Foot and ankle pain are very disabling and very common among the chronic pain population. The pain can become so severe and debilitating that it compromises a patient’s overall quality of life. The worldwide prevalence already standing at 23.9% is projected to rise with the rise in obese patients and the growing elderly population.¹ While lifestyle changes and preventative health strategies play a significant role, research shows that pharmacological management rates of foot/ankle pain were high and substantially exceeded nonpharmacological management.² With proper management, those with foot osteoarthritis (OA) are able to reduce and manage their pain and in effect resume their daily activities and remain active. However, there is very little research on management strategies for foot and ankle pain.¹ Surgery should be reserved for patients with moderate to severe disease due to high rates of complications and possible restriction in ankle range of motion (ROM). Early stages of the ankle OA and milder cases should be treated with more conservative, nonsurgical methods, such as pharmacological agents.³,⁴ The goal of pharmacological targeted therapy is to avoid invasive treatment modalities.

Foot and ankle pain is an unpleasant and uncomfortable experience following perceived damage to any tissue distal to the tibia or fibula; including bones, joints, ligaments, muscles, tendons, apophyses, retinacula, fascia, bursae, nerves, skin, nails, and vascular structure.⁵,⁶ The etiology of foot pain is multifactorial and can be associated with direct trauma, musculoskeletal overload, nerve involvement or neuropathy, loss of blood flow due to atherosclerosis, and infection such as diabetic ulcers.⁶ Foot and ankle pain may also be related to the presence of health conditions (eg, diabetes, gout, rheumatoid arthritis [RA], OA) or involve specific body structures (eg, plantar fasciitis, Morton neuroma, Hammertoe).

The 2 categories of foot and ankle pain are physiological and pathological foot and ankle pain. Physiological pain is characterized by an acute response to injury in healthy, properly functioning nervous systems, both peripherally and centrally. It relies on a feedback system that is in place to identify and warn the body of a harmful stimuli and remove that stimuli hopefully prior to inflicting immense tissue damage. The cascade of events with the nervous system produces the feeling of pain which is referred to as nociceptive pain.⁶ Pathological pain is experienced following nociceptive pathology; however, it involves dysfunction in the peripheral or central nervous systems or both. Pathological pain includes inflammatory pain, neuropathic pain, and chronic pain.

The primary aim of treatment is to alleviate pain, restore alignment, ROM in order to allow the patient to return their baseline or desired level of activity. The most important initial step is to determine that underlying cause of the foot and ankle pain. If disease or infection is the underlying cause, treatment of the underlying disease should be the initial goal. By targeting the disease process, pain can be significantly diminished. The most frequently used treatment modalities begin with conservative, nonpharmacological therapies such as rest and redistribution of load, orthoses and supportive footwear, and physical therapy and stretching.⁷ Although there are no clinical guidelines for the management of foot or ankle OA, it is reasonable to suggest that recommendations pertaining to the management of OA at other sites may be appropriately applied to the foot and ankle. The National Institute for Health and Care Excellence (NICE) guidelines for peripheral joint OA, developed largely from hip and knee OA trials, advise that core management strategies should include (1) advice and education regarding the disease and its prognosis, (2) strengthening and aerobic exercise, and (3) weight loss.¹