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The Connection Between Foot and Ankle Pain and Mental Health: Strategies for Emotional Well-being

Musculoskeletal symptoms affect up to 48% of the population at any one time, and feature disproportionately in women and the elderly. They are also important predictors of the onset of disability. This provides a vital public health context for the essay, showing the relevance of the topic and its potential importance for future interventions. This is followed by a review of the biopsychosocial model and its relevance to musculoskeletal pain. The biopsychosocial model states that physiological changes, psychological dispositions and social factors all have important interactions in determining illness behaviour and disease outcomes. This has only relatively recently been applied to the understanding of musculoskeletal pain but has already yielded important insights. This model provides the theoretical framework for the rest of this essay since psychological and social factors fit into clearly affecting outcome measures for foot and ankle pain. This information provides a basis from which the reader can be introduced to the specific example of foot and ankle pain.

Impact of Foot Pain on Mental Health

The world has come a long way in the last two decades when it comes to understanding the importance of mental health and its impact on overall well-being. There is now considerable evidence of an association between impaired mental health and the existence of chronic and/or painful conditions of the musculoskeletal system. This is not a surprise when one considers the way in which pain can dominate a person’s life, restricting their ability to carry out activities of daily living, their recreational activities, and their ability to work. There are many conditions that cause painful feet, and it is beyond the scope of the current article to discuss them all. But we will consider the effect that chronic heel pain can have on mental health as an exemplar of the relationship between foot pain and mental well-being. It’s well-documented that the experience of persistent pain can lead to the onset of depressive illnesses. In a longitudinal population-based study, Gureje et al found that older adults with persistent pain had more than a 2-fold increased risk of a diagnosis of major depressive disorder than older adults without pain. A similar result was also found for a study on younger adults; data from the National Comorbidity Survey revealed that those with chronic pain had 3-5 times the prevalence of either moderate or severe depressive disorders compared to pain-free individuals. Evidently, the experience of persistent pain has a substantial impact on the onset of depression.

Impact of Ankle Pain on Mental Health

This particular concept was studied in a group of elderly patients with chronic knee pain. It was found that the level of fear-avoidance beliefs predicted a degree of functional decline and higher depression scores at a 4-year follow-up. Similar findings have been shown in patients with chronic low back pain and osteoarthritis.

The social and functional limitations accompanying chronic pain are believed to be the principal cause of depression. Pain has the ability to change the way in which one moves. People suffering from foot and ankle pain have been shown to adopt a more sedentary lifestyle and take fewer, shorter walks. They also are more likely to adopt an irregular gait pattern. These changes further lead to decreased levels of aerobic fitness and lower limb strength. This decrease in physical activity and functional capacity can lead to a perceived loss of function and role as well as increased bodily harm and a fear-avoidance model of behavior. In other words, due to anticipation of pain, there is an increased likelihood that certain activities will provoke pain and thus are less likely to be performed. The result is avoidance of these activities, further reducing quality of life and adding to the sense of being disabled by the condition.

It is only in the last decade that research has addressed the prevalence of depression in those suffering from chronic illnesses. Higher rates of depression have been found in those with chronic back pain, migraines, and a variety of other musculoskeletal ailments. There is little doubt that persistent pain has a psychological impact. The dispute is to what degree the mental repercussions of ankle and foot pain go and what are the precise mechanisms that maintain a state of depression or anxiety. To date, there is very little research specific to ankle or foot pain and its effects on mental health. However, it is reasonable to extrapolate evidence from similar studies on other chronic pain conditions.

Strategies for Emotional Well-being

There are many forms of exercise that can be beneficial for foot and ankle pain. The warm water of a pool can be very soothing and the low impact nature of swimming can be an excellent cardiovascular exercise without subjecting painful joints to the forces generated by normal daily activities. Stationary biking is a similar low-impact activity that can be beneficial since the legs are close to weight-bearing without the same force being transmitted to the feet. Elliptical trainers and cross-country skiing machines are also good ways to get a similar type of work-out to walking or running with less impact, and many people with foot or ankle pain can use these machines effectively. In cases where pain is not too severe, simple walking can be a very beneficial form of exercise. This is especially true for people with arthritis where an increase in pain is often observed following inactivity. Weight loss can be a very important goal, since excess body weight is a major contributor to foot and ankle pain. High impact activities such as running and jumping should be strictly avoided, as these can often worsen pain and be detrimental in the long run.

Physical therapy can work very well for many cases of foot or ankle pain. This is especially true for some of the more chronic conditions that have been developing over a long period of time. Overall, by getting joints and muscles throughout the lower extremity to move in the most ideal way, and by not favoring one part of the foot to another with the way that weight is distributed, the pain that is generated can be reduced. Steps of physical therapy often start with a simple stretching and can progress into strengthening of certain areas to support the joints that are in pain. The therapist will also try to find out if any of the pain is being generated by an improper walking pattern that is putting excess stress on certain joints. If this is the case, gait retraining can be a very effective tool. In the cases of injury or acute pain, especially following a surgical procedure, a home exercise program designed by a therapist and based on the specific needs of the patient can be a very effective way to regain previous levels of function.

Physical Therapy and Exercise

Various research articles on the topic of orthopedic injuries have shown that there is a direct correlation between joint pain and obesity. Weight loss on any level can have a positive effect on diminishing foot and ankle pain.

A persistent problem with foot and ankle pain is the effect that it has on a person’s weight-bearing ambulation. Biomechanical abnormalities and antalgic gaits as an avoidance mechanism to decrease pain can lead to joint degeneration in the foot, ankle, and surrounding structures. This can create a progressive condition that is difficult to reverse and lead to systemic medical problems in joints located above the lower extremities.

Ankle sprains and other acute injuries can lead to an avoidance of physical activity and a sedentary lifestyle due to concerns of reinjury and a fear of painful joint movement. This can result in chronic systemic health problems and a further diminished quality of life for the individual.

A common impairment secondary to ankle sprains is chronic ankle instability. This condition can have detrimental effects on an individual’s ability to perform simple tasks such as walking or ascending or descending stairs, which may result in a decreased level of physical activity. A lack of physical activity will lead to decreased range of motion, strength, balance, and coordination of the injured foot and ankle, and an increased atrophy of surrounding muscles. This cycle will lead to greater impairment and increased symptoms.

Physical therapy is often a first line of treatment for fundamental impairments and gait deviations that create overuse damage and fatigue. Elements such as strength, balance, and range of motion within the foot and ankle have a large impact on the amount of stress that is placed on healing tissues, as well as an individual’s potential for future injury. An individual’s strength and coordination of the muscles that support the arch on the inside of the foot, as well as the peroneal muscles on the outside of the ankle, can affect how much force is exerted on the foot, thus creating various levels of trauma.

Pain Management Techniques

Foot and ankle pain often produces a variety of negative thoughts and emotions, from frustration at not being able to do normal activities to depression or anxiety about the future. Effective pain management strategies can be helpful in breaking this cycle. Medications are often the first thing people try for pain management. Pain medications come in the form of anti-inflammatory medications that are useful in reducing painful swelling and inflammation. Some of these, called NSAIDs (non-steroidal anti-inflammatory drugs), are available over the counter. In patients with more severe pain, stronger prescription NSAIDs are available. In addition to reducing the inflammation, there are a variety of pain medications that act on the nervous system to reduce pain. There are also other medications aimed at reducing nerve pain (called neuropathic pain). Discussing the medication options with a primary care doctor or rheumatologist is important to find the right medications for the individual and their specific condition. Cortisone injections have been found helpful in reducing pain and inflammation in some conditions. Adequan injections have been found to be useful in degenerative arthritis and some forms of inflammatory arthritis. Injections of a sugar/protein combination, called Glucosamine and Chondroitin, have become popular for pain reduction in osteoarthritis. Another injection for osteoarthritis is Synvisc, which is a synthetic joint fluid that is used to provide a cushion and lubrication in the joint, and can provide pain relief for many months.

Mindfulness and Meditation

The greatest meta-analysis conducted by Hofmann et al. in 2010 found that the effect size of mindfulness-based therapy was d=0.55, which is moderate and in line with CBT treatment for depression. For this reason, it seems that Mindfulness-Based Stress Reduction (MBSR) and other mindfulness-based therapies are effective interventions for chronic pain sufferers. Anecdotally, I have had patients state that mindfulness meditation has helped them more than anything else they have tried for their pain. Mindfulness helps patients observe the nature of their pain without becoming attached to it. In seeing that nothing is permanent, they can look forward to using pain management techniques and making positive lifestyle changes, knowing that the future is not necessarily as bleak as the present. Mindfulness can help patients cultivate a “beginner’s mind” where they can make a fresh start in life, despite emotional barriers caused by their pain. Staying present and embracing the current moment, patients can see that it is always possible to get out of the mental trap of thinking one can only be happy if certain conditions are met in the future. They can then begin to open their hearts to themselves and their pain, seeing this as a necessary first step in healing the self.

Mindfulness and meditation are current buzzwords and will only continue to grow in popularity, especially in the realm of chronic pain management. In his book “Full Catastrophe Living,” Kabat-Zinn defines mindfulness as “paying attention in a particular way: on purpose, in the present moment, and non-judgmentally.” However, the practice of mindfulness comes from the Buddhist tradition. Mindfulness helps patients become aware of the present moment. It involves learning to become aware of one’s current mental state and environment in a non-judgmental manner. Pain patients often react negatively to their pain, becoming angry, frustrated, or depressed with their condition. This is an automatic reaction that has been habituated over the years. Being mindful can help pain patients step out of this negative reaction pattern and have greater psychological flexibility in the face of their pain. This can be helpful in breaking the cycle of depression and anxiety that is often comorbid with chronic pain.

Seeking Support and Counseling

So what can be done to improve the situation? One option is to seek counseling from a qualified mental health professional. Cognitive-behavioral therapy (CBT), for example, has been shown to be effective in increasing function and decreasing feelings of depression in those with chronic pain. A counselor can also help a person with chronic pain develop strategies to cope with specific problems, such as people not believing the extent of their pain, or fear of being unable to complete certain tasks. At times, the goal of counseling may be to help a person with chronic pain make difficult decisions, such as changing to a less demanding job. This is an important, but at the same time, a difficult decision for those with chronic pain, and it can be helpful to have an objective third party to help weigh the pros and cons.

It is not uncommon for those with chronic foot and ankle pain to feel isolated and as though nobody understands what they are going through. They may be unable to participate in certain activities or lifestyles that their peers can, and this can be a major source of frustration. Some may be embarrassed about their difficulty with simple tasks, such as a feeling of losing their balance or being unable to stand or walk for periods of time. Unfortunately, foot and ankle pain can be mistaken as normal, especially as we get older, and those with chronic pain may have difficulty explaining the extent of their disability. This can lead to unhelpful advice or comments, or skepticism from friends, family, and employers. People with chronic pain become exhausted with the need to continually prove that their pain is real. This all adds to the emotional impact of the pain.

Thus, it is clear that we cannot trivialize foot and ankle injuries. Although medical advances have improved our understanding of the injuries and treatment options, little attention has been placed on the resultant impact to the mental health of the patients. Steps to improve patient education, treatment of associated injuries, and encouraging patients with positive reinforcement will be crucial in preventing the negative mental impact. In the most competitive society today, a debilitating foot or ankle injury is akin to tearing away the chance of reaching one’s potential job or position and this weighs heavily on the mind of the patient. Do we not owe it to the patient to help him reclaim his support and serve as the pillar to success? Career spanning various levels of competition and the longing for general physical health expertise are symbols of the human motivation to experience success and carry out personal achievement. Let us not forget that starting at the bottom, it is that much easier to fall.

From the premise about acknowledging the importance of foot and ankle in our daily lives up to the role of soccer shoes in preventing ankle injuries, we can surmise that clinicians and patients need to pay more attention to our foot and ankle. This is the most distal part of our body and it determines the foundation for our posture. Lack of knowledge and deficits regarding foot and ankle examinations, discouragement due to the prolonged and complicated foot and ankle injuries management have led to the negligence of this body part, which should not have taken place. Primary health care physicians, and informal caregivers such as coaches and parents, should focus more on foot and ankle injuries in the initial examination of lower extremity injuries, particularly for children and adolescents. As for surgeons and specialists, a more thorough orthopedic examination should be done as not to miss any associated injuries and despite the long and complicated foot and ankle injuries management, we should encourage patients and all stakeholders to remember the significant links to the quality of life and the mental health.

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