Sleep is an important phase of healing and recovery. But for people with foot pain, sleep can be difficult to achieve without pain and medication. A study by the National Sleep Foundation in 1999 found that 12% of people with chronic pain reported that they have disturbances every night. An additional 32% reported experiencing disturbances at least 5 nights a week. This shows that many people with foot pain have difficulty sleeping. A case study in 2007 by Eileen and Roger Goble found that people with foot pain disruptions often awoke from pain when the body is cooling. They would have to heat up the area around the foot with bedcovers to reapproximate normal body temperature and return to sleep. This can cause excessive tiredness the following day. In conclusion, sleep disruptions are common among people with chronic foot pain.
Foot pain can occur due to several reasons. A common problem is an abnormality in the inner longitudinal arch and forefoot. It occurs when the foot is overpronated during walking or running. Overpronation can cause several problems with the foot such as plantar fasciitis, flat foot, and osteoarthritis on the 1st metatarsalphalangeal joint. Another common problem is a deformity at the hallux. Hallux valgus is a common foot problem when there is a lateral deviation of the great toe. It can cause pain and problems walking for the person who has it. The last problem is when the foot is in an alignment of varus or valgus. This abnormal alignment can cause problems for a person. Most foot pain problems can cause a person to have difficulties in walking and standing for too long.
Foot and ankle pain is the main reason for sleep disruption among people aged more than 50 years old. An article stated that in 2003, as many as 50% of people aged 65 years and older had chronic foot pain.
Overview of Foot and Ankle Pain
Foot pain is common, with up to 70% of adults experiencing foot pain at some point in their lives. This high prevalence is not surprising given the complex nature of the foot and ankle, the demands we place on our feet, and the various pathological conditions that can affect the feet. Some studies have suggested that women may be more likely to report foot pain than men. As with other musculoskeletal conditions, foot pain may increase in prevalence and severity with age. Foot pain can have a deleterious impact on many aspects of health, including balance and functional ability, mood, social engagement, and quality of life. Pain beneath or around the medial malleolus is a frequent problem in the elderly, which can lead to significant disability, reduced mobility, fatigue, difficulty sleeping, and psychological distress. This is often attributed to a range of factors such as gait disturbances, arthritis, peripheral neuropathy, venous insufficiency, myofascial symptoms, tendon pathology, and referred pain from adjacent joints. Pain in the forefoot is common and problematic in older people, with one study reporting a prevalence of 57% for moderate to severe problems in this area. Pain in the first metatarsophalangeal joint is a frequent symptom of gout and can cause severe pain that often results in sleep disturbances and difficulty with bed clothes. Hallux valgus and lesser toe deformities are also highly prevalent in older people and can result in chronic pain and footwear-related problems.
Impact of Foot and Ankle Pain on Sleep Quality
Few primary studies have investigated sleep behaviors and pain interactions using new technologies. An appraisal of sleep medicine and pain research methodologies may provide useful insights into the complexities of sleep disturbances in chronic pain populations including electroencephalography and follow sleep studies. The mechanisms of pain and sleep interactions in patients with foot and/or ankle pain are still largely unknown. Future targeted research concerning patients with foot and/or ankle pain, and comparison studies with other chronic pain populations is suggested.
Sleep disturbances were in short supply across all medical disciplines in patients with chronic pain compared to the general population. Patients with foot and/or ankle pain and rheumatologic conditions share analogous patterns of sleep disturbance across all questionnaires and parts of the day. Non-specific sleep patterns intimate that patients with foot and ankle pain may experience the same degree of sleep disturbances as other chronic pain populations.
Sleep quality has been found by several studies to be directly related to sleep disturbance. However, to date, no complete synthesis or evidence-based recommendations are available for clinicians to manage sleep disturbances in patients with foot and/or ankle pain. This review was executed to appraise studies concerning sleep disturbances in patients with chronic pain, particularly foot and/or ankle pain, and to suggest areas for future research.
Managing Foot and Ankle Pain for Better Sleep
Most outpatient surgery patients will be given a single postoperative garment to wear after their surgery. Their surgical garment is to be worn at all times, with the exception of showering, laundering, and in some cases, for a short period for social events. Patients are advised to always wear their garment under loose fitting clothes. The garment can be washed in a washing machine and placed in the dryer. If a cosmetic garment is being worn, it should be changed and cleaned multiple times each day. Since the garment is intended to put constant pressure on the treated area, it can leave indentations on the skin’s surface. This is normal and is only a concern if the indented area starts to hurt. Any red areas should also be monitored. If a red area does not fade within a few hours or with the removal of the garment, this is a warning sign that too much pressure is being applied to the area. A white colored foam pad should be placed underneath the garment directly on top of the treated area at all times to evenly distribute the pressure from the garment and decrease the potential for leaving indentations. Any pinching or chafing experienced from the garment can be resolved with the use of foam padding or by switching to a different style of garment.
Pain Relief Techniques
Once pain has been effectively managed or alleviated, the final step is to restore function and prevent further occurrences of pain and/or reoccurrences of any pain that has been previously experienced.
In conjunction with oral medication and/or TENS, other alternatives to pain relief include the use of ice therapy to reduce pain and inflammation in the affected foot and/or ankle. This can be carried out by massaging the affected area using ice for 15-20 minutes, but always ensuring that the ice is never placed directly on the skin. Compression and elevation of the area will enhance the effectiveness of ice therapy. Muscle relaxation can be achieved through the use of contrast bath therapy, which entails the alternating immersion of both the foot and/or ankle between hot and cold water. This method is known to promote increased blood flow and subsequent muscle relaxation.
Step one involves trying to control and alleviate the painful symptoms. This can be best achieved using a combination of oral medication and topical treatments. Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) are considered to be effective with minimal side effects in reducing inflammation and pain associated with musculoskeletal conditions. Those individuals where oral medication is not appropriate may consider electrical therapy using transcutaneous electrical nerve stimulation (TENS). TENS is a safe and effective method of pain relief for adults by altering the perception of pain at the spinal cord level. This is achieved by sending small amounts of electricity in the form of a low current to the affected area via electrodes placed on the skin. This current creates a small electrical impulse, the frequency and intensity of which can be altered, with the intention of relieving pain.
The ultimate goal of achieving pain relief from foot and/or ankle pain is improving the individual’s ability to sleep. As a response to decreased activity and limitations on lifestyle, pain relief will help the individual to return to a more normal and active lifestyle, improving the quality of life. A positive cycle of pain relief, increased activity, and improved well-being can be attained by following a simple routine of strategic methods.
Proper Foot and Ankle Support
Another thing to consider is what supports are being used during the day, for what you are doing in the evening, and while you are sleeping. Many will spend the day in good supportive footwear, only to remove them and lie in bed without any support for the painful areas. There are numerous devices that can be used, but they vary in design, function, and effectiveness. Examples of foot and ankle supports include felted foam pads, arch supports, ankle braces, and custom foot orthotics. The patient with foot or ankle pain may need to experiment with different devices to find out what works best. An Australian-based systematic review supports the use of foot orthoses for improving foot pain and quality of life for those with rheumatoid arthritis. Currently, there is a lack of research specifically regarding foot and ankle support devices and their direct effect on sleep quality.
Many medical professionals agree that proper foot and ankle support is one of the most important things that a person with foot and ankle pain needs to do. Problems in the feet or ankles can cause issues in the knees, hips, and even the back. One study into knee pain concluded that custom foot orthotic use resulted in significant improvement in pain and functional ability. The result of this improvement of function and decreased pain may lead to better quality of sleep. Sleep has also been shown to be improved by offloading pressure from an injured area by using assistive devices or aids. A recent study showed that the use of a knee brace in patients with osteoarthritis and night pain resulted in a significant decrease in pain and, at the same time, resulted in significantly improved sleep compared to the control group. This showcases the importance of working to alleviate limb pain to improve sleep. Another study states that ankle braces are effective at decreasing the risk of acute ankle injuries.
Sleep Positions for Pain Relief
In a logical, step-by-step fashion, the paper establishes the importance of sleep position in pain relief and the need for modification of sleep positions by individuals with foot and ankle pain. A comparison is made between normal and abnormal sleep positions, citing evidence of the high prevalence of the abnormal position in patients with lower extremity pain. Statistical data is used throughout the paper to underscore the findings of the studies cited. Specific examples of pillow placement and methods of body position modification are provided to help guide a change in sleep position for the patient. The paper takes care to note when evidence is medical opinion and not fact, and provides guidelines for modifying sleep position that correspond with levels of evidence available on the subject. A sample case is used to illustrate how evidence-based guidelines for sleep position modification can be tailored to an individual patient. The final portion of the paper addresses ways that sleep position can be assessed and pertinent points to consider for assessment and outcome measures of sleep position change. This portion of the paper ends with determining a need for further sleep position-oriented research to provide better pain relief to patients suffering from lower extremity pain.
Lifestyle Changes for Better Sleep with Foot and Ankle Pain
It is common knowledge that exercise can help with improved quality of sleep. Exercise has been shown to be beneficial for those suffering from sleep complaints, possibly promoting more restful sleep. It is known that exercise can augment the effects of sleep aids. For example, the sedative effects of alcohol are increased in those who exercise. Furthermore, regular exercise can reduce symptoms of insomnia and sleep apnea. It is believed that the effects of exercise are similar to those of sleeping pills. Regular exercise may not only promote easier sleep, but can also help improve the length of sleep. Patients suffering from various sleep disorders can utilize exercise with proper timing as a healthy way to get a good night’s sleep. It is agreed that the ideal time to exercise is late afternoon. When done too near bedtime, it can interfere with sleep due to increased alertness, however it is not the same for all individuals. Findings from the National Sleep Foundation’s 2013 Sleep in America Poll demonstrate a compelling association between exercise and better sleep. A nationally representative sample of 1000 American adults. Half of the sample reported regular, vigorous exercisers and the other half were non-exercisers. The results showed that exercisers reported significantly better sleep than non-exercisers. They were about one and a half times more likely to say “I had a good night’s sleep” on workdays.
Exercise and Stretching
The text should focus on delivering information, explaining concepts, or detailing processes or systems. When chronic foot or ankle pain is interrupting sleep, treating the pain only is not always resolving the sleep disruptions. It is important to consider the additional interventions specifically targeting the improvement of sleep. One such intervention is the regular practice of exercise or stretching. There have been multiple studies on the effects of exercise on sleep. A study in 1998 by King, Oman, Brassington, Bliwise, and Haskell examined the effects of regular exercise on older adults with sleep disturbances. The subjects were randomly assigned to 4 months of regular exercise or to a non-exercise control group. Exercise group participants received 40 minutes of moderate to vigorous exercise 3 to 4 times per week. At the end of 16 weeks, exercisers had improved quality of sleep unrelated to effects of exercise on health. It was concluded that regular aerobic exercise improves the quality of sleep in the elderly with the addition that sleep improvements are not necessarily related to changes in health. Another study published in 2008 by Reid, et al. targeted the effects of acute exercise on the subsequent quantity and quality of sleep in sedentary middle-aged adults with sleep complaints. Following baseline sleep recordings, subjects were randomly assigned to an exercise or non-exercise control group. The exercisers completed a single bout of moderate intensity aerobic exercise (i.e., walking) for 30-40 minutes 4 times per week. After 16 weeks, participants completed a second sleep recording. The subjects who exercised had a statistically significant increase in average sleep duration and a trend for reductions in waking after sleep onset compared to control subjects. These two studies along with other published reports support that exercise is a powerful intervention for improving quality and quantity of sleep. With improved sleep, the pain burden may be less in persons living with chronic foot and ankle pain. This is especially helpful if exercise can be performed without increasing foot and ankle pain. So, it is important this population learn and practice exercises that can be done without increasing pain and that will not cause further injury to their foot or ankle. With respect to musculoskeletal conditions, the suitability of many exercises can be unclear. This is why it is best to exercise with guidance from a health professional. A physical therapist is an excellent choice.
Footwear Choices
An important factor that contributes to pain in the foot and ankle is improper footwear. Ill-fitting shoes and shoes that lack support increase mechanical disturbances in the foot. The two most common types of foot pain experienced by many individuals are plantar fasciitis and heel pain. These can be exacerbated by any type of shoe that lacks a supportive arch. As well, individuals with flat feet are more likely to experience pain in the foot and ankle. This is partially due to there being no arch in the foot, however it is also due to flat feet most closely resembling a deformed foot. Because of this, any type of shoe that lacks support and cushion in the arch (which is most footwear) will not support the foot properly and only further the deformity. With more pain being experienced and more foot deformity, there is ever-increasing mechanical disturbances in the foot leading to more leg and foot pain. High-heeled shoes and shoes with a narrow toe also increase mechanical disturbances and cause increased pain. This is due to the fact that high heels cause higher pressure on the front of the foot (often causing metatarsalgia) and narrow-toed shoes cause overlapping of the toes which leads to various types of toe deformity. With all of these conditions, pain in the foot and general foot deformities will lead to increased awakening from sleep. One way to prevent this is to correct any type of foot abnormality with the use of orthotics. This should be done in conjunction with proper footwear as mentioned above.
Sleep Environment Modifications
Regardless of any pain, the sleeper needs to get as comfortable as possible and sleep. You should decorate your room in light, pastel colors with pictures that make you feel happy. You should also get a soft gel foam anti-fatigue mat for the times at night when you have to get up. You will need night lights to see where you are going for those aforementioned bathroom trips without having to turn on bright lights. Maintaining a well-kept room with no clutter will reduce chances of tripping on something in the dark, and if the injury is painful enough to require crutches, a hammock for the night is not a bad idea. When it comes to the actual bed, it is important to have a comfortable mattress. Though a mattress does help cushion, a memory foam mattress topper might be necessary. A zero-gravity adjustable bed would be the prime choice as it will take pressure off the foot and ankle area. This might be a bit expensive, yet would be well worth it for anyone with chronic foot and ankle pain. A pillow should be placed between the feet and the bed. If you are a side sleeper, include a pillow between the knees.
Seeking Professional Help for Foot and Ankle Pain
Medications and treatments may also be used for foot and ankle pain, depending on the cause and medical diagnosis. Medications are often effective at reducing pain; however, many have undesired effects, especially at night. This includes NSAID medications, which often cause gastritis and reflux and can also unsettle the stomach. For those who take NSAID medications and continue upper limb work, it is possible that they may also experience arm symptoms and the same sleep disturbances when treating foot and ankle pain. Always take medication as directed by your doctor and consult them if you feel that the medication is affecting your sleep.
Physical therapy for pain management is another option. Your podiatrist may then refer you to a physical therapist with a treatment plan aimed at minimizing pain and improving function in specific lower limb structures. This method may take longer; however, it is more thorough and provides longer-lasting relief for pain experienced. Exercises may be difficult and cause muscle fatigue, making it also difficult to maintain ideal sleep conditions while treating foot and ankle pain.
Consultation with a podiatrist is important. Seek medical help from a podiatrist who will diagnose the cause of your foot or ankle pain and provide appropriate treatment plans. It is important to seek help and not ignore the pain. This can lead to more serious conditions that could require intensive treatment, which may be difficult to tolerate while maintaining ideal sleep conditions. A podiatrist can also provide advice on footwear and any changes that may be made to your environment to prevent further foot and ankle pain.
Consultation with a Podiatrist
The most positive finding from the recent study published in ‘Arthritis Care and Research’ is that foot pain in older adults is a manageable condition. Often, the severity of foot pain can lead to restrictions in the types of activities they undertake, which can significantly impact overall health and well-being. This study has shown that while foot pain is a strong predictor of lower body disability over time, this association was significantly lessened in those who demonstrated an ability to decrease or increase their level of physical activity. A podiatrist will be able to guide you on the best types of activities for your condition and help you continue to lead a healthy and fulfilling lifestyle. Essentially, treatment from a podiatrist for your foot and ankle pain can restore the health and function of your feet, thereby improving your quality of life and promoting better sleep.
If your foot and ankle pain has become severe and is negatively impacting your sleep quality, it may be time to see a specialist. There are podiatrists who specialize in the foot and ankle and will provide a thorough assessment of your condition. Identifying structural deformities and types of inflammatory arthritis, a podiatrist will play a crucial role in providing the best treatment and management plan. Assessment may involve a physical examination and an analysis of the way you walk. In some cases, it may be necessary to organize further tests such as blood tests and medical imaging (x-ray, ultrasound, CT, or MRI).
Physical Therapy for Pain Management
When foot and ankle pain is chronic or not associated with a particular injury, static biomechanics of the foot and lower extremity are often the cause. Excessive pronation or supination of the foot can cause many chronic conditions such as plantar fasciitis, tendonitis, and joint pain. An effective way to address chronic foot and ankle pain is through the use of orthotics. Specially trained professionals will conduct a thorough examination of the lower extremity and make a device designed to change the mechanics of the foot and improve alignment of the lower extremity. This can be an effective treatment for many chronic foot and ankle ailments. Static biomechanical foot problems can benefit greatly from joint mobilization and manipulation techniques. A skilled physical therapist or chiropractor can use these techniques as a way to increase the available range of motion of the joints in the foot and improve the function of the static stabilizers. Exercises specifically geared towards these stabilizers will help preserve the changes in the joint achieved with mobilization and manipulation.
A podiatrist may refer a patient to physical therapy when pain and disability impair daily activity. Physical therapy often involves functional training (weight bearing and walking training), mobilization and manipulation, strengthening exercises, electrical muscle stimulation, taping, bracing, and the use of a shoe insert or orthotics. The ultimate goals of physical therapy include restoration of function and prevention of further problems. A solid understanding of what to expect with physical therapy can help increase the odds of success.
Medications and Treatments for Foot and Ankle Pain
Orthotics are a frequently used treatment for foot and ankle pain. They are external devices worn in the shoes, designed to control alignment and function of the foot. This is done by reducing the amount of deforming forces, as well as improving foot posture and overall function. Orthotics are often used to alleviate pain in the lower limb and can also help in prevention of recurring problems. Custom orthotics are specially made to suit an individual’s foot and are a more expensive but also more effective and durable option than prefabricated orthotics. The prescription of custom orthotics is usually made by a podiatrist, although some physicians and physiotherapists with specialist orthotic training are also able to perform this.
Medications are often the first-line treatment in relieving foot and ankle pain. Oral anti-inflammatory medications are helpful in reducing swelling and pain. Occasionally, stronger painkillers or anti-inflammatory drugs are required if the pain is more severe. Side effects from these medications can occur, and it is important to discuss this with a doctor. Other forms of medication may include the injection of local anesthetic and/or corticosteroid into the painful area. This is often performed under ultrasound guidance and can provide significant pain relief for a number of weeks or months. It is not a treatment for the underlying cause of the pain but may assist in pain relief to allow other treatments to be more effective. Topical anti-inflammatory creams and gels may also be effective in pain relief, although the benefit of these treatments can sometimes be limited.
