Podiatrists play an extremely vital role in the prevention of falls for seniors. We are an essential medical touch point in the cycle of care because we are trained to identify patients who are at risk for falls, and able to address the primary biomechanical problems that cause falls. Problems that contribute to falls include osteoarthritis, unstable foot and ankle joints, weak muscles, Dropfoot (Hemiplegia), posterior tibial tendonitis, tendon contraction, peripheral neuropathy, flatfeet, malformations in the toes, Equinus Foot, Charcot Foot, gait abnormality and lack of muscle coordination (Ataxia).
According to a recent article in the Journal of the American Medical Association (JAMA), falls and related injuries are more than twice as high among adults with arthritis as arthritis-free adults. Because the growth rate for the population age 65 and older is expected to climb from 40.3 million in 2010 to 67 million by 2030, there is a serious need to step up efforts for fall prevention for seniors with arthritis and to provide intervention strategies for patients with arthritis of the foot and ankle.
The foot and ankle problems that place seniors at highest risk of falling have Chronic Ankle instability, Hallux Rigidus (hallux-rig-i-dus) known as big toe arthritis, and Ankle, Hindfoot, and Midfoot Arthritis. Here is a brief overview of the symptoms, causes, and treatments for these conditions.
Chronic Ankle Instability
Chronic Ankle Instability is characterized by a weak ankle that “gives way” on the lateral (outer) side of the ankle on a fairly regular basis. This occurrence is unpredictable and can occur while walking, running, or when standing. Common symptoms include pain, tenderness, and swelling.
The primary cause is usually the result of a prior ankle sprain or injury (i.e. fracture) that did not rehabilitate properly or fully heal. Consequently, the ligaments surrounding the ankle remain stretched, weak, and sometimes torn. Other causes are not injury related. These include arthritis, inflammation in the synovium (joint lining), and a buildup of scar tissue, a damaged nerve, or nerve entrapment condition.
Physiotherapy is the most common treatment to rebuild ankle strength. Special bracing is also used to provide support. Surgery is considered if ligaments need to be tightened on the outside of the ankle to add support. In some cases, a tendon may be grafted from the other ankle to rebuild stability.
Hallux Rigidus (Big Toe Arthritis)
Hallux Rigidus is a form of degenerative arthritis in the metatarsophalangeal (met-a-tar-so-pha-lan-gel-al) joint (MTP) that usually develops in adults between the ages of 30 and 60, and is more prevalent in females. This condition is the most common form of arthritis in the foot. It is a progressive condition that limits the toe’s range of motion over time.
This condition occurs when the cartilage of the big toe is injured or because of an abnormal foot anatomy that puts an excessive stress load on the MTP joint. The deterioration of articular cartilage covering at the end of the bone results in a bone-on-bone condition.
Initial symptoms include joint stiffness, swelling, pain, discomfort, and restricted range of motion. The condition tends to be aggravated during cold and damp weather. Walking becomes difficult and recreational activities are restricted. Manual labor that requires stooping or squatting is also restricted.
As the condition advances, pain is present even during rest. Walking becomes abnormal and evidenced with a limp. Bone spurs in the heel often develop making it uncomfortable to wear shoes, especially high heels. Often, these conditions lead to associated pain in the knee, hip, and lower back.
The actual cause of this condition is not known. Related risk factors include prior trauma, an elongated big toe, differences in foot anatomy, and family history. Any of these factors can contribute to wear and tear of the joint and development of arthritis.
Non-surgical treatments include anti-inflammatory and pain medications, cold and hot therapy, cortisone injections, and shoe wear and custom orthotics that limit MTP joint motion.
Surgery may be done if non-surgical treatments fail. Three options are used depending on the severity of the problem. These include the following: a Cheilectomy (kl-lek’-toe-me) for mild to moderate MTP damage; an Arthrodesis (are-throw-dee’-sis) permanent fusion of bones if the cartilage is severely damaged; or an Interpositional Arthroplasty (are-throw-plas’-tee) for patients with moderate to severe hallux rigidus who are unwilling to accept the loss of motion of the big toe.
The Cheilectomy procedure is joint sparing, preserves joint motion, maintains joint stability, and alleviates pain caused when pushing off the toe. Arthrodesis is a permanent correction that eliminates pain but restricts movement of the big toe. Interpositional Arthroplasty replaces damaged bone with soft tissue to allow some motion in the big toe. It is effective but not as reliable as Arthrodesis.
Ankle, Hindfoot and Midfoot Arthritis DJD (Degenerative Joint Disease)
Arthritis is also common in the ankle, hindfoot, and midfoot. Ankle Arthritis is present where the tibia (shinbone) rests on the talus (upper bone of the foot). Hindfoot Arthritis is present in three joints: the subtalar or talocalcaneal (ta-lo-kal-ka-ne-al) joint (that connects the talus to the heel bone); the talonavicular joint (where the inner midfoot bone connects to the navicular bone); and the calcaneocuboid joint that connects the heel bone to the cuboid (outer midfoot bone). Midfoot Arthritis is present in the metatarsocuneiform joint where the metatarsals (forefoot bones) connect to the cuneiforms (small midfoot bones).
There are three types of arthritis. Osteoarthritis, commonly referred to as wear and tear arthritis, occurs after reaching middle age. Rheumatoid Arthritis is a chronic, progressive autoimmune disorder that attacks flexible (synovial) joints and destroys cartilage. It is a rare form of arthritis and mostly starts between ages 30-50; although younger people can have it. Post-Traumatic Arthritis can occur at any age following an injury such as a sprain, fracture, or torn/stretched ligament.
Arthritis symptoms of the foot vary depending where it is present; however, the common symptoms include swelling, stiffness and reduced mobility, tenderness and pain, and difficulty walking.
Nonsurgical treatment may include cold therapy, anti-inflammatory and pain medications, supportive footwear, custom orthotics, home therapy, alternate non-load bearing recreation and fitness activities, custom orthotics, foot braces, balance braces, casting, corticosteroid injections, and laser therapy.
Surgical treatment is considered when nonsurgical treatment does not provide sufficient response or pain relief. Surgery consists of Arthroscopic Debridement, Arthrodesis, and Arthroplasty. Candidates for joint replacement are at end stage arthritis and ankle joint surfaces are destroyed. Patients are in severe pain and unable to do normal daily activities. Because of advances in implant design, Arthroplasty is becoming the treatment of choice. It provides total relief from arthritis pain, and restores joint movement and patient mobility. Also, less stress is transferred to adjacent joints reducing the occurrence of arthritis. The outcomes for this procedure are very positive; however, if the implant fails, revision surgery is required.
A wide range of strategies are required to prevent falls. People with foot and ankle arthritis and balance impairments are at greatest risk. These patients should be channeled to a podiatrist for a comprehensive Fall Risk Assessment and treatment.
Visit myfootandanklecenter.com to view an assessment tool, and a video on MLS Laser treatment for pain management and arthritis.
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