Foot and ankle
The foot preserves crucial functions for the body since it bears total body weight and acts as a stable lever to propel the body forward. The foot begins at the lower end of the tibia and fibula which are two bones of the lower leg. The foot is an extremely complex anatomic structure made up of 26 bones and joints that work coordinately with several muscles and a number of ligaments. The medial malleolus is the prominence on the inner side of the ankle while the lateral malleolus is the prominence on the outer side of the ankle. At the base, a grouping of bones form the tarsals make up the ankle and upper portion of the foot. Bones, ligaments, joints and muscles around the foot and ankle are responsible for various important functions, including movements e.g. stretching and tiptoeing, supporting body weight, walking, standing and providing balance.
Foot and ankle problems
Based on the causes, foot and ankle problems can be divided into 2 main types, including:
- Traumatic injuries: Foot and ankle injuries often include sprain, strain and fracture.
- Foot and ankle deformities: Foot deformities are a group of both congenital and acquired conditions involving structural abnormalities or muscular imbalances that impair the function of the foot. The deformities are further classified according to clinical appearances. Since the foot transfers ground reaction forces, foot deformities can significantly lead to serious impairment of other parts, such as knee, hip and spine at the back. Foot deformities can result in limited weight bearing that eventually induces walking abnormalities. If left untreated, it can potentially cause other serious movement-related conditions which interfere with overall health and quality of life.
Common foot and ankle deformities
Abnormalities can be found in any part of the foot that can be subdivided into 3 parts:
- Forefoot: The forefoot is the most anterior aspect of the foot and toes.
- Midfoot: The midfoot is made up of five of the seven tarsal bones. The junction between the hindfoot and midfoot is termed the Chopart joint.
- Hindfoot: The hindfoot is the most posterior aspect of the foot.
Foot deformities can lead to a wide variety of signs and symptoms, extending from pain to walking instability. Foot deformities that are frequently diagnosed are:
- Hallux valgus or bunion – a deformity of the joint connecting the big toe to the foot. The big toe bends towards the other toes and the joint becomes red and painful.
- Toe deformity – a misalignment of the toe bones e.g. hammertoe, claw toe and mallet toe.
- Flat foot or fallen arch – a postural deformity in which the arch of the foot collapses, with the entire sole coming into complete or near-complete contact with the ground.
- High arched foot or cavus foot – an abnormally high arch in the foot, leading to an excessive amount of weight placed on the ball and heel of the foot when walking or standing.
- Ankle deformities caused by abnormal foot arch or ankle itself.
Causes of foot and ankle deformities
Foot and ankle deformities can be derived from different causes which can be either acquired or congenital. These causes often include:
- Genetic abnormality: Some forms of foot and ankle deformities are likely inherited.
- Joint wear and tear due to aging or overuse.
- Wearing ill-fitting footwear: Unhealthy footwear that potentially indices acquired foot deformities include high heels, tight shoes, too wide shoes and shoes with poor weight bearing design.
- Previous foot and ankle injuries: If former injuries of bones and/or ligaments in the foot had been treated inappropriately, these substantially lead to nonunion (unhealed fracture), malunions (bones improperly aligned when immobilized), joint misalignment, articular cartilage damage and eventually foot deformity and foot instability.
- Charcot arthropathy or charcot foot: Progressive degeneration of a weight bearing joint caused by complications of diabetics and impaired peripheral nervous system (peripheral neuropathy). Its destructive effects on the foot and ankle begin with a cycle of uncontrolled inflammation while foot deformity is a late stage of the syndrome.
At Orthopedic Center, Bangkok International Hospital, foot and ankle care provided by well-trained and highly experienced orthopedic surgeons specialized in foot and ankle aims at treating all foot and ankle conditions by using the latest technology adhered to international standard of care while taking patient’s need and quality of life into consideration.
Foot and ankle injuries
Foot and ankle injuries can be caused by either direct contact or indirect contact. An acute injury may occur from a vertical force, direct impact, fall, twisting, jerking or bending foot or ankle abnormally. As a result, it can potentially lead to foot fractures, particularly in patients with osteoporosis or the elderly. However, the severity of injuries is dependent on the mechanism of injury and the strength of individual’s bone. In addition to physical examination and presenting symptoms, imaging tests e.g. X-ray and computerized tomography (CT scan) are crucial in some cases to make an accurate diagnosis, leading to an appropriate treatment plan.
Treatment of foot injuries
Two main treatment options for foot injuries include conservative treatment (non-surgical treatment) and surgical treatment.
- Conservative treatment: Conservative treatment or non-surgical treatment is often primarily considered in patients with mild to moderate injuries in which affected bones, ligaments or muscles do not significantly impair their movement, weight bearing and the use of their feet. Conservative approaches intent to reduce pain and improve mobility without surgery. Several conservative approaches focus on helping patients manage pain and relevant symptoms as well as addressing their underlying conditions, deformities and instability without undergoing invasive surgeries. Non-operative approaches consist of pain management and injection, physical therapy and shoe modifications. In addition, braces and splints are often used temporarily to immobilize and protect joints, reduce pain and decrease swelling, leading to enhanced bone healing which normally takes 6-8 weeks.
- Surgical treatment: In case that patients experience some forms of fracture that are not be able to treat with conservative approaches, surgery might potentially be considered. To surgically repair severe fractured bones in the foot, especially medial malleolus and lateral malleolus, open reduction and internal fixation is a surgery that is often performed to fix severely broken bones with hardware e.g. plates, rods or/and screws. Other surgical procedures such as tension band wiring as an internal fixation method might be used in some patients to convert distraction forces into compression forces, resulting in promoting bone healing and absolute stability in the affected area. Besides surgical treatments, postoperative rehabilitation program greatly accelerates recovery process, leading to shortened hospital stay and a quick return to daily life and activity. To treat complex fractures, the ARTIS pheno is a cutting-edge robotic imaging system that enhances both efficacy and safety of minimally invasive orthopedic surgeries. It is a 3D fluoroscope that provides high resolution 3D (CT like imaging) intra-operative images, enabling instant decision making and facilitating control for better outcomes. 3D or CT like images give more detail of bony fracture, evaluate quality of reduction and verify implant position, thus minimizing the chances of postoperative complications.
Nevertheless, foot and ankle surgeries might widely vary among individual patients, depending on the location of injury, damage degree and severity, bone strength and associated injuries. The most effective surgical approach for each patient is thoroughly considered by orthopedic surgeons specialized in trauma care. Individual factors e.g. underlying diseases, previous use of affected area before injuries and operative risks are taken into consideration prior to the determination of the most appropriate surgical technique.
Apart from fractures, there are a number of ligaments found in the foot and ankle. Ankle sprains are common injuries that occur in people of all ages, both non-athletic and athletic groups. Ligaments in the foot and ankle help stabilizing joints and preventing excessive movement. A sprained ankle develops when these ligaments are forced beyond their normal range of motion. It typically occurs when rolling, twisting or turning the ankle in inappropriate ways. As a result, it can stretch or tear ligaments, leading to pain, swelling, bleeding and bruising as well as restricted range of motion and instability in the ankle. Pain caused by a sprained ankle aggravates when moving or bearing weight on the affected foot. However, signs and symptoms of a sprained ankle might vary, depending on the severity of the injury.
Severity of ligament injuries
Ligament sprains can be of the following grades:
- Grade 1: mild pain with stretched ligaments which does not affect foot stability
- Grade 2: moderate pain with partial tearing of the ligaments that might slightly disrupt foot stability
- Grade 3: severe pain with complete rupture or tear of the ligaments that significantly impairs foot stability
Treatment of injured ligaments
Immediately after an ankle injury, a simple treatment protocol known as RICE (Rest, Ice Compression and Elevation) can relieve pain, reduce swelling and promote healing and flexibility. Additionally, it is highly recommended to refrain from aggravating factors – HARM (Heat, Alcohol, Running and Massage) especially in the first 48-72 hours after injuries. During resting, pain medications can be taken as prescribed while using braces or splints to restrict motion for additional support.
In case of severe ligament injuries that do not completely heal after applying conservative approaches or significantly disrupt foot stability and daily use, orthopedic surgeons potentially perform surgical approaches to repair damaged ligament and reconstruct it with tissue from a nearby ligament or tendon, if needed. Due to advanced surgical technology, foot and ankle surgery can be conducted by using a minimally invasive technique, called arthroscopic surgery in which a small fiber optic camera (an arthroscope) is inserted through a small incision and used to visualize inside a joint, enabling the orthopedic surgeons to repair the damaged ligaments.
Minimally Invasive Foot and Ankle Surgery at Bangkok International Hospital
At Bangkok International Hospital, minimally invasive foot and ankle surgeries are performed by highly experienced orthopedic surgeons certified in foot and ankle care. Foot and ankle arthroscopy is a minimally invasive procedure that enables the orthopedic surgeons to clearly view and subsequently repair or correct damaged parts by using surgical tools sized ranging from 1.9 to 2.7 mm. through small incisions, sized 4-7 mm. With 4K Ultra-HD technology and advancements in surgical technology, the arthroscopic surgery is able to treat a wide range of foot and ankle conditions, including anterior and posterior ankle impingement, bone spurs, loose bone fragment, intraarticular soft tissue scars, osteochondral lesion, ankle ligament and tendon repair and reconstruction. Compared to conventional surgery which larger incisions are required, arthroscopic surgery with smaller incisions results in less pain and minimized postoperative complications, leading to faster recovery time and shorter hospital stay.
Given the complexity of the foot and ankle, which consists of tendons, ligaments, muscles, bones and distinct joints, treating conditions and injuries affecting these structures requires a comprehensive care from foot and ankle specialists, covering orthopedic surgeon and physiotherapist as well as orthotist or prosthetist and rehabilitation specialist which is particularly required in athletic care program. Customized rehabilitation care emphasizes upon performance enhancing program, gaiting, balancing and muscle training for physical improvement. Besides treatment and rehabilitation, custom-made shoes might be also essential for some patients to achieve the best possible treatment outcome.
Senior Director of Orthopedic Center, Bangkok International Hospital
Orthopedic Surgeon (Foot and Ankle), Orthopedic Center, Bangkok International Hospital
Orthopedic Surgeon (Trauma), Orthopedic Center, Bangkok International Hospital