Best Practice & Research Clinical Rheumatology
Volume 17, Issue 1 , Pages 87-111, February 2003

Foot and ankle disorders

  • Géza P Bálint, md, frcp, DSc (Consultant)

      Affiliations

    • Corresponding Author InformationCorresponding author. Tel.: +36-1-438-8331; Fax: +36-1-438-8324.

4th Department of Rheumatic Diseases, National Institute of Rheumatology and Physiotherapy, 38–40 Frankel L. Street, Budapest 1023, Hungary

3rd Department of Rheumatic Diseases, National Institute of Rheumatology and Physiotherapy, 38–40 Frankel L. Street, Budapest 1023, Hungary

Orthopaedic and Trauma Department, Uzsoki Hospital, 62 Mexitói Street, Budapest 1145, Hungary

3rd Department of Rheumatic Diseases, National Institute of Rheumatology and Physiotherapy, 38–40 Frankel L. Street, Budapest 1023, Hungary

Article Outline

Abstract 

Foot pain is very common, especially in women, owing to inappropriate footwear. Overuse, repetitive strain and minor, easily forgettable injuries may result in chronic foot and ankle pain. Rheumatoid arthritis, spondyloarthropathies and gout frequently affect the foot, often as a first presentation. Charcot's joints and foot infections are not rare in diabetes. The rheumatologist should be familiar with foot disorders, either localized or as manifestations of generalized disease. History taking, physical examination, identification of the source of pain by intra-articularly given local anaesthetics and imaging methods should be used to reveal the underlying disorder. Correct diagnosis and efficient therapy—including local steroid injections, physiotherapy, orthoses, surgery—are necessary not only for treatment but also for preventing biomechanical chain reactions.

This chapter gives an overview of the epidemiology, diagnosis and treatment of foot pain and foot disorders caused by both local and generalized diseases.

Keywords:  ankle, foot, pain, disease, diagnosis, imaging, assessment, treatment, rheumatoid arthritis, spondyloarthropathies, diabetes, Charcotarthropathy

 

The great grandmother of mankind, Lucy (Australopithecus afarensis), who lived 3 million years ago in Africa, was the first hominid to have a human footprint.1 She was probably able to walk rather long distances in erect position. Her hands became completely free for work. The ability to use hands started the rapid development of the brain in her descendants. We may say, therefore, that her human character was rooted in her feet.

In modern times foot problems are very common owing to a civilized lifestyle and the use of unsuitable shoes, repetitive strain and injuries. General practitioners and different specialists—including rheumatologists, orthopaedic surgeons and specialists in sport medicine—are visited by a number of patients with foot problems. It is a matter of chance whether the patient seeks help from a general practitioner, orthopaedic surgeon or rheumatologist.

This chapter provides an overview of the most common ankle and foot disorders, including their diagnosis and treatment.

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1. Epidemiology of foot pain and deformity 

Foot problems are rare in those populations who do not wear shoes.2., 3. On the contrary, 80% of 356 healthy women (20–60 years of age) were reported to have foot pain while wearing shoes; 76% had one or more foot deformities, and 88% wore shoes on average 1.2cm smaller in width than their feet.4 In the high-heeled gait, subjects walk significantly slower, have a shorter stride length, and have increased knee flexion at heel strike and during the stance phase. During the swing phase there is significantly smaller knee flexion and slightly smaller hip flexion.5 Out of 106 senior citizens who had sustained a fall, 28% stated that their shoes were the primary cause of their fall.6 The problems caused by inappropriate footwear occur less often in teenage girls—who often wear athletic shoes, sneakers or sandals. On average, females are nine times more likely to have various foot problems compared with males.7

A total of 459 subjects—73% aged 65 years or older—were examined in the Italian town of Dicomano. The prevalence of foot pain, pes planus or cavus, calluses and corns was significantly higher in females. Pain was found in 21.8% only at standing and in 9.6% at rest. The most common physical signs were calluses and corns (64.8%), hypertrophic nails (29.6%), hallux deformities (21.2%) and absence of arterial pulses (15.9%). Vascular foot disorders were more frequent in the older age group, but in this respect no differences were found between the sexes.8

The American national estimate reveals that 60% of women aged 65 years and older have bunions versus 40% of older men.9

Within the framework of the Women's Health and Aging Study, 32% of 990 disabled women had foot pain classified as either moderate, or chronic and severe. Severe foot pain was common in obese women 65–74 years of age and in patients with osteoarthritis of the hand and knee. Walking speed, and five repeated chair stands, was slower in women with foot pain. Bunions and hammer toes were very common in older women (70 and 50%, respectively) but these were not associated with chronic and severe foot pain. This finding suggests that severe foot pain may play a key role in disability in older women.10

A recent cross-sectional, retrospective study from Australia aimed to investigate the relationship between foot problems, balance, functional ability and falls among 135 community-dwelling men and women aged 75–93 years. Eighty seven percent of the sample had at least one foot problem. Compared with the men, women had a significantly higher foot problem score. The foot problem score was significantly associated with performance on a co-ordinated stability test, stair ascent and descent, alternate stepping test and timed 6-metre walk. Subjects with a history of multiple falls had a significantly higher foot problem score.11

The cost of foot problem caused by ill-fitting shoes has also been studied.12 In the USA, the annual direct cost of surgery and post-operative care for foot deformities caused by shoes was estimated to be as high as US$ 1.5billion, and the indirect costs added a further US$ 1.5billion.

However, despite all the costs, disadvantages, discomforts and sufferings, high heels communicate important information about the mating suitability of the wearer: they give more shapely contours to the ankle and leg, and they accentuate the shape and the movement of the pelvis, buttocks, abdomen and bosom.13 Rossi concludes: ‘high heels may well be the most potent aphrodisiac ever concocted’.14 But don't forget that all these costly and risky feminine practices with high heels aim for better natural selection and the survival of mankind.

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2. Diagnosis and assessment of foot pain 

Physical examination is the basis for diagnosing foot disorders. Unfortunately, sensitivity and specificity studies of physical examination signs are lacking. This is understandable if we consider that, before the availability of modern imaging methods such as ultrasound (US) and magnetic resonance imaging (MRI), plain radiography and surgery were the only means of proving the underlying pathology. Hopefully the routine use of US and MRI may initiate more evidence-based studies on physical examination signs. Inspection of the skin, callosities and deformities such as hallux valgus, mallet toes, flat foot, valgus and varus deformity, is very important. The foot should be inspected in both weightbearing and non-weightbearing positions from all aspects. It is essential to inspect the gait of the patient so that the knee, hip joint and spinal participation of gait can be assessed.

Different kinds and localization of swellings can also be seen and palpated. Palpation should include examination of arterial pulses, articular and non-articular swellings and bony protuberances—first of all for tenderness.

Examination of passive joint movements should be meticulously performed, including the ankle, subtalar, the Chopart and the metatarsophalangeal (MTP) joints; pain caused by such movements should also be registered.

2.1. Identifying the source of pain 

Identification of the source of pain is not easy owing to the packed arrangement of joints, tendons, ligaments and entheses in the foot. As well as revealing tenderness, examination of passive and active movements is used for identifying the source of pain. Pain presenting at certain passive or active movements, with restriction of the same movement, may identify impingement syndromes. Pain at certain passive or resisted active movements may identify enthesopathies, i.e. passive dorsiflexion and/or resisted plantar flexion of the foot may provoke enthesopathic pain of the Achilles tendon.

Some authors have suggested that the source of articular pain can be identified by using injections of local anaesthetics guided by fluoroscopy or arthrography.15., 16. This method proved to be useful in surgical planning. Lucas et al17 simultaneously gave steroid injections to 106 intra- and extra-articular sites in 47 patients. Of these patients, 47% had relief from pain even after 2 weeks. If the pain and inflammation of a foot joint could be controlled by local injections, pathological, biomechanical consequences might be prevented. Clearly, more studies are required in this field.

2.2. Assessment of foot pain and function 

Budiman-Mak et al developed a foot function index (FFI) in 1991.18 Partly the same authors changed the VAS rating of FFI to a verbal rating scale and also omitted the ‘limitation’ scale. The new instrument's (FFI 5-point scoring) internal consistency and construct validity was compared to the original instrument and good agreement was found.19 The American Orthopedic Foot and Ankle Society developed a foot rating score (AOFAS clinical rating score) system in 1994 which has since been widely used.20 This system was recently criticized for its theoretical limitations by Guyton21, especially for the small number of intervals and quantitatively unequal intervals for some items.

Recently a self-administered instrument was developed and validated for assessing foot pain and disability.22 The questionnaire, consisting of 19 items, was tried on 45 rheumatology patients, 33 patients attending general practitioners for foot-related disorders and 1000 responders to a population survey for foot disorders. Rowan developed a rather complicated scale for measuring chronic foot pain.23 The scale consists of 39 items, 16 in sensory, 10 in affective and 10 in cognitive subscales and for all items five different answers can be given. The foot and ankle outcome score (FAOS) for assessing ankle ligament reconstruction was also recently developed and validated.24 All of these recently developed instruments clearly need more testing in clinical practice.

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3. Imaging of the foot 

Although imaging of the foot has been much developed in recent decades, and new imaging modalities are now part of the daily routine, with a few exceptions plain radiography still has the priority in the algorithm of diagnostic imaging. The final branches of these algorithms are usually terminated by MRI, providing ample morphological information of soft tissues, hyaline cartilage and bone structure. Ultrasonography, however, is increasingly used by clinicians as an extension of physical examination and undoubtedly will take over the priority in many fields. US has a monopoly in real-time examination and in office-based imaging. US fills the gap between plain radiography and MRI regarding superficial structure resolution and examination of bone surface where a suitable acoustic window allows US examination.

3.1. Plain radiography 

Routine X-ray films give a good overview of the ankle and small joints of the foot and are able to detect rather large osteoarticular pathologies, bone deformities, stress fractures, accessory bones, erosions, periostitis and bony spurs.

Routine projections include non-weightbearing views of anteroposterior, lateral, medial oblique and lateral oblique projections. The medial oblique view helps to evaluate forefoot, the lateral oblique the tarsal and Chopart joints. Special lateral views are recommended for the toes and axial and lateromedial tangentional projections are recommended for the sesamoid bones. Anteroposterior, lateral, internal oblique and mortise views are used for the ankle. The internal oblique view provides additional information about the talocalcaneal relationship and lateral malleolus.

Weightbearing and stress views provide information about the function of the arches of the foot, the suspending tendons and the ligaments. Valgus, varus, drawer, flexion, extension and subtalar inversion stress views are used. It should be remembered that radiological signs develop late, or can be hidden—for example, an osteochondral lesion of the tarsal dome or acquired tarsal coalition.25., 26.

3.2. Bone scanning 

Bone scanning is a sensitive but rather non-specific imaging method used for detecting bone pathologies. 99mTc phosphonate scans show hot spots of increased osteoblast activity. 67Ga and 111In or 99mTc-HMPAO-labelled leukocyte scans are used for detecting inflammation, infections and tumours. 111In-labelled leukocyte scans are considered more sensitive than 67Ga scans for detecting infections.27

Bone scanning is advised in case of:

1.suspicion of bone and soft-tissue infections, especially in the presence of metal implants;

2.suspicion of metal implant loosening;

3.mapping the foot involvement of a multilocular (i.e. Paget's disease, hypertrophic osteoarthropathy) or generalized bone and joint disease (i.e. hyperparathyroidism, early rheumatoid arthritis (RA) or spondyloarthropathies (SpA);

4.suspected reflex sympathetic dystrophy (RSD);

5.badly localized uni- or bilateral foot pain and/or swelling. The sites of increased uptake should be investigated further with other imaging methods.

In their study of healthy volunteers O'Duffy et al have shown that false-positive bone scans occur in a rather high percentage of healthy subjects. Fortunately, the false-positive scans were always of low intensity and occurred most commonly in the midfoot and in the first MTP joint.28

3.3. Ultrasonography 

Ultrasonography (US) of the ankle and surrounding ligaments and tendons, including normal anatomy and pathological changes, was excellently summarized recently by different research centres. It was concluded that US is an excellent tool for diagnosing tendinitis, tenosynovitis, tendon tears (full-thickness and partial, transverse and longitudinal as well) tendon subluxation, joint and bursal effusion, ligamental damage, plantar fasciitis, ganglions, Morton's neuroma, soft-tissue masses and non-metal foreign bodies.29., 30., 31., 32.

Synovial effusion can be a non-pathological finding in the hindfoot and ankle. Nazarian et al investigated the hindfeet and ankles in 30 normal volunteers. The presence of fluid in the anterior recess of the ankle, retrocalcaneal bursa, in the tendon sheath of the posterior tibial tendon and the common peroneal tendon sheath does not necessarily imply underlying abnormality.33

In his fundamental works, Koski has shown that US can detect plantar tenosynovitis metatarsalophalangeal arthritis, plantar bursitis, subtalar, midtarsal and talocrural arthritis in different arthritides, especially in early RA.34., 35., 36., 37.

The importance of US as an extension of physical examination was shown by Karim et al.38 In this study the site-specific diagnosis (synovitis, tenosynovitis or enthesitis) was changed after US examination in 13 patients out of 19 with foot disorders. A pilot study comparing US, MRI and conventional radiography of the fifth MTP joint in RA showed the superiority of US over plain radiography for detecting erosions—and, in some instances, superiority even over MRI.39 This result needs to be confirmed on a larger cohort of patients with early RA.

US is useful for detecting clinically silent enthesopathies of the ankle and foot in SpA.40., 41., 42. Gibbon and Long extensively studied the plantar aponeurosis of asymptomatic volunteers, of idiopathic plantar fasciitis, with locally inactive inflammatory arthropathies and with Achilles and ankle ligament injuries. Compared with asymptomatic volunteers they demonstrated that significant plantar aponeurosis thickening was present not only in clinically active plantar fasciitis but in locally inactive SpA patients as well.43 Sonography is a primary imaging method for diagnosing Achilles tendon injury44; however, Movin et al45 found that contrast-medium-enhanced MRI revealed greater sensitivity than US, demonstrating intratendinous pathology.

Different pathological changes of the Achilles tendon, such as tendinosis or paratenonitis, can be shown by US.46., 47. Retrocalcaneal bursitis frequently accompanies both tendinosis and paratenonitis, especially when the distal third of the Achilles tendon is affected by either non-inflammatory conditions44 or inflammatory enthesopathy.48 Sonography may predict the outcome of achillodynia, helping to choose conservative or surgical treatment.49

In the past few years musculoskeletal US has become not only a diagnostic but also a powerful managing tool. More and more rheumatologists use US guided joint and soft-tissue aspiration and injections.50., 51., 52., 53., 54. The effect of US-guided steroid injections for treating plantar fasciitis and retrocalcaneal bursitis was also evaluated by ultrasonography.55., 56., 57., 58. However, early results of US-guided and palpation-guided injection of idiopathic plantar fasciitis did not show a significant difference between the two methods.59

The results of US changed the treatment plan for local injections and also for indications of DMARDs in the study of Karim et al.38 US seems to be an effective and cheap method for assessing the effect of DMARDs and new biological treatment of SpA with heel pathologies.60., 61. Both of these latter groups used not only grey-scale but the power Doppler method for detection of increased blood flow around the Achilles tendon.

3.4. Computed tomography (CT) scan 

Computed tomography is the best imaging modality for detecting and assessing bone pathologies involving bone cortex and trabeculae in detail. CT scans can be the first radiology method for diagnosing talocalcaneal coalition26 although posterior–superior oblique projection in a standing position with plain X-ray film was also recommended for this purpose. CT plays a minor role in the evaluation of musculoskeletal abnormalities—with the exception of complex fractures and primary or secondary bone tumours and the detection of sequestrae in chronic osteomyelitis.62., 63., 64.

3.5. Magnetic resonance imaging (MRI) 

MRI certainly revolutionized the imaging of the foot. MRI of the ankle and foot has been excellently reviewed by Rosenberg et al and by Ashman et al.65., 66. The cross-sectional panoramic view provided by MRI visualizes soft tissues, including hypertrophied synovial membrane, almost in anatomical detail—but it also shows hyaline cartilage and is a unique method for depicting bone marrow. Bone marrow oedema can be caused by different pathologies and may occur also in healthy subjects due to physical activity.67 Peterfy's excellent review on the MRI of RA lists all currently available advantages of this imaging method, including detection of early erosions, quantification of synovial inflammation using gadolinium contrast enhancement, tendon pathologies and insufficiency fractures.68 MRI is useful for evaluating cartilage, and MRI methods have also been developed for quantification of the glucose–aminoglycan (GAG) concentration.

MRI is a useful method for assessing enthesopathies in SpA69, although standardized methods have not yet been developed. Ankle impingement syndromes65., 70., 71., sinus tarsi syndrome72., 73., osteochondral lesions74., 75., stress fractures65, tendon tears72., 76., fasciitis77, plantar plate rupture, Morton's neuroma and MTP joint synovitis66 can be excellently visualized by MRI, although most soft-tissue lesions can also be detected with US. MRI seems to be an inevitable requirement in planning surgery and post-surgery follow-up.63., 77., 78., 79. Pre-operative MRI findings correlate very well with pathological changes found at surgery.80

Early diagnosis of osteomyelitis of the foot is of great importance, especially in diabetic patients with Charcots joints. The osteoarticular changes of both conditions are very similar: marrow oedema, fragmentation, dislocated fractures, joint disintegration etc. Moreover, the two conditions may coexist. The differential diagnosis can be made on different localizations: osteomyelitis localizes in toes, metatarsal heads, calcaneus and malleoli, while Charcots joints mostly affect Lisfranc and Chopart joints. The so-called ‘secondary signs of osteomyelitis,—adjacent soft-tissue abscesses, cellulitis, sinus tracts, soft-tissue involvement—are of differential diagnostic value. The sensitivity of MRI in diagnosing osteomyelitis is about 77–100% and its specificity is 80–100%.76

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4. Ankle and tarsal pain 

Involvement of the ankle joint is not rare in RA81., 82., but other kinds of arthritis–including Lyme disease and HIV-associated arthritis83— may also affect this joint. Bilateral ankle arthritis is characteristic of acute sarcoid arthritis, often associated with a redbluish discolouration around the ankle.84 Sarcoidosis and tuberculous synovitis may coexist.85

4.1. Ankle sprains and impingement syndromes 

Ankle sprains or repetitive injuries (athletes, ballet dancers) are common sources of pain in the ankle. The injury of the lateral ankle ligaments is usually caused by inversion stress, leading to chronic lateral ankle instability. A number of other injuries, such as anterolateral impingment and peroneal tenosynovitis, may be associated. Interestingly, MRI was found to be relatively insensitive for detecting both anterolateral impingement lesions and peroneal tenosynovitis.86 Minor injuries are easily forgettable but may cause impingement syndromes often mistaken for arthritis—and they can cause secondary osteoarthritis.87 Therefore, some essential knowledge about impingement syndromes may be important even for the rheumatologist. However, it is not known how often impingement syndromes occur in inflammatory joint diseases (Table 1, Table 2, Table 3, Table 4).

Table 1. Anterolateral impingement.64., 86., 88., 89.
InjuryInversion injury

Symptoms and signs

Anterolateral ankle pain, localized tenderness in the area of antero-inferior tibiofibular ligament and/or anterior talofibular ligament

Imaging

May occasionally show small osteophytes on the anterior tibial margin
Stress radiographs are normal in 50%; in the other 50% increased anterior translation of the talar dome can be seen
Table 2. Anterior impingement.87., 89., 90.
InjurySupination or repeated dorsiflexion

Symptoms and signs

Chronic, anterior ankle pain, pain at dorsiflexion, restriction of dorsiflexion

Imaging

Osteophytes of the distal tibia and the talar neck, especially on oblique radiographs
MRI: ‘meniscoid’ mass within the lateral gutter of the ankle when joint fluid is present
Table 3. Anteromedial impingement syndrome.68., 91.
InjuryInversion injury, fracture of the ankle or the talus

Symptoms and signs

Anteromedial ankle pain, anteromedial tenderness, swelling pain at dorsiflexion and supination, restriction of the same movements

Imaging

Plain radiography: anteromedial talus osteophytes
MR arthrography: abnormal appearance of the anteromedial capsule and irregular synovial folding anterior to the tibiotalar ligament and the medial malleolus, tibial osteophytes
Table 4. Posterior impingement syndrome.63., 71., 92.
InjuryCommon in ballet dancers, full weight-bearing in maximal plantarflexion, especially when os trigonum is present

Symptoms and signs

Tenderness behind the lateral malleolus, pain at passive plantarflexion

Imaging

X-ray film: may detect os trigonum or trigonal process
MRI: may show hypertrophy or tear of the posteroinferior tibiofibular ligament (PITF), transverse posterior tibiofibular ligament, or the so-called tibial slip running between the PITF ligament and the transverse ligament

4.2. Treatment of impingement syndromes 

Conservative treatment consists of rest, proper footwear, bandages and aids to support the ankle, non-steroidal anti-inflammatory drugs (NSAIDs), physiotherapy intra-articular steroid injections to reduce synovial inflammation, but only two or three times in a 10–14 days interval. When conservative treatment fails, arthroscopy with debridement and removal of the hypertrophic synovial tissue and the osteophytes provides good results.87., 88., 91., 92.

4.3. Lateral pre-malleolar bursitis 

This adventitious bursa develops in people sitting with their feet plantarflected and inverted for prolonged time, as Muslims sit during prayer. The mass should be differentiated from the pre-malleolar fat pad, or ganglion. Transillumination of the bursa, or US examination, may help in differential diagnosis. Anti-inflammatory drugs and physiotherapy should be tried, with avoidance of sitting on the foot. If a conservative treatment fails, surgical excision of the bursa is the best solution. Intrabursal steroid injections should be avoided.93

4.4. Tarsal tunnel and the anterior tarsal tunnel syndrome 

These well known entities are not discussed here.

4.5. Posterior tibial tendon dysfunction 

This relatively common disorder has been reviewed by Pomeroy et al.94 The tendon suspenses the medial arch of the foot. Dysfunction presents usually in middle aged obese women. It is common in RA and also occurs in SpA.95 Dysfunction and rupture of the tendon results in acquired unilateral flatfoot, valgus hindfoot, forefoot abduction and talonavicular subluxation. Inspecting the foot from behind, more of the lesser toes are visible lateral to the ankle joints than on the uninvolved side, due to pes planovalgus (‘too many toes sign’).96 Initially, pain presents medially, later also laterally. The tendon sheath is tender and swollen. At heel rise pain presents under the medial malleolus and the valgus hindfoot does not invert. A more specific and sensitive finding is difficulty in performing (or inability to perform) a single-limb heel rise. Resisted inversion of the fully plantar flexed foot is weakened. Weightbearing bilateral anteroposterior and lateral X-ray films are used for detecting subtle unilateral deformities.94 Posterior tibial tendon pathologies can be diagnosed by US. In this surgery controlled study two-tendon ruptures remained undiagnosed by MRI.97 The common view, that insufficiency of the tibialis posterior tendon causes flat foot, was recently challenged by Yeap et al98 based on their experience with tibialis posterior tendon transfer.

The treatment of the acute initial stage is tenosynovectomy and debridement of degenerative areas. In later stages the treatment is more conservative, using immobilization methods and different orthoses. Local steroid injections should be avoided. When conservative treatment fails tendon transfers and different kinds of arthrodesis can be considered to diminish pain and maintain the patient's ambulation.94

4.6. Peroneal tendinitis 

The peroneus tendons are found behind and under the lateral malleolus. Both peroneal tendons are frequently affected in RA.79 The peroneus longus tendon passes three tunnels where the tendon can be damaged:

1.at the calcanear trochlear process;

2.at the inferior peroneal retinaculum;

3.at the cuboid notch, where the tendon sharply changes its direction passing the plantar surface of the foot.

Os peroneum is present at the cuboid notch in 20% of the population. Patients with peroneus longus tendinitis have lateral hindfoot pain and cavovalgus foot deformity. Treatment should be primarily conservative, but tendon rupture needs surgical treatment.99

4.7. Sinus tarsi syndrome 

The tarsal sinus and tarsal canal is a cave located between the posterior subtalar and the talocalcaneonavicular joint from postero-medial to antero-lateral direction. In the sinus, an arterial anastomosis, three roots of the inferior extensor retinaculum, the cervical ligament, the tarsal canal ligament and fatty tissue can be found.

The syndrome consists of lateral foot pain, perceived foot instability and tenderness of the sinus tarsi. Injection of local anaesthetics relieves pain. It is most often caused by inversion injury but is also caused by inflammatory joint diseases.72., 73., 100. MR imaging is suitable for diagnosing the syndrome, showing obliteration of fat in the sinus tarsi space.65 Osteoarthritis of the subtalar joint can be a consequence. Treatment of sinus tarsi syndrome consists of locally given steroid injections. In chronic cases surgical treatment includes synovectomy and reconstruction of the collateral ligament.101

4.8. Tarsal coalition 

Tarsal coalition is a complete or incomplete union of the tarsal bones. The congenital form typically becomes symptomatic in the second or third decade of life, causing pain and restricted movement. Narrowing of joint space, irregular opposing cortical surfaces and deformity of the sustentaculum tali can be best visualized by CT scans.63., 65. This can be a consequence of inflammatory joint diseases.100

4.9. Transient osteoporosis of the foot 

Transient osteoporosis of the foot is not rare. The condition can be differentiated from the RSD, by the following features:

•trauma or other diseases are never associated with the onset;

•vasomotor changes and skin alterations are lacking;

•the burning, throbbing, spontaneous pain characteristic of RSD is not experienced.102., 103.

The ankle and foot are affected equally often. Bone scans show increased uptake and are helpful in early diagnosis. The synovial fluid is non-inflammatory and bone biopsy shows osteoporosis with reparative bony regeneration. Prednisolone, lumbar sympatectomy or calcitonin treatments are ineffective.104 Isolated transient osteoporosis of the talus has also been reported.105

4.10. Osteochondral lesion of the talus (OLT) 

The term osteochondral lesion of the talus (synonyms: osteochondral defect, osteochondral fracture, osteochondritis dissecans) is used to describe separation of a fragment of articular cartilage with or without subchondral bone of the talar dome. When the fragment can be seen on X-ray films, ligamental injury is usually detectable. When X-ray films are negative and bone scintigraphy is positive MRI can be used be for diagnosing.74 A revised classification of the lesion based on MRI findings was recently developed.75 Classical avascular necrosis of the talus due mostly to trauma can be differentiated by MRI.65

Treatment strategies of osteochondral lesions have been systematically reviewed by Tol et al.106 Although these authors could not draw a definite conclusion owing to variability in treatment results, non-operative treatment was successful in only 45%, while excision, curettage and drilling was successful in 85%, excision and curettage in 78%, and excision alone in 3%. Transplantation of osteochondral drafts—the mosaic plasty—is a newly introduced method which gives very good results.107., 108. Autologous chondrocyte transplantation can also be a promising method for the future.109

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5. Heel pain 

Posterior heel pain is usually associated with pathologies of the largest tendon of the body, the Achilles tendon. According to Hippocrates ‘This tendon, if bruised or cut, causes the most acute fever, induces Q-chocking, deranges the mind and at length, brings death’.110 That was the fate of Achilles.

Although the tendon can withstand a load of 400kg, it often ruptures in athletes111; however, rupture can also occur in the elderly while carrying out unusual physical effort.

There are three locations of injury in the Achilles tendon47:

•2–6cm proximally from the insertion;

•at the enthesis: enthesopathy;

•at the muscle/tendon junction.

The site of the rupture is usually in a relatively hypovascular region of the tendon 2–6cm proximally from the insertion. At the first presentation 25% of injuries may be missed.46., 112.

Other causes include: rheumatic diseases, chronic haemodialysis, diabetes, steroid treatment, especially locally given steroid injections. Xanthomas with heterozygous familial hypercholesterolaemia113 and orally given fluoroquinolone may also induce tendinopathy. The pathomechanism of the latter is poorly understood. The incidence of this disorder is 15–20/100 000 with fluoroquinolone use. The tendinopathy is often bilateral, and pain may start even a few hours after the first dose of fluoroquinolone. MRI imaging frequently shows intratendinous foci during fluoroquinolone treatment even in the absence of any clinical signs.114 The rupture is unusually painful in fluoroquinolone-induced tendinopathy. Otherwise—especially in chronically developing ruptures—the pain is not severe or is totally absent. Different pathological changes of the Achilles tendon have been described.46., 47. In biopsy specimens Movin et al found only tendinosis without inflammation.45 In the paratenon (the Achilles tendon has no real tendon sheath) inflammation can also be found.115 US may predict the outcome of achillodynia.49 Differentiation of full- and partial-thickness tears can be made using sonography with 92% of accuracy proven by surgical findings.116 The treatment of Achilles tendon injury can be conservative: immobilizing the ankle. However, surgery is required in the case of complete rupture, providing good results but a rather high (15%) percentage of complications.117

Achilles tendinopathy, calcaneal enthesopathy and retrocalcaneal bursitis are the main and characteristic features of SpA69., 118. with known histological119 and radiological features. Heel pain is often the first manifestation of the disease.120 The inflammatory type of enthesopathies are characterized by irregularly defined erosions and/or deposition of bone with defined excrescences in the healing stage.121 Pacheco-Tena et al developed a radiographic index to assess tarsal arthritis, including enthesopathies in SpA.100

Retrocalcaneal or subcutaneous calcaneal bursitis, also known as ‘pump bumps’, is rarely a complication of inflammatory joint diseases but is usually caused by irritation of stiff heel counters. The overlying skin is usually reddish or hyperkeratotic. Treatment consists of wearing counterless shoes, padding and NSAIDs. Local steroid injections should be avoided because of the danger of infection.

The most common cause of inferior heel pain in the middle aged and the elderly is plantar fasciitis, an enthesopathy of the calcaneal tuberosity usually caused by overuse, repetitive strain or microtrauma. In young patients SpA are the most common cause of plantar fasciitis. The treatment consists of rest, night splints, use of soft, rubber heel pads, support of the longitudinal arch, NSAIDs and local steroid injection.59., 122. Surgical release of the plantar fascia is rarely required; healing problems of the overlying skin are relatively frequent. Endoscopic plantar fasciectomy is also used—probably causing a smaller number of complications.123

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6. Midfoot pain 

The middle part of the foot, located between the Chopart and Lisfranc joints is called midfoot. The joints of the midfoot have only a narrow range of movement. The construction is firm—but at the same time it is also elastic. The disorders of the midfoot often cause the flattening of the longitudinal arch. The most frequent cause of adult-onset acquired flatfoot is the dysfunction of the posterior tibialis tendon. Other causes are: inflammatory arthritis, tarsometatarsal osteoarthritis, tarsal coalition, Charcot arthropathy, traumatic disruption of ligaments and neuromuscular diseases. Diagnosis can be made using weightbearing lateral and anteroposterior X-ray films.94 The most common diseases affecting the midfoot joints are rheumatoid, psoriatic arthritis, gout and diabetic Charcot's joints.

Accessory navicular bone, present in 4–21% of the population, can also be a cause of medial midfoot pain. Romanowski and Barrington published data on 10 patients with this syndrome.124 Type II accessory navicular, a larger triangle or heart-shaped ossicle attaching with cartilaginous or fibrocartilaginous synchondrosis to the navicular bone, was found to be the source of symptoms, presumably due to chronic stress reaction. Increased uptake on bone scan and inflammatory changes found in biopsy supported this hypothesis. Accessory navicular bone may also damage the posterior tibial tendon.94 Treatment consists of resting from sports activities or else surgical excision of the accessory bone. The Mueller—Weiss syndrome is osteonecrosis of the navicular bone; this occurs more frequently bilaterally in adult women.125

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7. Forefoot pain 

The forefoot is the commonest site of foot pain. The cause of forefoot pain is not easily identifiable by physical examination, although it is mostly located in the metatarsal region. Plantar plate disruption is a common cause of metatarsalgia. It occurs frequently in women wearing high-heeled shoes.126 The second MTP joint is most commonly affected. Diagnosis can be made by MRI.66

Overstrain of the MTP region often results in bursitis of the intermetatarsal bursae or adventitial bursae beneath the metatarsal heads.127., 128. Bursitis can also be caused by repetitive trauma, infection, RA, seronegative spondylarthritides or gout. MTP arthritis is also common in this condition. SpA causes typical sausage toes which are caused mainly by flexor tenosynovitis.129

The differential diagnosis from MTP arthritis and Morton's neuroma is difficult but can be important—especially when surgical treatment is considered. Ultrasound or MRI can be used for differential diagnosis.31., 66.

Morton's neuroma is located most often between the 3rd and 4th metatarsal heads. The neuroma is not a true neoplasm but is caused by peripheral fibrosis of the compressed interdigital nerve. Histology of the neuroma is undistinguishable from normal intermetatarsophalangeal nerves.130 The nerve compression can be caused by the metatarsal heads, intermetatarsal ligaments and bursae. The pain presents on the opposing sides of the two toes, accompanied with hyp- or paraesthesias. For differential diagnosis between Morton's neuroma and MTP arthritis local anaesthetics can be given either into the interspaces proximally to the metatarsal head or into the corresponding MTP joint. This ‘ex juventibus’ effect may show which pathology is the probable cause of pain.131

Ganglia are the most common soft-tissue masses of the foot, and are often located dorsally to the MTP joints and tendons. They are probably caused by repetitive trauma.132

Stress fractures of the metatarsal bones are not rare in runners or ballet dancers but they are also found in the middle aged or elderly doing sporting activities.133 Stress fracture also occurs in diabetic osteoarthropathy134 and RA.135 Radiologically occult fractures can be detected by MRI imaging.66 With MRI and/or bone scintigraphy even the pre-fracture state of stress injury can be diagnosed.136

Freiberg's infraction is probably an aseptic necrosis of the second or third metatarsal head, causing secondary osteoarthritis. High-heeled shoes, repetitive injury or trauma may be causative factors.137

Foreign body granulomas due to thorns, glass, plastic or wood particles are not rare on the plantar surface of the foot. The foreign bodies can be visualized by US or MRI.138 Plantar fibromatosis or Ledderhose disease is a benign but locally often aggressive ‘tumour’ of the fascia.139, identical to Dupuytren's contracture of the hand. At physical examination tender or not tender mass also fibrous can be palpated at the medial and proximal aspect of the plantar fascia. It can be visualized by both sonography140 and MRI141; however, physical examination is usually sufficient for a reliable diagnosis. The treatment is subtotal fasciectomy, but recurrences are not rare.139

Forefoot pain is commonly caused by pathologies of the first MTP joint, especially by hallux rigidus.142., 143. The treatment of hallux rigidus is mostly surgical. Simple bunionectomy with medial capsulorrhaphy is used less often than previously.144 The implant arthroplasty provides good results. The probability that the implant would not have been removed was found to be 82% at 15 years.145 The use of mosaic plasty has been recently reported.146 In a follow-up study the non-operatively treated hallux rigidus patients rated their pain as staying the same over a 14-year period despite significant radiological deterioration.147

Sesamoiditis is a painful inflammatory condition caused by repetitive injury to the plantar aspect of the forefoot. Reactive soft-tissue inflammation such as tendonitis, synovitis or bursitis often accompanies the condition.148 Osteoarthritis of the sesamoid bones is also common. In young and middle-aged people with sporting-activity necrosis, non-union fracture, disruption, hypoplasia, osteochondrosis of the sesamoids may appear. When 6 months of conservative treatment is not effective, sesamoidectomy should be performed; this gives good results.149

It is commonplace that the first MTP joint is the commonest place of acute gouty attack, although CPPD or hydroxiapatite arthritis may also occur in this joint. Chronic tophaceous gout is characterized by extra- and intra-articular erosions, often causing Martel's hook (overhanging margin of bone erosion); MRI may help in differential diagnosis.150 Intraosseus tophi in the metatarsal bone and other bones of the foot mimicking bone tumour have been also reported.151

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8. Rheumatoid foot 

If the hand is the ‘visiting card’ of the rheumatoid patient, the footprint is his/her real, non-idealized CV, hidden in shoes. Indeed, looking at the undressed feet of our patients much can be learned about their hygienic or biomechanical problems. The importance of a patient's education and joint protection is often emphasized. Regarding the foot, do we efficiently fulfil these tasks in our daily routine? We should not forget that RA is both a generalized and a local disease. Even when the general clinical parameters are satisfactory, the patient can be much troubled by painful subtalar or midtarsal joints. However, the general features of the disease—such as vasculitis, neurological involvement due to either cervical myelopathy or mononeuritis multiplex—can be presented on the foot, which is also a common site of silent, overlooked infections.

The prevalence of foot involvement in RA varies from 53 to 92%.81., 82., 152., 153. Foot pain is an early symptom and can be the only symptom in rheumatoid patients.81., 153. Haas et al154 followed up 70 feet of 36 rheumatoid patients; the first MTP joint was found to be affected most often (57%), the tarsometatarsal joints especially showing progressive changes. Radiological progression measured by the Larsen index and worsening of the foot biomechanics was observed in 97% of patients. These authors concluded that, in addition to effective general drug treatment, there is a need for effective local treatment.

The rheumatoid involvement of the forefoot begins with the destructive synovitis of the MTP joints. The metatarsal heads herniate through the destroyed plantar capsule and the proximal phalanges are dislocated dorsally. The digital flexor tendons are displaced and extend the MTP joints instead of flexing. The imbalance of intrinsic and extrinsic muscles leads to mallet, hammer and claw toe deformities. The subluxation and dislocation of lesser MTP joints leads to lateral instability of the hallux and drifts into valgus position. The extensor hallucis longus tendon is displaced in the first web space, acting as an adductor instead of an extensor and increasing the valgus deformity. An adventitious bursa usually develops on the medial plantar side of the first MTP joint, causing pain.155

Kirkup et al found big toe involvement in 194 feet in 200 RA patients.156 Hallux valgus was the most common deformity (59%) followed by hallux rigidus. Talonavicular arthritis often appears during the first stages of the illness, causing valgus deformity and collapsing of the longitudinal arch.157 Foot pain occurring in early stance is a sign of subtalar joint disease, while MTP arthritis causes pain in the late stance.158 Both inflammatory and local mechanical factors should be treated early to avoid progressive hindfoot deformities.159

Ankle involvement in RA varies between 8.8 and 53% 81., 152. but heel pain is uncommon.160 Plantar and posterior calcaneal spurs and erosions may develop.161 Subtalar synovitis almost regularly precedes the involvement of the talocrural joint.162

Chronic inflammation of tendon sheaths and biomechanical strains can lead to tendon ruptures. The posterior tibial tendon is the most frequently involved tendon.72., 79., 94.

Shi et al163 investigated foot deformities of RA related to disease severity. Hallux valgus, splaying of forefoot, flattening of the longitudinal arch and valgus hindfoot are the typical deformities of the rheumatoid foot. Disease severity is closely related to the progression of foot deformities in RA. Different angles measurable on weight-bearing a–p and lateral X-ray films are used for assessing severity of deformities and their progression.157., 163. Based on the investigation of Keenan et al164 it can be accepted that valgus deformity of the hindfoot results from exaggerated pronation forces on the inflamed subtalar joint. The intensity and duration of activity of the tibialis posterior muscle was significantly increased in an effort to support the collapsing longitudinal arch. In patients with valgus heel the pressure on the MTP heads is higher and is shifted medially from central.165 To prevent these events tarsal arthritis should be efficiently combated with drug treatment, local injections, physiotherapy, proper shoes, orthoses and also with surgery.

The gait of rheumatoid patients is characterized as slow and shuffling, with reduced velocity and stride length, and with the loss of the usual heel–toe pattern. The single-limb stance time is shortened, while double stance time is lengthened. Platto et al158 evaluated the relationship among pain, mobility and structural deformity of the foot. Hindfoot disease was associated with greater impairment of pain and mobility than was forefoot disease. Foot deformity did not correlate with functional ambulation at all. Foot pain, however, correlated well with velocity and especially with stride length.

Undisplaced stress fractures may be mistaken for rheumatoid synovitis. Clues to diagnosis include acute onset of pain, tenderness and swelling over bone rather than over a joint.135

8.1. Treatment 

The basis of successful management is satisfactory control of inflammation. Not only general treatment but also early local treatment—intra-articular steroid injections—may be useful; however, well-designed trials are lacking. Support or correction of hypermobile, malaligned joints with prescription footwear, shoe modifications and foot or ankle orthoses are essential. They relieve pain by transferring weight-bearing from the metatarsal heads, absorbing shock, reducing shearing forces and accommodating deformity. Inspite of this, prescription of sufficient footwear and orthoses is often neglected.82 Non-surgical management was reviewed by Shrader.166 Unfortunately only a few double-blind, controlled trials were done to assess the use of foot orthoses. Conrad et al167 showed that patients wearing functionally posted orthoses were less likely to develop hallux valgus compared to controls. They also compared the effect of rigid and placebo orthosis on foot pain and disability, but found no differences. In a controlled trial, extra-depth shoes improved pain, gait velocity and stride length in RA patients.168 In a cross-over study, semi-rigid orthoses worn in supportive shoes were effective in the treatment of metatarsalgia but did not improve function. Supportive shoes with or without soft orthoses did not provide any pain relief.169 Although the use of proper shoes and orthoses is important, an additional 15–30% improvement can be achieved by patient education.170

When conservative treatment fails, surgical interventions should be considered. Early synovectomy provides only temporary relief.171., 172. For the first MTP joint arthrodesis is the best solution; for the lesser MTP joints resection arthroplasty provides good results.155 Arthrodesis of the ankle very often fails173, and the use of ankle prosthesis turned out to be disappointing. However, subtalar and tarsal joint arthrodesis gives satisfactory results.174

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9. Diabetic foot 

Out of the 15 million diabetics in the United States, 15–20% are hospitalized during their life for a foot-related complication, primarily ulceration, infection and ischaemia.175 Diabetes often complicates rheumatic diseases as well. There should be special concern about local injections, physiotherapy and medication in the diabetic population owing to the greater risk of infections and other complications.

The coexistence of diabetes mellitus and RA is higher than expected from simple coincidence owing to shared genetic risk factors.176., 177. In type I diabetes Forgács178 found that RA is often rapidly progressive. Mutilating articular processes frequently involve large joints, attributable to diabetic neuropathy.

It is a common misconception that ‘impaired circulation’ is the primary cause of diabetic foot problems. On the contrary, neuropathy, especially sensory neuropathy is the pre-eminent source or initiating event not only in the development of Charcot's joints but also for almost all ulcerations and most infections.179 Sensory neuropathy leads to decreased perception of minor trauma, followed by ulceration, tendineal, ligamental, articular injury and bone fractures.180 Motor neuropathy usually occurs later181, resulting in crural muscle atrophy and/or intrinsic muscle wasting. That may lead to foot deformities: foot drop, equinus, hammer toes and prominent plantar metatarsal heads.182 The dysfunction of the posterior tibialis muscle leads to the well known characteristic deformities that include pes planus, overpronation and forefoot abduction, hindfoot valgus and collapse of the medial arch.183

Autonomic dysfunction, vascular fragility, ischaemia and reduced muscular activity all result in an increase of extracellular fluid, resulting in diffuse swelling and oedema characteristic of advanced diabetes.184 Oedema of different compartments of the foot increases intracompartmental pressure and may amplify the ischaemic cascade. Ischaemia, with increased susceptibility to infection185, also contributes to poor wound healing in diabetes. Autonomic neuropathy may also result in dry skin with cracking and fissuring, creating a portal of entry for bacteria.186 The loss of protective sensation combined with trauma, high plantar pressure and poor wound healing may lead to ulceration. Pedal ulcer is the most common lesion of the diabetic foot. A 3-year prospective study of 754 diabetic outpatients found an annual foot ulcer incidence of 5.6%, while the prevalence of prior foot lesions was 28%.187 Pedal ulcers are portals of entry for infection and directly overlie more than 90% of cases of pedal soft-tissue infections and osteomyelitis. Physical signs of chronic osteomyelitis include deep penetrating ulcers, purulent drainage, or sinus tracts leading to bone. Patients generally present with mild constitutional symptoms.188 The diagnosis of osteomyelitis and differential diagnosis from Charcot's joint is not easy. Bone scan positivity can raise a suspicion, and MRI provides the diagnosis as it is described in Section 3.5 the Imaging section of this chapter.

Approximately 0.1–5% of diabetics with neuropathy develop neuropathic or Charcot's joint189, usually involving the tarsal or tarsometatarsal joints. The initial diagnosis of acute Charcot arthropathy is often clinical, based on profound unilateral swelling, increased skin temperature, erythema, joint effusion and instability, and bone resorption. The medial longitudinal arch is often collapsed. Pain is usually mild, often even missing.

In differential diagnosis diabetic osteoarthropathy should be distinguished from degenerative, inflammatory, tumorous, neurogenic arthropathies of other origin—such as chronic alcoholism190, Thévenard's disease191 and other osteolytic processes.

Necrotizing fasciitis is a life-threatening complication of diabetes, with a mortality rate approaching 30–46%. Exquisite pain and early systemic toxicity are the most consistent clinical features.192., 193. Necrotizing fasciitis is best diagnosed by MRI.194 Treatment consists of extensive debridement and high-dose intravenous antibiotic treatment.

Prevention is considered to be the key element in avoiding ulceration and infection. Patient education plays a primary role and includes instructions for foot hygiene, proper footwear, and foot exercise. The patient should inspect her/his foot every day. These are not easy tasks, especially for rheumatic patients, but early treatment of newly developed lesions provides better results.187

Management of the diabetic foot is largely determined by its severity, vascular status and presence of infection.187 The most important task is to ensure satisfactory control of diabetes. Rest, elevation of the leg and relief of pressure are essential components of treatment and should be initiated at the first presentation. Ill-fitting footwear should be discarded and replaced with surgical sandals. The total-contact cast is considered the optimal method for protecting the non-ischaemic ulceration during ambulation by off-loading high-pressure areas under the foot.195 Acceptable alternatives are the MABAL shoe196 or removable walking braces. Recently, pamidronate infusions were also advised for treating Charcot's joint.197

Most diabetic foot infections are polymicrobial. Treatment should be initiated with broad-spectrum bone-seeking antibiotics. Treating the underlying ischaemia is important to achieve a successful outcome. Surgical drainage and deep debridement or local partial amputation are also necessary adjuncts to antibiotic therapy.198 Treating the underlying ischaemia is important to achieve a successful outcome.199

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10. Summary 

Foot pain is very common, especially in females, due to inappropriate footwear. Overuse, repetitive strain and minor, easily forgettable injuries may result in tendino- and enthesopathies, impingement and tunnel syndromes, stress fractures, osteochondral lesions causing biomechanical abnormalities and secondary osteoarthritis.

The site of first presentation of inflammatory joint diseases is not rarely the foot. RA affects mainly the forefoot and the midfoot. The hindfoot and the ankle are usually affected later, partly as a sequel of abnormal biomechanics. Spondyloarthropathies most often affect the heel. Neurogenic osteoarthropathies and foot infections are common complications of diabetes.

Diagnosing the source of foot pain is not always easy but is of great importance. Early appropriate treatment may prevent biomechanical sequels and secondary osteoarthritis. Proper physical examination, use of imaging methods and ‘ex juventibus’ treatment with local anaesthetics can be used to obtain a sufficient level of diagnosis.

As well as general medical treatment, local treatment of foot disorders, including orthoses, physiotherapy, local steroid injections, endoscopic and open surgery, is important not only for combating local disease but also for preventing biomechanical sequels. Box 1Box 2

Box 1. Practice points

•mechanical foot pain is common but foot pain can also be the first symptom of inflammatory joint diseases

•diagnosis of the source of foot pain and the underlying local disorders is important not only for efficient treatment but also for preventing biomechanical sequels

•as well as history taking, physical examination, plain radiography, the newer imaging methods (especially ultrasonography and MRI) and guided injections of local anaesthetics can be used to reach the sufficient level of diagnosis

•foot disease in rheumatoid patients should be treated with special care with the object of keeping them ambulatory

•foot infection and neurogenic osteoarthropathy are not rare complications in diabetes

•local injections, orthoses, physiotherapy, endoscopic and open surgery are important not only for combating local disorders but also for treating foot involvement in generalized diseases

Box 2. Research agenda

•more controlled trials are necessary with existing and validated instruments for assessing foot pain, foot and ankle function

•guidelines for using newer imaging methods for diagnosing and assessing foot disorders and evaluating their treatments should be developed

•controlled trials are clearly needed to evaluate the efficacy of drug treatment, local steroid injections and foot orthoses in foot involvement in generalized diseases and local disorders

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Acknowledgements 

The authors would like to thank Katalin Dúl and Anna Mária Kósa for their excellent technical assistance.

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PII: S1521-6942(02)00103-1

doi:10.1016/S1521-6942(02)00103-1

Best Practice & Research Clinical Rheumatology
Volume 17, Issue 1 , Pages 87-111, February 2003

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