28 Sep Foot pain and ankle sprain

Foot pain and ankle sprain, neuromas and bunions were discussed by local specialists Damian Clark (knee surgeon, NBT), Steve Hepple (foot and ankle surgeon, NBT) and Hugh Davies (GP, Bristol).

We have a lot of patients who suffer persistent ankle and foot pain following eversion or inversion ankle sprain injuries, who have normal X-rays. They often do not seem amenable to physiotherapy. Is MRI the best investigation for post-injury ankle or foot pain? At what stage would you like to see these patients if they are not improving?

Post ankle sprain and persistent foot pain symptoms are most commonly due to soft tissue impingement around the ligaments, osteochondral lesion, syndesmotic injury (high ankle sprain) or peroneal tendon problems. Other diagnoses are possible and sometimes the sprain can simply be slow to settle.

With persistent and significant foot pain symptoms beyond 3 months, it is reasonable to investigate further and MRI is usually the first line investigation (assuming normal X-rays have been previously performed).

However, dynamic ultrasound may be necessary to pick up impingement or peroneal tendon problems. If there is abnormality on any of these investigations and/or symptoms are failing to settle beyond 3 months referral is recommended.

Is there good evidence for MTPJ and toe IPJ/PIPJ fusion for severe pain in toe arthritis? These cases are now hard for GPs to get through the funding policies and I have many patients who struggle with chronic pain.

Hallux Rigidus (1st MTPJ arthritis) is a significant clinical problem with a major impact on the quality of life and ability to work. There is minimal evidence that long-term orthotic treatment is beneficial. Although, stiff-soled shoes or a rigid insert may alleviate some of the pain. It is very well treated by cheilectomy or fusion which in most cases improves the symptoms with good function thereafter.

The condition is often labelled as a ‘bunion’ referring to the lump that forms around the joint. However, this confuses the condition with hallux valgus, in which there is a deformity of the toe but usually no arthritis although a mixed pattern is possible.

The drive to reduce referral for procedures of limited clinical value has led to a decrease in the availability of surgery for both procedures. In my opinion, there is no justification for this restriction in referral patterns as both conditions can affect function and hallux rigidus can certainly be very painful.

In respect of lesser toes, frank arthritis is rare but fusion is often performed to correct deformities of the toes such as clawing or hammering. These procedures are justified when rubbing of the toes causes trouble with shower/ulceration etc.

Is there any benefit in injecting metatarsalgia and Morton’s neuroma, or is there better evidence for surgery for either of these two conditions?

Metatarsalgia is a symptom referring to pain under the ball of the foot. There are numerous potential causes that have to be distinguished either clinically or after an investigation. Some of the causes such as Mortons neurone or intermetatarsal bursitis are amenable to injections.

These injections are by no means foolproof and do have associated risks. Therefore I would recommend that they are performed with ultrasound guidance to ensure that the diagnosis is confirmed and the injections are appropriately sited.

Surgery is often performed if conservative measures fail. Success rates are around 80-90% but the patient is left with permanent numbness in the affected web space so is not usually first-line treatment.

Avascular necrosis of ankle bones post-surgery is probably the most severe and persistent problem I have seen in my foot and ankle patients. Is there any good post-op advice you can give patients to give them the best chances of good bone healing?

Avascular necrosis of bones in the foot and ankle is a rare condition that can occur spontaneously or after surgery. Non-union or delayed union is more common after surgery. After surgery patients should follow the post-operative instructions given to them.

Smoking is known to decrease bone healing and can increase the risk of non-union by up to 16 times. Patients should, therefore, stop smoking before undertaking major hindfoot fusion and should be encouraged not to use NSAIDs if possible as they also slow bone healing.

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