Non-surgical treatment for foot and ankle problems

Why non-surgical care comes first

Many foot and ankle problems improve without an operation, and non-surgical treatment carries fewer risks. For a bunion, a bent toe, heel pain, an arthritic joint or a sprained ankle, conservative measures are the first step recommended by orthopedic and podiatric organizations.^[1,9,2,10] Surgery is considered when a well-tried course of non-surgical care hasn’t helped enough.

That doesn’t mean non-surgical care is a delay. For some conditions, such as an early flatfoot, an early tendon problem or a flexible toe, appropriate early treatment can keep the problem from progressing and may avoid surgery.^[11,12]

The main tools

Footwear and padding

Shoes with a wide, deep toe box, adequate length, a low heel and a supportive or cushioned sole reduce pressure on bunions, bent toes and painful joints. Protective pads cushion prominences and calluses.^[1,13]

Inserts, orthotics and braces

Over-the-counter or custom inserts, and ankle braces, are used to redistribute pressure, support the arch or stabilize a joint.^[8,3] The evidence is mixed. Foot orthoses for plantar heel pain reduced pain in the medium term compared with sham orthoses. Whether the change is clinically important is uncertain, and custom and prefabricated orthoses performed similarly.^[5] Reviews found few high-quality studies of orthoses for adult flatfoot and for bunions.^[14,6] For preventing another ankle sprain, bracing has strong support.^[15]

Exercise, stretching and physical therapy

Structured exercise is among the treatments with the strongest support. Supervised exercise reduces the chance of another ankle sprain.^[16,17] It is the basis of treatment for Achilles tendinopathy.^[18] It also helped most people with early posterior tibial tendon dysfunction, in a structured program of an orthosis and exercise.^[19] Plantar fascia stretching reduced first-step pain in the short term.^[4]

Activity changes and weight management

A temporary change in how you train, work or stand lets an irritated structure settle. Weight management reduces load on joints and is part of the treatment for arthritis and plantar heel pain.^[20,2]

Medication

Anti-inflammatory medicines can ease pain and swelling, but they aren’t right for everyone. An ankle-sprain guideline advises care with them, because they carry risks and may interfere with natural healing.^[17,1] Discuss any medicine with your physician, especially if you have kidney disease, stomach problems, heart disease, or take blood thinners.

Injections

Injections are used selectively, and the evidence differs by condition:

• Corticosteroid injections reduced heel pain in the short term. In a meta-analysis of 47 trials the benefit was not clear beyond a few weeks, and it was less effective than some alternatives in the longer term.^[21] They are not recommended in the Achilles tendon.^[7]
• For big-toe arthritis, corticosteroid and hyaluronic acid injections have had varied results, and roughly half of people treated non-surgically go on to have surgery within one to two years.^[22]
• Platelet-rich plasma and other injectable treatments reduced heel pain in the short term in a large meta-analysis. Only shockwave therapy showed a benefit in the medium and long term.^[23]

Shockwave therapy

Extracorporeal shockwave therapy delivers pulses of energy to the painful tissue. In a large meta-analysis of treatments for plantar fasciitis, it was the only treatment that improved pain in the medium and long term.^[23] Evidence in insertional Achilles tendinopathy also favors it, alone or with eccentric exercise.^[24]

Immobilization

A brace, walking boot or cast rests an injured tendon, ligament or bone. It is used for short periods, because prolonged immobilization can weaken muscles and cause stiffness. In a Charcot foot, complete protection from weight-bearing is the essential treatment.^[25]

Treating what’s behind the problem

Blood sugar control, nutrition, bone health, calf tightness, a medicine that affects tendons, and inflammatory conditions may all contribute to a foot problem. Addressing them is part of the plan. For people with diabetes, regular foot screening and proper footwear prevent ulcers.^[26]

How long to try, and when to reassess

The right duration differs by condition. As examples, surgery for plantar fasciitis is generally saved for people who haven’t improved after about 12 months of thorough non-surgical treatment.^[2] For Achilles tendinopathy, it is considered after about six months.^[7] For a painful flatfoot, it is considered if pain hasn’t improved after several months of appropriate treatment.^[8] A useful approach is to agree on what to try, for how long, and what signals it is time to reassess. Worsening pain, a new deformity, an open sore, or loss of function are reasons to be seen sooner.

When to seek care

Non-surgical care should get better results over weeks to months. If your symptoms are getting worse or aren’t improving, ask for a reassessment.