Pain in the foot can come from different sources, tendons, ligaments, muscles, nerves, and bones, as well as joints. In this blog, we will be talking about joint pain.
Use this blog as a guideline, but a qualified healthcare provider may be needed to help you make a diagnosis. This information is not intended to provide you with a diagnosis. It is intended to make you more informed, and knowledgeable so that you can seek resolution of your condition from the right approach.
A joint is where two bones come together and move in relation to each other. The two bones are covered with articular cartilage. This is a smooth glistening surface that allows pain-free movement of the bones. We are born with hyaline cartilage; this is the glistening surface that allows a joint to move without pain. As we age or because of various causes that we will discuss, the cartilage can get pitted, worn down, or disappear entirely from the joint. When this happens, movement is no longer pain-free. The broad term for this is arthritis. Depending on the degree of the damage, movement can be a nuisance with minor pain with no activity restrictions or all the way to severe, with complete loss of function and stiffening of the joint.
Over Diagnosis of Arthritis
Arthritis is an over utilized diagnosis when the cause of a problem is not well understood. If you have been told you have arthritis, be skeptical of this diagnosis and note that this diagnosis cannot be made without taking X – rays.
Osteoarthritis (OA) is the most common form of arthritis. Commonly occurring from wear and tear in our bodies. 80% of people over age 65 will have OA somewhere in their body. The most common location for this is in the knee but is frequently seen in the feet as well.
What causes this condition?
The biology of a joint is very complex. You have chondrocytes that are the cells that produce the extracellular matrix which is the glistening surface for bones to glide on. Without living and healthy chondrocytes, the joint will eventually fail to work.
Osteoarthritis involves not only the cartilage, but affects the underlying bone, with bone cysts developing and the joint capsule becomes very swollen and painful. It may be that as the cartilage degrades, the particles of cartilage get into the joint capsule and cause the inflammation of the joint to occur. Once this process starts, it can progress quickly, as the inflammation of the joint can cause additional cartilage damage and secretion of cartilage degrading proteins.
The causes of OA remain unknown, but research has made substantial progress in identifying many factors or areas that can contribute to developing OA. Some of these can be controlled and others, really cannot be controlled.
- As you get older, the chondrocytes are not as active and the joint starts to wear from years of use. The mitochondria of the joint also appear to be less active.
- Obesity is defined as a BMI of over 30. Fat tissue produces its own substances that can lead to cartilage damage and inflammation of a joint. So, this is a risk factor independent of the stresses applied to a joint.
- Nutrition can affect the condition. Some foods can provide the precursors for building articular cartilage.
- Joint instability from a previous sprain or ligament injury, can lead to high forces in certain areas of the joint. This is common in the ankle after a number of ankle sprains.
- Joint misalignment, such as a foot that is rolling too much to the inside. This will put a lot of excessive force on the inside of the forefoot and can cause arthritis in the big toe joint.
- Muscle weakness and inactivity can cause the cartilage to become very soft and wear down quickly.
- Gender, females are more predisposed to arthritis than males and generally have a smaller bone structure and less area to distribute forces.
- Occupational activity, if you are standing all day on your feet, this may be a cause of arthritis in the foot. Kneeling on hard floors, and lifting heavy loads are hard on the joints as well.
- Athletic activity, long distance running, football and ice hockey players have a higher incidence of knee OA.
- Ethnicity, African Americans have a higher level of knee OA. In contrast, Asians have less OA in their hips.
- Genetics, do you have a blood relative with OA or history of joint replacement? You are more likely to have the same problems.
What can you do about arthritis?
Nonsteroidal anti-inflammatory drugs (NSAIDS) have been a mainstay of treatment of osteoarthritis in the past. These drugs are no longer considered the primary treatment for this condition because of the risk of side effects. These drugs can be taken over the short term for pain control, but there is still a risk of complications. If they are to be taken for any extended period they should be monitored closely by your physician.
Ibuprofen is one of the first and most common anti-inflammatory drugs. This is available over the counter as Advil. Naproxen is an over-the-counter anti-inflammatory drug in the form of Nuprin. These drugs can be taken at the recommended dosage for short periods of time only, unless monitored by your doctor. It is not recommended to take these if you have stomach problems or kidney disease.
Oral Cortisone can be taken for relief of the inflammatory component of arthritis. This does provide significant pain relief when your pain is extremely bad. This medication needs to be taken according to the prescription given to you by your doctor and followed closely. These drugs, taken over a long period of time can have severe complications on many other areas of the body. If they are to be taken over a long period of time your physician will need to closely monitor, you for side effects and consider alternative therapies if you develop complications or require long term medication.
Injections of Cortisone can be administered by your physician, directly into the joints involved. These do provide symptomatic relief of the inflammation associated with the arthritis. Inflammation is one of the main three events that occur with arthritis. These injections will not have a beneficial effect on the cartilage, or the bone issues associated with arthritis. Repeated injections will have decreasing benefits, usually. Cortisone can damage the articular cartilage if it is given regularly and can actually aggravate the arthritis.
Nutritional supplements such as chondroitin and glucosamine have beneficial effects at lowering the pain associated with arthritis. They do not eliminate the pain, but they will lower it. Since these drugs are inexpensive and have very few side effects and are available as an over-the-counter vitamin type of food, it is worth a try to see if this will provide any help for you if you have arthritis.
Hyaluronic acid can be beneficial if injected directly into the joint. This is commonly known as a rooster comb injection and is FDA approved for injection in the knee. It can have beneficial effects in the foot and (can be given without FDA approval) in joints of the foot. Several injections are often needed to provide relief of pain in the foot.
Platelet Rich Plasma (PRP) can be given as an injection into the joint. This is a product obtained by spinning about 15 mL of your blood in a centrifuge and concentrating the platelets in your blood. The PRP contains factors of proteins that decrease the inflammation of the joint. This injection does not actually build up the thickness of the cartilage but can provide some relief of pain. This is not a covered service by insurance companies as they consider this experimental. There is quite an amount of literature on this therapy. There is no consensus on how many injections is optimal or the timing or concentration of the injections. Ask your physician to see if you are a candidate for this therapy or for more information.
Mesenchymal stem cells can be injected into a joint and provide significant reversal of the arthritic process in early studies. There are not large studies looking at these therapies. The stem cells are either obtained from your bone marrow or from your fat. It does not seem to matter where they come from, but they do have a significant benefit in generating cartilage tissue in the joint. These injections can be quite expensive, and it is hard to find a qualified provider willing to do this.
In the future, therapies such as monoclonal antibodies, human fibroblast growth factor, and gene therapy are all being researched and may provide reversal of the process of osteoarthritis. Until this science is perfected, artificial joints are commonplace in the hip, and knee They are very helpful, when the arthritis gets very painful. Ankle implants are also becoming much better and more commonplace, and a good alternative for some people. These continue to be popular when arthritis continues to deteriorate.
What about the foot?
There are implants available for the big toe joint, but I do not currently recommend them. These simply do not allow the movement needed for normal motion of the big toe and are unable to replicate the normal mechanics of the toe.
Fusion, therefore, is often the procedure done when arthritis becomes painful in the big toe. If a surgeon can operate on a joint such as the big toe before it gets bad, it is possible to restore motion of the joint by removing the spurs around the joint that restrict mobility of the toe and possibly doing cartilage restoration procedures. These are all dependent on timing. This is one instance where I believe earlier surgical intervention is beneficial, rather than waiting until things are bad, and a fusion may need to be done. Maintaining motion of the big toe joint is desirable, if possible, as this affects the movement of many other joints in the feet, knees, hips, and lower back.
There are thirty-three joints that can be affected by arthritis in the foot. Most of these are gliding joints and we normally fuse or stiffen these when arthritis becomes too bad. There are no artificial joints currently available for arthritis in these joints. Fusion eliminates the pain of bone on bone grinding but will not allow any motion to occur from the joint. Sometimes this is a limitation to some degree and other times it’s barely noticeable. It is a procedure that is often performed by a Foot and Ankle surgeon and is usually successful at stopping the pain. It does require a significant amount of time off your foot for recovery and a risk of complications; the most common being that the bones do not fuse or connect. Many people are led to believe that there is nothing that can be done about arthritis. A fusion is a viable procedure for you, if you’re having significant pain and have tried some other treatments without success.
I believe that much of the arthritis we see in the big toe joint and in the midfoot can be prevented by allowing the foot to move normally. Since other therapies for arthritis in the foot are so invasive, it is smart, I believe, to try to prevent arthritis when possible. After years of research and in private practice, I wanted to help my patients find an affordable option to help with foot pain. Motion in the forefoot early on, before the onset of arthritis, is critical in taking good care of your feet. Our Cluffy Lux Step insole is designed to promote proper motion of the foot. Treat your feet right and they will probably treat you well and keep you as active as possible for your whole life.
About the Author
James Clough, DPM, is a podiatric surgeon and has been in practice for over 35 years. Dr. Clough’s philosophy of practice is to employ the best technology and the latest procedures to achieve optimal outcomes for his patients. He prefers a conservative approach to most foot problems initially, is able to treat complex foot deformities surgically, and has a special interest in foot biomechanics and sports injuries.
Dr. Clough received his medical degree in podiatry from the California College of Podiatric Medicine in San Francisco, followed by a surgical residency at Metropolitan Hospital – Parkview Division in Philadelphia, Pennsylvania. Dr. Clough is a Board-Certified diplomate with the American Board of Foot & Ankle Surgery and a Board-Certified fellow with the American College of Foot & Ankle Surgeons.
His diabetic limb salvage techniques can help diabetic patients preserve their foot function and avoid amputation. Using biologic grafts, Dr. Clough can help heal wounds more quickly, reduce infection rates, and reduce protein loss (which can impact blood sugar levels).