Categories
Healthcare Delivery

Common causes of pain in foot and ankle in the elderly

Our feet bear a lot of load and this could create problems with symptoms like corn, ingrowth and bunion…writes Dr Anuj Chawla

Our feet tolerate a lot of pressure whenever we stand, walk, or run. The pressure of our entire body weight is transmitted to our foot. Mobility in the joints of our feet is responsible for our ability to walk on uneven surface, shock absorption and thus enabling forward propulsion of our body. As we grow old, there are lot of factors- systemic (related to blood vessels, nerves and skin) and local (wear and tear of joints, stiffness, deformities and weak bones) that can contribute to pain in the foot. Foot pain in elderly can cause walking difficulty and further impair balance. This could lead to loss of independence which would be detrimental to their overall well-being.

The most common triggers of pain in foot and ankle region in elderly are:

Trigger #1: Corns/callus

The skin on the heel and ball of the toes is thicker to withstand pressure which these areas encounter during weight bearing. With ageing, the pressure remains constant but the ability of the skin and fat to withstand stress diminishes, thus predisposing to calluses. Callus is an area of thickened skin in the sole of feet in response to increased pressure. It may be simply due to loss of fat with age, due to underlying unnoticed deformities in the foot or may be a prequel of something sinister like an ulcer in a diabetic patient.

Corns are painful areas of thickened skin that might occur due to ill-fitting shoes. As people grow old, the shape of the foot may change and resultant misfit shoes may predispose to corns. They are most commonly seen in outer aspect of little toe, top of small toes as well as in space between the toes.

Treatment:

Wearing a well-fitting comfortable footwear is the first thing to do when you notice corn or callus. Medicated corn caps may be tried but with caution as it can dissolve the normal skin as well thus worsening the situation. Corn caps and salicylic acid creams are contraindicated (not to be used) in diabetics and with poor blood flow. For diabetics, evaluation of the foot is necessary if a callus is noticed. Pairing of calluses can be done for painful corn and excessive callus by a foot and ankle specialist but an underlying bony problem needs to be identified as well.

Trigger #2: Ingrown toe nail

Cutting of toes nails require flexibility in joints of the body, manual dexterity and a good vision. Unfortunately, all of these are affected with age thus limiting the ability to cut the toe nails. The nails also become dull and brittle with age thus making them more prone to nail disorders. All these factors topped up with inability to maintain a good toe nail hygiene predisposes elderly people to develop toe nail disorders. Ingrown toe nails happen when the side of the nail grows under the skin next to the nail. It mainly affects the big toe but can involve any other toe. Inflammation secondary to nail growing under the skin may cause pain, swelling, redness or pus discharge under the nail.

Treatment:

Soaking feet in warm water, cutting toe nails straight, pushing the skin away with a cotton ball and using over the counter medicine or creams can be used in the beginning for those who develop ingrown toe nails. An infected ingrown toe nail needs oral or topical antibiotics but in few cases may need surgery to decompress the infection. In cases where the condition does not settle down despite the above mentioned procedures, a small surgical procedure to remove full/ part of toe nail may be needed.

Trigger #3: Bunion

A deformity where big toe deviates towards the second toe is called bunion. In elderly population, development of arthritis and other mechanical factors can predispose one to develop bunions. Also, wearing narrow toed shoes in adulthood predisposes one to have bunion and lesser toe deformities in elderly. Bunion may lead to pain not just in the big toe but can also cause secondary pain under second or even third toe.

Treatment:

Once a bunion develops in elderly, the only way to remove it is by surgery. However, measures like using a proper footwear and doing some exercises can help in alleviating the pain arising from bunion. Also, bunion pads, inserts and arch supports can be used for symptomatic relief. In severe cases, surgery is needed to align the toe to its normal position by releasing the soft tissues and even cutting the bone. These surgeries are normally performed as day surgery by foot and ankle specialists and patient can immediately walk post-surgery with a special shoe.

Trigger #4: Flat feet

As the ligaments and muscle responsible for maintaining the arch stretch out with time, in old age the arch of the foot reduces its height. This condition is named Adult Acquired Flat Foot (AAFD). Due to this problem, people may experience pain in inner aspect of ankle and in severe cases on outer aspect, which is worse with physical activities. They may also notice swelling in the inner ankle or arch region. People also notice a change in the shape of the foot. A consequence of this deformity is alteration of not just the foot but the whole lower limb biomechanics and thus can result in overpronation, ankle/foot sprain, hip/knee/lower back pain, limb length discrepancy and loss of stability. 

Treatment:

Evaluation and treatment of flatfoot requires a comprehensive knowledge of this deformity and resultant altered biomechanics as well as critical clinical judgement. Mainstay of treatment in earlier cases may be insoles including medial arch support and heel wedges as well as physiotherapy to strengthen and stretch the muscles of your feet. Surgery is reserved for those cases which are way too advanced or have failed a trial of non-operative management and can vary from heel shift procedures and tendon transfer to fusing the joint in severe cases.

Please refer to my detailed article on flat feet for more info on this ailment and treatment protocols: https://bit.ly/3b9idoe

Trigger #5: Arthritis/Osteoarthritis

The progressive wear and tear of the joints due to a multitude of reasons trigger arthritis. The loss of protective cartilage in the joint as we grow old leads to osteoarthritis. It may cause episodes of inflammation which manifests as pain, swelling and stiffness around the joints.

In India more than 180 million people in India suffer from arthritis and its prevalence is much higher than many well-known diseases such as diabetes, AIDS and cancer. According to arthritis foundation, close to half of the people in their 60s and 70s may be suffering from arthritis affecting their feet. It can reduce the walking speed and can lead to impaired balance thus leading to difficulty in performing daily activities in the geriatric population.

Treatment:

While we should understand that there is no research-proven treatment as yet that can reverse/ stop the progression of arthritis, there are still a lot of options that can reduce the symptoms. Wearing comfortable shoes, exercises, weight reduction, gentle massage of the foot and over the counter pain killers and creams may help us combat the symptoms associated with arthritis. In more advanced cases, surgery may be needed which may include cleaning of the joint (debridement), fusion (arthrodesis) or replacement (arthroplasty).  

About the Author

Any pain in the foot or ankle should be evaluated by a foot and ankle specialist to accurately diagnose the condition. Dr. Anuj Chawla is one of the leading Orthopedics and foot & ankle surgeon in India. He can be contacted at dranujchawla@gmail.com. For consultation with Dr. Anuj, book an appointment by visiting the website: http://dranujchawla.com/.

Dr. Anuj’s social channels:
Twitter: @dranujorthoFacebook: https://www.facebook.com/doctoranujchawla/

Leave a Reply

This site uses Akismet to reduce spam. Learn how your comment data is processed.