Indeed, the debilitating effects of chronic pain can have a profound psychosocial impact, decreasing the quality of life for seniors. Our aim is to raise awareness of the issues and to provide an overview of the most common conditions that cause pain, disability, and loss of function. In addition to osteoarthritis and gout, systemic diseases such as diabetes and peripheral neuropathy are significant contributors to foot and ankle pain. These topics are not covered in depth in this review but are important to mention in the context that there are often multiple factors that increase the complexity of diagnosis and management of these conditions. Our primary focus is on musculoskeletal pain and its management. In this first part of the review, we will consider the lower limb as a whole before focusing on the foot and ankle because even though the foot is frequently the source of pain and disability, symptoms often have upstream causes. With the demographic shift towards an older population, it is important to address these issues now and in the future. Understanding the causes and effects of foot and ankle pain is the first step in finding ways to maintain mobility and function in seniors.
Causes of foot and ankle pain in seniors
While foot pain is one of the most frequent types of pain reported by older adults, there have been very few studies of the prevalence and its impact. To clearly understand the scope of the problem and to advocate for the foot health of older adults, more research is needed. This will help to ensure that the disabling effects of foot problems receive the proper attention in the future. High priority should be placed on studies of the underlying bio-mechanical issues, effective treatment and prevention, and the causes of various foot problems in older adults. This study of podiatry and lower extremity health in the aging population will lead to improved mobility, independence, and quality of life for older adults.
There are a number of beliefs regarding why aging causes foot problems. They include: increased weight, changes in gait, years of poorly fitting shoes, decreased fat pads on the bottom of the heel, and medical conditions such as diabetes and arthritis. It is estimated that about 70% of people aged 65 years and older will suffer from foot pain. The most common are: osteoarthritis, general foot pain, pain in the ball of the foot, joint pain, and bunions. Women are more likely to experience foot pain than men. An individual’s ability to walk long distances or stand for extended periods of time is often limited by pain from these conditions. In addition, studies have shown that foot problems are widespread and growing, yet given very limited medical and public health attention. The effects of foot problems often limit a person’s ability to function in the community. This can lead to an older adult becoming isolated, sedentary, and depressed, thus increasing his or her risk of developing other health problems.
Impact of aging on foot and ankle health
Finally, the prevalence of diabetes in seniors is increasing and with it, the potential for foot problems. Nerve damage from diabetes (neuropathy) can cause a loss of sensation in the feet. When this occurs, anything that causes pressure on the feet or irritation to the skin may go unnoticed and eventually turn into a foot ulcer. Diabetes also causes changes in blood flow to the feet. These changes make it more difficult for injuries to heal and can also cause a delay in healing from any type of foot surgery.
Osteoarthritis affects the feet in many people beginning at the age of 60. The joint changes are the result of a lifetime of bearing weight on the feet. As the cartilage on the bottom of the foot wears down and the spaces between the bones decrease, there is an increase in pain and deformity in the foot. Osteoarthritis can also cause a rigid hammertoe if it affects the cartilage in the toe joints. In even more severe cases of arthritis where pain is chronic and debilitating, fusion of the joints may be considered.
If you’re 65 or older, it’s likely that your feet have been exposed to more than 75,000 pounds of pressure – just from daily walking. Years of use can take their toll on your feet. The fat pads on the bottoms of the feet become thinner, and the foot becomes wider. There is an increased risk of pain on the bottom of the feet as well as a higher incidence of stress fractures due to a decrease in bone density. The feet will spread and lose the arch, and there is often pain in the ankles due to the changes in gait.
Common Symptoms of Foot and Ankle Pain in Seniors
Inflammation is a normal response of the body to injury and is a complex process that brings in cells and chemicals from the immune system to fight off foreign invaders and promote healing. Plasma and proteins leak out of blood vessels, and fluid accumulates in the surrounding tissues, which results in swelling. An inflammatory response can become harmful if it is not effectively controlled by the body and can contribute to damage inside the body. Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen or naproxen are often used to treat acute inflammation, and corticosteroid injections are utilized for more severe, local inflammation caused by conditions such as arthritis or tendonitis.
Swelling and inflammation in feet and ankles commonly affect the elderly, as it can be associated with systemic medical conditions such as heart disease, arthritis, or kidney or liver failure. If the swelling does not improve quickly, is severe, or is not associated with an injury, contact a doctor for an evaluation.
Swelling and inflammation
Inflammation can cause the joint to lose its shape and function, and in severe cases, it can result in deformity. Because of the damaging effects of inflammation, it is very important to control it with rest, ice, and anti-inflammatory medication. It is also important to identify and avoid activities that cause increased pain and swelling in affected joints.
In the case of infection, acute inflammation has a protective purpose by localizing the infection in one area. But some forms of inflammation can cause more harm than good, and this is often the case in the foot and ankle. Arthritic inflammation is one of these harmful forms. It is associated with redness, heat, swelling, and pain. It is due to the synovium membrane thinning and breaking, allowing the inflammatory cells to invade and destroy the joint.
Swelling and inflammation are the body’s instantaneous reaction to an injury or stress. Inflammatory cells rapidly move into the tissue. This is often associated with increased fluid in the area and swelling, which can be very painful. Much of the pain associated with swelling is due to the pressure it exerts on surrounding tissues.
Difficulty walking or standing
Many seniors express that they have difficulty walking or standing. This can be due to a number of biomechanical reasons resulting from the structures in the foot being less competent at shock absorption. Studies have shown that a main contributor to balance-related problems in the elderly lies in the plantar intrinsic muscles of the feet. These small muscles are key to controlling stability at the ankle joint, a major player in balance and proprioception. If these muscles aren’t as strong as they should be or if they are impaired in some way, it can lead to a decline in balance function. Static balance (ability to maintain an upright posture) and dynamic balance (ability to maintain postural stability while performing daily activities) have both been shown to decline with age. This can result in an increased rate of falling in a population of elderly people. In fact, falls in elderly people have been shown to result in a 10% increase in emergency room visits for foot and ankle injuries. Difficulty walking can be encapsulated into one gait change. It is known that gait in elderly people is considerably different from gait in younger people and changes even more in the presence of foot pain or deformity. Alternative gait patterns are often an attempt to offload painful areas and maintain some degree of mobility. This may give short-term benefit but can cause further issues in both the foot and other areas of the body. An example being that an altered gait pattern has been shown to increase the rate of knee pain in people with symptomatic foot osteoarthritis.
Joint stiffness and limited range of motion
The last symptom that this paper will cover is the joint stiffness and limited range of motion in the elderly. Just as arthritis itself, this can become a major disability in some seniors. Movement happens at articulations, which are the places where two bones meet. If the movement at an articulation is limited or cut off, it essentially loses its function. The joint pain associated with arthritis causes movement to be more painful. This develops into a mentally determined mindset to avoid movement. The end result is atrophy and further weakening of the muscles in the joint and the surrounding area. As muscles weaken and the joint atrophies, it becomes less capable of supporting the body and more changes occur in the joint positioning and alignment. This creates more pain and even more avoidance of movement, which starts an unfortunate downward spiral for the elderly patient. This can become crippling for seniors as they try to maintain their independence with age.
Managing Foot and Ankle Pain in Seniors
RICE Therapy (Rest, Ice, Compression, Elevation) can be used to relieve pain and prevent further injury to a foot or ankle. Icing an area that is in pain will help to reduce swelling and inflammation. Compression of an ankle or foot injury can help to reduce swelling as well and prevent further injury. Elevation helps to reduce swelling by allowing fluids to drain downhill to the body’s center. In addition, NSAID medications (non-steroidal anti-inflammatory drugs) such as ibuprofen can be used to relieve pain and inflammation in a foot or ankle. Keep in mind that while these medications can help relieve pain and reduce swelling, they do not aid in the healing process of an injury. Always consult your physician before taking any medication.
The main goal when managing foot and ankle pain in seniors is to maintain a high quality of life while keeping pain levels to a minimum. Early treatment of foot and ankle problems is essential in preventing their condition from worsening. One of the most important things seniors can do to keep their feet pain-free is wear the right shoes. Often times foot pain can be significantly reduced by simply wearing a shoe with proper support, and in some cases pain can be alleviated by an orthotic worn inside the shoe. When selecting a shoe, it is important to avoid slip-on shoes and slippers, as they do not hold the foot in place and can cause an increase in instability.
Non-surgical treatment options
Rest, activity modification, and over-the-counter pain medications are common interventions used for mild foot and ankle pain. However, many of the non-surgical treatment options available for seniors suffering from foot and ankle pain are often overlooked and can have a significant impact in modifying their symptoms. Custom shoe wear using inserts and orthotics can assist in providing better foot support and offloading painful areas. Inflammatory type arthritis can be calmed by the use of ice and/or heat applied to affected joints for 20 minutes up to 3 times a day, and some seniors find using a walking aid such as a cane can relieve pressure of lower extremity joints during activity. Weight loss has been proven to significantly reduce foot and ankle pain in the obese and overweight population. In a recent community-based cohort study, weight loss led to a long-term reduction in foot pain for obese women. Given no surgical or drug therapy intervention, they lost an average of 10.6 kg, with a 75% reduction in foot pain and improvement in function lasting to the 18-month follow-up. Weight loss has been proven to significantly reduce foot and ankle pain in the obese and overweight population. In a recent community-based cohort study, weight loss led to a long-term reduction in foot pain for obese women. Given no surgical or drug therapy intervention, they lost an average of 10.6 kg, with a 75% reduction in foot pain and improvement in function lasting to the 18-month follow-up.
Surgical interventions for severe cases
Some patients with foot and ankle pain may fail to achieve adequate relief with these nonsurgical treatments. In some of these cases, surgery may be necessary to provide lasting pain relief. This can usually be accomplished using a minimally invasive technique. In the more severe cases, however, this is not a possibility. The type of surgery recommended will vary with the severity of the arthritis and the patient’s lifestyle. Identification of the correct procedure for the patient is crucial to maximizing the chance of symptom improvement. The identified problem within the joint may be treatable with a simple arthroscopy. This is a useful tool for removal of any loose cartilage or to smooth off any areas of damaged cartilage. Fusion of the joint is a successful method of pain relief, though it obviously results in a loss of joint movement. Despite this, fusion will be particularly useful for patients with high physical demands or those who are unable to achieve any easing of symptoms from other methods. Joint replacement (arthroplasty) is becoming increasingly common for treatment of severe ankle arthritis. This is due to advances in the implants used and the growing body of evidence supporting the long-term benefits of this procedure. The decision to pursue joint replacement should involve discussion of the potential outcomes based on the patient’s age, demands, and life expectancy.
Physical therapy and exercises for pain relief
When patients visit doctors with complaints of foot and ankle pain, they are typically interested in learning about pain relief. Exercise and physical therapy are the cornerstones of treating and preventing problems of the lower extremity. There are a wide variety of therapeutic interventions. Systematic reviews have suggested that exercise therapy is effective at decreasing pain and disability related to persistent musculoskeletal conditions. More research is required to determine which types of exercises are most effective for particular foot and ankle diagnoses. This will allow clinicians to better tailor exercise regimens to specific patient populations. Stretching exercise is used to improve the extensibility of musculotendinous structures in an effort to increase function and decrease pain. This can be done for the Achilles tendon and plantar fascia, and specific exercises have been developed. Manual therapy and joint mobilization techniques are utilized to treat the stiffness and limited joint play commonly associated with many foot and ankle diagnoses. Published evidence exists supporting the use of joint mobilization for patients with functional ankle instability. Static and dynamic balance activities are an important component of conservative treatment for older adults and have been shown to decrease the risk of falls, which often result in foot and ankle injuries. This article will review several common foot and ankle diagnoses and outline suggested treatment regimens. Although it acknowledges the use of therapeutic modalities, the primary focus will be on exercise interventions.
Lifestyle modifications and self-care tips
A less desirable but often required option is a wheelchair for lower extremity unloading in patients with advanced disease in multiple joints. This can be a crucial step in preventing further joint damage in a patient who has been largely dependent on NSAIDs for pain control. A temporary switch to a wheelchair has the potential to decrease the need for more invasive treatment in the future. This is because NSAIDs and pain medications have not been shown to effectively slow the progression of joint degeneration.
An assistive device such as a cane, crutch, or walker may significantly decrease the load on a lower extremity joint. This occurs because the device partially unweights the contralateral lower extremity by improving its efficiency in the gait cycle. A cane is often prescribed for patients with various knee conditions, while a walker is typically reserved for patients with severe ankle or rear-foot problems. A patient with multiple lower extremity joint involvement may require a walker so that they can bear weight more evenly on both sides.
In osteoarthritis, joint damage often occurs when the load being placed on the joint is too much for the body to repair. In the foot and ankle, the body weight from just normal walking can often be quite excessive on a specific joint. This makes it extremely difficult to rest the joint because people are on their feet for much of the day. Therefore, simply offloading the weight from a damaged joint can often provide significant pain relief. This can be achieved through assistive devices or footwear modifications.
Studies have shown that patients with osteoarthritis and chronic pain have reported an increased quality of life when they have successfully incorporated self-care and lifestyle changes as part of their overall foot pain management. This is partly because many self-care regimens are aimed at preventing further damage to the joint, thus slowing the debilitating effects of arthritis.
Lifestyle modifications or self-care regimens for chronic foot pain can be one of the most important treatment modalities for a senior who has been diagnosed with degenerative joint disease in the foot and/or ankle. It is well understood that as humans age, we are more likely to suffer from increased pain and discomfort from various musculoskeletal conditions. This is partly due to the excessive wear and tear that has accumulated in the affected joints over the years.
Preventive Measures for Foot and Ankle Pain in Seniors
Obesity has fast become a major risk factor for a number of different health problems and chronic diseases in the developed world. In the specific context of lower extremity pain, recent studies have identified a very strong link between foot, knee, and ankle pain with an increase in body weight. Pain at multiple sites was also found to be more frequent in obese individuals. It has been suggested that the pain experienced is in part due to excessive loading of the lower extremity, and research has shown that a reduction in body mass can, in fact, lead to a decrease in pain. This evidence suggests that maintaining a healthy weight is a very important factor in preventing foot and ankle pain in the elderly.
Choosing appropriate footwear is crucial to preventing and reducing foot and ankle pain in the elderly. The foot undergoes structural changes as we age, often leading to the flattening of the arches and a widening and elongation of the foot. It is no surprise then that a recent study identified that over 60% of elderly individuals were wearing shoes that were too small. It is important to note that ill-fitting shoes can be a very potent source of foot pain and have been attributed to the onset of a variety of problems, including corns, calluses, and even ulcers and infections in patients with diabetes. This suggests that the majority of elderly foot pain may be a result of what is essentially a correctable problem. Properly fitting shoes should be large enough to accommodate comfortably existing deformities in the toes and forefoot and should provide stability and cushioning. High-topped shoes can often help prevent recurrent ankle sprains. It is also crucial that patients with arthritic changes within the foot or ankle seek the advice of a physician or chiropodist so that they can be fitted with orthotics to minimize further damage and enhance stability.
Choosing appropriate footwear
Never purchase shoes which are too small with the idea that they will stretch to fit. High heels should not be worn for prolonged periods – high heels can damage your feet and cause foot pain, wearing them occasionally is fine, just try not to spend too much time on your feet. Heel height should not exceed 4cm. Shoes that are slip-on or have Velcro fastenings are best for people with mobility problems or swelling of the feet, they can also have an adjustable closure.
Comfort is key – it may seem obvious but shoes should always feel comfortable and not cause any pain. Uncomfortable and painful shoes can cause joint stance and ambulation, which can result in stress on your feet, legs, hips, and lower back, with signs ranging from leg muscle fatigue and back pain to bunions and osteoarthritis.
Invest in the right shoes. Footwear is very important. If your shoes do not fit well, you may have foot pain. If you have existing foot pain, your shoes can make it worse. You can get rid of foot pain or prevent it from happening by wearing footwear that fits well. Well-fitting footwear does not mean you have to spend more money. If you do not know what type of shoes to buy, you may want to look for advice from a podiatrist or orthotist.
Maintaining a healthy weight
High blood pressure and cholesterol levels also have damaging effects on the feet. High blood pressure can cause gout, and hypertension is a risk factor for peripheral arterial disease. High cholesterol contributes to peripheral arterial disease, which affects the flow of blood to the feet and can result in infections and amputations.
Osteoarthritis and gout-related foot problems were also found to be 2.5 times higher in those with a BMI over 30. The high incidence of diabetes can lead to nerve damage, numbness in the feet, skin changes, infection, and sometimes amputation. It is essential for those with diabetes to prevent the progression of the disease by maintaining healthy blood sugar levels and a healthy weight.
Increased fat mass can lead to a connective tissue disorder, where the long-term result is a flattening of the arch and a noted spread of the foot. This can cause an increased shoe size and problems fitting into comfortable footwear. Studies have indeed shown that increased BMI contributes to symptomatic, severe osteoarthritis in the feet and non-traumatic joint pain. Weight loss can reduce the risk of developing severe joint damage and can have a significant effect on relieving pain in foot osteoarthritis.
Weight loss, or maintaining a healthy weight, is a vital aspect in minimizing foot and ankle pain. Being overweight can significantly affect the feet, increasing the risk of developing chronic and disabling conditions. Obesity is defined as an abnormal accumulation of body fat, 20% or more over an individual’s ideal body weight. Obesity can cause excess weight on the feet to cause an abnormal amount of stress to be placed, leading to the arch collapsing and the development of conditions such as plantar fasciitis and osteoarthritis.
Regular foot care and hygiene
There are several precautions to take to help manage the symptoms of foot and ankle pain. One of the most common and effective ways of preventing and alleviating foot pain is wearing properly fitted shoes. In a study conducted by the Institute for Aging Research of Hebrew Senior Life, 1 in 3 participants reported buying athletic shoes that were at least 6 years old. This is a common mistake among seniors. It is not necessarily the frequency of buying new shoes that matters, but the quality and fit of the shoes. Ill-fitting footwear can cause a whole host of foot problems. High-heeled shoes can cause foot pain and bunions, and tight shoes can worsen hammertoes and ingrown toenails. Shoes with an extra wide toe box (the space in the toe area) are recommended, as they put less pressure on the toes. According to a study published in 2011, around 36% of participants had some sort of bunion. Qualified footwear can relieve bunion pain and stop bunions from worsening. Weight management is also an important factor to consider. Overweight individuals and those with a higher body mass index (BMI) are at a greater risk for disabling foot pain, which can lead to reduced mobility and a poorer quality of life. A study published in 2011 showed a strong association between overweight women and flat feet. Flat feet can cause foot pain and pain in the ankle or knee, which is often disabling in seniors. Weight loss can reduce pressure on the feet and lower the occurrence of general foot pain. A podiatrist can provide information on the effect of weight on foot pain and will be able to recommend a healthy diet and exercise plan.
Importance of regular check-ups and screenings
Routine foot care visits may consist of a health assessment, advice on self-care, the treatment of any identified problems, and if necessary, a referral to a specialist for a non-foot related issue. Patients who seek this advice on a regular basis are taking a significantly proactive approach to their health. This is most often the best way to deal with any problems, or better yet, prevent them from occurring in the first place. Regular care from a podiatrist has been shown to reduce the number of amputations in diabetics by up to 85%. This is an extraordinary statistic that should serve as evidence to all who are unsure of the benefits of preventative foot healthcare. Kagel et al performed a cost analysis of the podiatric care of diabetics and concluded that preventive care saves both lives and money. It is therefore the most effective way to keep high-risk patients on their feet and out of the hospital. High-risk patients are covered by Medicare and are therefore entitled to cost-free visits to a podiatrist.
In elderly patients, there are certain risk factors that make them more susceptible to developing serious foot complications. These include, but are not limited to, poor vision, diabetes, poor circulation, and certain neurological conditions such as Parkinson’s. What all these risk factors have in common is their ability to reduce one’s health awareness. Poor vision may prevent an individual from noticing a toenail problem, therefore allowing an entry for a portal of infection. Diabetics often lose the sensation in their feet and thus are unaware of an injury. Poor circulation and neurological conditions may inhibit an optimal healing response. The result of these complications can be a small problem that goes unnoticed and ultimately becomes a serious medical issue. Up to 70% of lower limb amputations that are not a result of trauma are performed on diabetic patients. This is a staggering statistic that emphasizes the need for preventative foot healthcare in high-risk patients. Regular visits to a podiatrist can often prevent such amputations from ever occurring.
