INJECTION THERAPY FOR MIDFOOT OSTEOARTHRITIS

Anatomy of foot

Strength, balance, stability, and flexibility are all built into the foot. This is accomplished by a complicated system of 33 joints (26 bones) that articulate to produce a wide range of movements.
 
The foot is divided into three sections (as seen in the image below):
 

The rear foot and ankle 

Four bones make up the back foot and ankle:

  • The tibia is a bone in the lower leg (large long bone of the shin)
  • The fibula is a bone in the lower leg (smaller long bones of the session)
  • The talus is a type of talus that is found (ankle bone)
  • The calcaneus is a bone in the heel of the foot (heel bone)

Two joints are formed by these four bones.

  • The talus bone articulates with the tibia and fibula bones of the shin to form the talocrural joint, which is responsible for dorsiflexion (flexing the ankle, such as when stretching the calf) and plantarflexion (pointing your toes down such as when wearing high heels).
  • The subtalar joint, which is responsible for inversion and eversion, is formed by the talus and calcaneus bones articulating (turning your ankle inwards and outwards respectively).

The midfoot

The articulation of five irregularly formed bones forms the midfoot. These are the bones:

  • The cuboid 
  • The navicular
  • The lateral cuneiform 
  • The middle cuneiform 
  • The medial cuneiform 

The midfoot offers the following benefits:

  • A flexible, shock-absorbing arch that allows you to fine-tune your interaction with the ground when ambulating (Thomas et al., 2015). Chi and colleagues (Chi et al., 2000)

The forefoot

The forefoot is made up of the lengthy bones that form the foot’s five digits or toes.
The forefoot’s long bones are known as:

  • Phalanges 
  • Metatarsals.

Because of the multiple strains imposed on the midfoot during weight-bearing and mobility, osteoarthritis is frequently associated with this part of the foot.

A complex web of joints is formed by the articulating surfaces of the five bones of the midfoot. Articular cartilage is a protective, friction-reducing layer that covers these joints. When a joint is repeatedly or inappropriately loaded, the articular cartilage thins out, exerting extra pressure on the underlying bone. Osteoarthritis is the name for this progressive condition. The synovium, a small layer of connective tissue within the joint capsule, becomes irritating when osteoarthritis is present. Synovitis, the ensuing synovial inflammation, has been linked to the progression of osteoarthritis and is typically responsible for the episodic painful flare-ups in osteoarthritis symptoms

Osteoarthritis is a condition that affects weight-bearing joints, particularly the hip and ankle.

The following are some of the risk factors for developing osteoarthritis (Thomas et al., 2015):

  • Osteoarthritis is more common as people get older. Midfoot osteoarthritis affects 12% of the population over the age of 50, with the majority of symptomatic cases occurring in persons over the age of 75.
  • Sex – studies have indicated that females are more likely than males to acquire midfoot osteoarthritis.
  • Increasing body weight — as your body weight rises, the pressure on your load-bearing joints rises as well. Increased pain associated with osteoarthritis might be caused by the added weight on the tiny joints of the midfoot.
  • Trauma – prior fractures can cause articular cartilage injury by disrupting the joint surfaces.
  • Poor biomechanics and muscle weakness – If your body weight isn’t evenly distributed over your foot due to weak calf and hip muscles, poor lower limb alignment, leg length discrepancy, poorly fitting shoes, or a changed walking and/or running style, pressure on the midfoot joints can increase, causing more pain.
  • Sporting activity or your job can place too much stress on your midfoot joints, resulting in arthritic changes over time, such as in football or jogging.
  • Diabetes – diabetes is thought to be caused by a reduction in blood supply to the feet, but the specific process is unknown.

How do you know if you have midfoot osteoarthritis? 
Osteoarthritis of the midfoot is a degenerative disorder that often develops over months or even years before causing symptoms.

The following are some of the symptoms of midfoot osteoarthritis:

  • A deep, nagging, dull discomfort in the middle of the foot. Pain normally starts out as intermittent, but as osteoarthritis progresses, symptoms become more consistent.
  • Synovitis can be identified by intermittent episodes of increasing, acute pain that lead you to limp.
  • Stiffness – After a period of rest, your foot may feel stiff and tight. Osteoarthritis-related stiffness usually goes away as soon as you start moving, then reappears after a period of rest. Stiffness generally becomes permanent as the illness worsens.
  • Amorphous transformation. Osteoarthritis in its later stages can cause the damaged joints to change shape or grow in size. Joint deformation is the term for this.

How is osteoarthritis of the midfoot diagnosed?

An proper diagnosis of midfoot osteoarthritis is critical since it tells your doctor about the best treatment options for you. Clinical examination and diagnostic imaging are used to identify midfoot osteoarthritis. The gold standard for diagnosing osteoarthritis of the foot is an X-ray (see image above) or an MRI scan.

Clinical evaluation

The clinical examination is performed to assist build an osteoarthritis hypothesis. Clinical examination alone cannot be used to provide a formal diagnosis of osteoarthritis. Clinical assessment, on the other hand, can reveal the elements that are linked to your pain; it is necessary for remedial rehabilitation and is an important part of the diagnosis process.

An orthopaedic consultant, podiatrist, or physiotherapist will usually do a midfoot osteoarthritis assessment, which includes the following:

Physical assessment

The following items are included in the physical evaluation:

  • Your foot’s structural assessment will include a look at the arch.
  • On examination, the range of motion of the foot and ankle joints was measured.
  • Muscle strength assessment in the calf and foot
  • Joints of the foot that can be palpated (felt)
  • Gait analysis is part of the functional testing.
  • Footwear evaluation

Following the clinical evaluation, your clinician may recommend additional diagnostic tests. These may include the following:

Blood tests

You may be referred for a battery of blood tests if your symptoms are suspected to be caused by a systemic inflammatory condition. This can be done by your general practitioner or a specialist.

 X-ray or MRI scan

You may be referred for an X-ray or an MRI scan if your clinician suspects you have midfoot osteoarthritis. Both are widely regarded as the gold standard imaging tools for diagnosing bone and joint disorders, such as fractures and osteoarthritis. Without an X-ray or an MRI, a formal diagnosis of osteoarthritis can be made but not verified. Both can see the presence of osteoarthritis as well as the severity of the condition. Many people, however, have symptoms that are unrelated to X-ray findings. Symptoms within the afflicted joint may be substantially worse than expected if synovitis is present. Diagnostic ultrasonography is the best way to see synovitis (more later) Many patients with severe osteoarthritis on imaging, on the other hand, can function normally with only minor symptoms.

Diagnostic musculoskeletal ultrasound imaging

Diagnostic musculoskeletal ultrasonography has been shown to be a highly effective imaging tool for assessing synovitis edoema and inflammation. It’s also been found to detect early bony alterations in joints such bony osteophytes and corticol irregularity, both of which are linked to osteoarthritis (Wakefiled et al, 2000. Kaeley et al, 2020).

What are the options for treating midfoot osteoarthritis? 

Midfoot osteoarthritis is frequently neglected, with many people suffering from symptoms for years before seeking medical assistance. It is critical to begin treatment as soon as possible in order to reap the greatest advantage from it.

For the treatment of midfoot osteoarthritis, many people react well to physiotherapy rehabilitation. Maintaining adequate levels of flexibility and strength around the damaged joints is crucial for maintaining function and managing the symptoms of osteoarthritis, according to research.

The following are common physiotherapy treatments:

  • Provide recommendations for activity modification and pain management.
  • Stretching your calf muscles
  • Muscle strengthening exercises for the hip, calf, and foot are frequently advised to rectify muscle imbalances in the lower limb that may be related to midfoot osteoarthritis.
  • Joint manipulation and soft tissue treatments are used to help relieve pain and enhance function in the joints and surrounding muscles of the foot and ankle.
  • Offloading the midfoot joints can be done with orthotics (insoles) or physiotaping procedures. For personalised orthotics, a referral to a podiatrist is sometimes required (Dugarte et al., 2016). (see below image)
  • Here are a few pointers you might want to try for yourself:
  • Take a break from strenuous activity. If this isn’t possible, make the best modifications you can. This could entail taking frequent rests or walking with the aid of a stick.
  • Losing weight will lower the pressure in your foot, resulting in less discomfort and symptoms.
  • Stretch your calf muscles gently.
  • Heel lifts and other calf strengthening exercises can help strengthen your ankle muscles. Always begin with double leg and work your way down to single leg if discomfort permits.
  • Pain relief from osteoarthritis can be achieved with over-the-counter oral medications like paracetamol or ibuprofen, or a topical anti-inflammatory gel like Voltarol. Before taking any drug, consult your pharmacist.

What if conservative management does not help?

If your problems persist after you’ve completed a course of physiotherapy and rehabilitation exercises, an injection may be therapeutic.
Ultrasound guided injectable treatment has been used to treat the pain and inflammation associated with osteoarthritis for decades, and it is especially helpful in the following scenarios:

  • Symptoms that last longer than three months
  • Symptoms that make it difficult to sleep
  • Symptoms that make it difficult for you to do daily tasks
  • Symptoms that make it difficult for you to work or engage in recreational activities
  • Symptoms that make it difficult for you to finish a physiotherapy rehabilitation programme

An injection is not a treatment in and of itself. According to research, an injection should be used in conjunction with physiotherapy to produce the best results. Joint Injection recommends starting therapy for midfoot osteoarthritis within two weeks of receiving your injection.

Patients tolerate musculoskeletal injections conducted under ultrasound guidance better, are more accurate, and have less post-injection problems than landmark injections, according to current evidence. This procedure employs diagnostic ultrasound to create real-time imaging of target tissue, allowing for visualisation of the needle tip and precise drug delivery to the source of your discomfort. Because there is only a few centimetres between the bones of the mid-foot joints, all foot injections at Joint Injections are done under ultrasound guidance for maximum impact.

For the treatment of midfoot osteoarthritis, there are two ultrasound-guided injection options:

1. Corticosteroid injection guided by ultrasound

A corticosteroid is a powerful, injectable anti-inflammatory drug that has been used to effectively relieve pain and inflammation associated with osteoarthritis for decades. Before being injected under ultrasound imaging, a corticosteroid is mixed with a local short-acting analgesia. The use of ultrasonic imaging and a short-acting local anaesthetic allows for a precise and comfortable injection.

2. Hyaluronic acid injection guided by ultrasound

Hyaluronic acid is a synthetic version of hyaluronic acid, a naturally occurring molecule found in joints. It has been demonstrated to have potent anti-inflammatory qualities as well as providing joint lubrication. It is frequently used as an alternative to corticosteroids in the treatment of osteoarthritis when combined with a short-acting local anaesthetic.

On all injections, Joint Injections can supply you with same-day service. A referral from your primary care physician is not required. You have the option to self-refer to our service. Our highly skilled doctors include fully licenced independent prescribers, physiotherapists, musculoskeletal sonographers, and injection therapists who can assess, diagnose, prescribe the best drug, and provide the injection all in the same session.

Joint Injection’s experts are dual-trained, highly specialised physiotherapists and musculoskeletal sonographers with extensive experience diagnosing all foot and ankle disorders. We provide a ‘one-stop’ clinic, which means you’ll get an examination, a diagnostic ultrasound, and, if necessary, an ultrasound-guided injection.