Informing patients 6: Ankle Pain – Benefits and Risks and Treatment Alternatives An information resource for practitioners

The law on consent requires health practitioners to inform patients of the benefits and risks of treatment and alternative treatments.  This article is part of a series to equip practitioners to inform their patients.  It is to be noted that it is difficult to find information on benefits and risks of treatments so please feel free to provide feedback so we can develop this resource.

This list is a generalised list to use a resource and needs to be applied using your osteopathic expertise, based on the patient’s condition, presentation, preferences and understanding.

N.B. this information is written for practitioners with medical knowledge, if you are suffering with shoulder pain please seek advice from a health practitioner.

Ankle Pain

Education and activity modification

Pain education.  Start activity as soon as possible (few days rest with severe sprain).  Reassurance about natural progression of condition.  Weight loss.  Supportive shoes, avoid barefoot with fasciitis. Ice packs.

Achilles tendinopathy – 12 weeks for symptoms to resolve

Plantar fasciitis – 6 months to complete recovery, 80% complete resolution within 1 year

Benefits: low-cost option, possibility of improvement in pain, empowers patient

Risks:  Yellow flags may be barriers to improvement

Orthotics and heel pads

May offer some benefit.   Custom orthoses offer no significant benefit over shelf orthoses.  Magnetic insoles no better than ordinary.  Heel lift of 12mm beneficial for tendinopathy.

Night splints are generally not advisable due to poor compliance and lack of effectiveness.

Benefits: Relatively low cost, reduced pain

Risks: Dependency on orthotic, weakening of foot muscles and arch supports

Manual Therapy and exercise

Extracorporeal shock-wave therapy – may be beneficial, efficacy uncertain

Low level laser therapy – increases collagen production

Hydrotherapy, mobilisation, exercise. Strengthen by eccentric loading exercises and correcting lower limb biomechanics for tendinopathy.  Plantar fasciitis – stretching dorsiflexion and rolling on ball.

Taping may offer short-term benefit.

Benefits: Helps improve range of motion and reduce muscle tension, may help reduce likelihood of recurrence of symptoms.  Reduction in pain.  Pre-operative preparation.  Empower patient.

Risks: May have increased tenderness after hands-on treatment for 24-48 hours (1 in 2), improvement may take a few sessions.  Small risk of nerve compression causing temporary tingling and numbness (1 in 100).

Corticosteroid injection

Not beneficial for tendinopathy – causes atrophy and tendon rupture in 8%.  Useful for short-term relief of pain but unlikely to affect long-term outcome.

Benefits: Pain reduction

Risks: infection, tendon rupture, hyperglycaemia in people with diabetes, local tissue atrophy, flushing, fat pad atrophy

Analgesia

Aim: to control pain and help the person keep active

Medication Benefits Risks Additional Information
Paracetamol No gastrointestinal toxicity, well-tolerated   More effective taken regularly, rather than as required
NSAIDs – Ibuprofen

(naproxen, diclofenac)

Anti-inflammatory.  Limited evidence of effectiveness for short-term pain reduction. Dyspepsia

Gastrointestinal bleeding

Cardiovascular and renal adverse effects

Exacerbate asthma

Not effective for neuropathic pain

Gastroprotection may be required

 

Topical NSAID May be of benefit, especially in acute conditions.  Diclofenac cream may help with knee OA. Large amounts can cause systemic effects including hypersensitivity and asthma.  Photosensitivity is also a risk so care is needed in sun.  
Combined analgesics Combined beneficial effects

*Reduces number of tablets to be taken.

Risk of overdose and renal toxicity *Now recommended to be taken as separate tablets apart from chronic stable pain, although limited evidence
Codeine (weak opioid), dihydrocodeine, tramadol Mild-moderate pain treatment, tramadol may be effective with neuropathic pain Constipation, aggravate asthma, risk of dependence, drowsiness, renal side-effects

Tramadol – rarely – convulsions, psychiatric reactions.

Sedative effects can add to psychological factors and exacerbate feelings of helplessness and depression.

 

Surgery

Remove fibrotic tissue and adhesions, surgical release of tissues.  Not unless had pain for long period > 6 months.  Surgical repair is necessary in tendon rupture asap.

Benefits: Increased mobility, decreased pain

Risks: Thrombosis, infection, nerve or blood vessel damage, complex regional pain syndrome, strokes, heart failure, pain, bruising, swelling, no change or recurrence of symptoms, scar tissue, reaction to anaesthetic

References

NICE Clinical Knowledge Summaries, available at: http://cks.nice.org.uk/

www.patient.info

Evidently Cochrane website http://www.evidentlycochrane.net

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