Ankle and forefoot pain

Pain in the ankle and forefoot area is usually caused by a strain resulting from incorrect application of pressure on the foot, leading to a localised issue in the ankle or forefoot area. Impaired ankle and forefoot movements may also display no symptoms; however, the movement may be compensated in, for example, the knee and hip which, in turn, causes pain.

Reasons for ankle pain

Typical symptoms of incorrect application of pressure are:

• injuries of the Achilles tendon,
• issues in the Achilles tendon
• pain in the ball of the foot and toes
• a calcaneal spur; and
• plantar fasciitis, i.e. inflammation of the connective tissue in the sole.

Ankle pain is often connected to the following symptoms or injuries

• Ligament injury of the ankle
• Sprained ankle
• Ankle osteoarthritis
• Ankle injuries of athletes and active people

Examining ankle and forefoot pain

When examining the reasons for incorrect application of pressure, it is important to understand the individual structure of the foot to see if the position under pressure corresponds with the structure. Simply studying the standing position provides a great deal of information about any incorrect application of pressure on the foot. In addition, the functions of various joints in the ankle and forefoot area must be examined.

Impaired movement and position of the ankle and forefoot

Sometimes, severe pain can be caused by joint-based impaired movement, i.e. disrupted sliding of the joint. In that case, normalising the motion of the joint by using manual techniques may provide a quick relief.

Other common factors causing an incorrect application of pressure include impaired position and motion control. In these situations, the position and motion-related sensations relayed by the foot are not normal. The situation may have developed as the result of a sprained ankle or slowly due to passive use of one’s legs. When looking for the reason for pain and incorrect application of pressure, it is also extremely important to know the history of the patient’s symptom as well as any changes in the symptom behaviour. The reason for the symptoms cannot be reliably determined without this information.

“Flatfoot”

Adult acquired flatfoot has gained little attention in Finland and its treatment has mostly relied on various supported insoles. In adult acquired flatfoot, the longitudinal arch of the foot drops and the front part of the foot turns outwards. The heel bone becomes twisted and the mobility of the ankle is impaired.

When under pressure, a foot appearing to have a low arch, i.e. so-called flatfoot, may have a high-arch structure, placing the sole of the foot under severe, continuous and stretching pressure which may lead to locally impaired metabolism and, as a result, inflammation.

Flatfoot often develops due to a failure in the tendon running on the inner side of the ankle. It may also be the result of an acute injury, but usually it stems from a deteriorated tendon. The symptoms include pain on the inside of the ankle and foot, strain under the outer malleolus and a resulting difficulty to walk.

On the other hand, a foot may have a naturally low-arch structure that does not prevent its normal movements. The functions of the foot structure and joints may be perfect and the position normal even when standing, but in functional movements, such as tiptoeing, the person loses control and starts to feel pain.

Supportive insoles may alleviate the pain, but the ailment often progresses nonetheless and may, over the years, result in partially malaligned joints. Such situations call for arthrodesis surgeries. If the patient has not developed osteoarthritis, the situation can be fixed with a tendon transplant or a heel bone readjustment. The peroneus muscle often also requires lengthening. After the surgery, the patient needs intensive physiotherapy to achieve a successful end result.

Rehabilitation of ankle and forefoot and exercises

Physiotherapy and rehabilitative exercises for the ankle and forefoot may significantly differ, even if the symptom is the same. An exercise meant to improve the condition of the other leg may worsen the issue if repeated with the other leg.

The so-called flatfoot can often be returned to a normal position through exercises. Similarly to slowly and unnoticeably developing a bad posture in a desk job, the posture of a leg may also change over time. The malalignment may not alert the person to its presence until the first pains occur. Specifically designed exercises can change the functions of the leg. It usually acts as a shock absorber and, on the other hand, as rigid leverage when pushing ourselves forward.

The exercises require the patient to focus and they may feel frustrated at first. However, continued exercise will yield results in a matter of weeks, which motivates the patient to continue. Improving motion control and boosting the efficiency of running and pushing upwards or forwards motivates young, athletic people to carry on with the exercises.

The exercises aim to restore the correct movements and muscular balance. They start with finding the correct position control for the ankle and forefoot when no pressure is applied. The progress is gradual as the patient’s skills develop from position control when pressure is applied to motion control, moving on to integrated, functional exercises such as running.

How are the ankle and forefoot able to bear our weight?

Thanks to their bony structure, the ankle and forefoot are quite load-bearing, but even a small error when touching the ball of the foot to the ground during a run can result in a failure of the structural support, transferring the pressure to areas that are not designed to bear heavy loads.

Focusing on the support points of the sole forms the basis for normal application of pressure. When examined on a mirrored table, for example, the support points may appear normal, whereupon an extremely typical functional error of the foot may go unnoticed. The support point for the ball of the foot near the big toe is achieved by leaning on it, which is not properly executed due to muscular activation as the operating model of the muscles has changed. Passiveness in the front of the foot often leads to incorrectly applied pressure, resulting in severe pain. Using low-quality or excessively supported footwear may lead to a passive natural support system in the forefoot.

Activating the incorrect muscles leads to an incorrect pressure model, often resulting in a painful forefoot, ankle and/or knee. The pain may be targeted at the bony structures and/or overactive or passive muscles or the connecting tendons.

Even if no pain has occurred yet, correct functions of the lower limbs are useful. Correct foot functions prevent corns, hammer toes and cramps. In addition, correct foot functions make exercise more effective and economical.

When to wear supportive insoles?

The purpose of a supportive insole is to support the ankle and forefoot in the middle position in order to improve the foot’s chances of correcting its movement. Preparing supportive insoles is in order when the ankle and forefoot cannot otherwise be fully rehabilitated due to their structure or functions. At the moment, the reasons for using insoles are often insufficient or incorrect.

At worst, a supportive insole may even aggravate pain in the foot. If the correct position of the ankle or forefoot is prevented by joint-based impaired movement, for example, the foot cannot be forced into the correct position with an insole. This would result in an even greater strain on the structures in the foot, often causing more pain. In this case, the correct treatment would be to mobilise or manipulate the joint areas with restricted mobility, after which the functions of the ankle and forefoot should be rehabilitated through exercises.

Careful and thorough examinations are vitally important before preparing the insoles to ensure that they are necessary. Malalignment and incorrect functions of the forefoot may be caused by the aforementioned passiveness in the front of the foot which cannot be corrected with insoles. Even in these situations, insoles may be useful in alleviating acute pain and supporting the exercises.

Any support insoles should be prepared under close cooperation between the technician and the physiotherapist. If support insoles are prepared, they must be enabled to function correctly. A poor choice of shoe may alter the desired effect of the insole. For this reason, insoles should only be used in neutral shoes, as opposed to shoes with prefabricated support structures such as a support for overpronation, i.e. twisting the ankle inwards when walking.

Ankle and forefoot pain in children and young people

If a young person suffers from problems with their lower extremities or there are clear signs of malposition, we recommend turning to a professional at an early stage. All pains should not be dismissed as ‘growing pains’. Early correction of movement considerably expedites rehabilitation. Even children are often ordered to rest in the event of pain in the lower limbs. As the reason for the symptoms has not been diagnosed and treated, the pain may be alleviated when resting but return when pressure is applied.

After an examination, a professional, specialised physiotherapist can tell when a problem may not be resolved by rehabilitation at that time. In that case, specialists such as orthopaedists and other physicians can be consulted. Close cooperation with physicians and other therapists guarantees successful results.