this, I shall lead you into our last story, and the one promised in the previous episode.
So I just spoke about the typical presentation of plantar fasciitis, the same presentation that one of our patients once came in to seek treatment for. BUT, there is a MINOR (to be heard as major) important detail that I feel you should know she'd already previously undergone surgery on BOTH her feet to slice the plantar fascia in order to relieve her pain and guess what?! It didn't help! It may have potentially given her a softer sole of the foot, but her symptoms remained!
And this is where the nerve supply of the foot comes into play the sole of the foot is supplied by the tibial nerve (well its branches), which as mentioned in the previous anatomy episode, is a branch of the sciatic nerve. The sciatic nerve, and in turn the tibial nerve, is derived from the spinal nerves L4 to S3, which have their nerve exits all the way up in our low back, the lumbar and sacral areas. So low and behold, can you guess where her ongoing plantar fascia distribution pain was stemming from? That's right, she had a lumbosacral issue that was causing her problem all the way into her foot! Nowhere near the foot itself! Just because it looks like a zebra, and walks like a zebra, doesn't mean it's always a zebra it could just be a stripey horse!
And with that last-ditch lame joke attempt, I shall wrap this episode up, as I feel like you may have heard enough from me today. I hope today's episode has given you a better understanding of the more commonly seen afflictions of the foot and ankle, and we'll continue on with more in the next episode.
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For those of you who are coaches, dancers or athletes, and may find difficulty with expressing or executing movement patterns, please do connect with us on our website www.jurmainehealth.com.au (spell JH out) or please socialise with us on Facebook (jurmainehealth) and Instagram (jurmainehealthbody).
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