Can treating foot and ankle pain prevent knee replacement?

Ross A. Hauser, MD. Danielle R. Steilen-Matias, MMS, PA-C.

Can treating foot and ankle pain prevent knee replacement?

“Everything hurts, but it’s my knee, that is really bad.”

Often we will see patients who are trying to make challenging decisions. They have significant knee pain, ankle, and foot pain. What should they address first? If they consider knee replacement, post-surgical rehabilitation may present a great challenge with their ankle and feet preventing them from walking well. In the same light, addressing the ankle or the foot first would make rehabbing difficult if the patient has significant knee instability and pain.

One of the benefits of regenerative medicine injections is that you can treat more than one painful area at the same treatment visit. For the patient who has significant knee, ankle, and foot pain, treating three joints at the same visit may bring cumulative added benefit to relieving your joint pain, painful walking, and unstableness on your feet. Simultaneous treatment of multiple joints may also help reduce or prevent the need for a knee or ankle replacement.

Below is a video demonstration of these injection treatments, Prolotherapy and PRP.

Prolotherapy is an in-office injection treatment that research and medical studies have shown to be an effective, trustworthy, reliable alternative to surgical and non-effective conservative care treatments. In our opinion, based on extensive research and clinical results, Prolotherapy is superior to many other treatments in relieving the problems of chronic joint and spine pain and, most importantly, in getting people back to a happy and active lifestyle. This is why it is the Caring Medical treatment method of choice.

Sometimes Platelet Rich Plasma Therapy is referred to as PRP Therapy, PRP injection therapy, plasma replacement therapy, or simply PRP shots. PRP treatment takes your blood, like going for a blood test, and re-introduces the concentrated blood platelets from your blood into areas of chronic joint deterioration.

Joint pain, like a knee or an ankle, is usually not a problem that sits in isolation. This means the bad joint is causing and contributing to pain problems in other joints. We see patients all the time who come in and tell us, “everything hurts, but it’s my knee, that is really bad.”

In this article, we will show you research on how one damaged joint can lead to multiple joint pain and how joint replacement surgery may fix one problem and create another. We will also show you how regenerative medicine injections, given in multiple joints may spare you a lot of knee and ankle, and foot pain.

Before we move forward, most articles that involve joint replacement deal with people 55 and over. But what if you are a younger person, a construction worker? Homebuilder? Someone who makes their living being on their feet all day? What if you are very active in sports? What if you have worsening deterioration of your joints? There is a strong likelihood that you will be pain managed until such time as you get old enough or your joint degenerates enough for joint replacement. Unless of course, you decide to look into regenerative medicine.

Are you a construction worker? Homebuilder? Someone who makes their living being on their feet all day? Can regenerative injections help?

We invite you to explore these articles on our websites for answers on ankle and knee replacement:

Only 1 in 11 patients over the age of 55 have knee pain without anything else hurting – it is, therefore, likely you are in the 90% of people who have multiple joint pain.

On average people over the age of 55 had pain in 4 joints.

The hip, knee, ankle and toe joints make up the joints of the lower extremities. The primary function of these lower extremity joints is to support the weight of the head, arms, and trunk during daily activities that involve movements such as walking, running, climbing stairs, sitting and exercising. Naturally, the forces exerted on the lower extremity joints are many times that of the upper body, thus the muscles and ligaments of the lower extremity must be much bigger and stronger. Each lower extremity joint has unique features for specific biomechanical functions. The hip joint’s ball-and-socket configuration provides it with inherent stability while supporting substantial mobility. The knee joint, the largest and most complex joint in the body, has important biomechanical functions, including the transmission of forces through the lower limb, shock absorption, and conservation of energy during activities, such as walking and running. The ankle and foot joints have the incredible task of bearing the weight of the body during ambulation and running and must be sufficiently pliable to handle uneven ground

The motions of the hip, knee and ankle joints rarely occur independently. These joints are functionally related and must work in concert for most types of movement to occur. For example, all three are involved in running, climbing, and standing from a seated position. The strong functional association between the joints of the lower limb is reflected in the fact that about two thirds of the muscles that cross the knee also cross either the hip or the ankle. Unfortunately, due to these innate connections, when one of these joints becomes damaged or unstable, over time other joints in this functional triad can be affected, causing more joint instability, more dysfunction, and increased pain.

In this illustration, we can see that foot-to-neck instability and joint pain can start with foot pronation or neck pain that travels down the body or up the body.

Individuals with knee and foot problems were 14 times more likely to experience difficulty standing and walking

If you are reading this article, you probably do not need to be provided with much research to suggest that you have a lot of things that are hurting you in addition to your knee and ankle. But research has a way of showing you that you are not alone and that there are medical professionals trying to help come up with some answers for you.

Here is research from the University of Leeds, Chapel Allerton Hospital in the United Kingdom, published in the journal Arthritis and Rheumatism. (1) It makes the suggestion to doctors that they need to treat multiple joint pains. Here is what they found:

It was more unusual for a person over the age of 55 to have single joint pain than multiple joint pain. In fact, the average person over the age of 55 had on average, pain in 4 joints.
Although the knee was the most frequently involved joint, isolated knee degenerative disease accounted for only 1 in 11 patients with knee pain.
Although single-joint disorders increased the risk of experiencing functional difficulty, this risk was substantially increased with multiple joint problems: individuals with knee and feet problems were 14 times more likely to experience difficulty standing and walking.

CONCLUSION: “Multiple-site joint problems are much more common than single joint problems. Although individual joint problems have a considerable impact on a person’s functional ability, this risk is substantially increased when other joints are involved. With the increasing burden associated with the aging population, it is essential that the management of joint pain be considered in light of the impact of multiple, rather than single, joint problems.”

This study was from 2006. Certainly, medical research has progressed. Indeed it has, in 2019 researchers suggested this problem was much worse than originally thought and should be identified as a “syndrome.”

“Multisite pain warrants further consideration as a unique geriatric syndrome”

Here is research lead by the University of Massachusetts, Beth Israel Deaconess Medical Center, Boston, and Harvard Medical School. It was published in August 2019 in the journal Aging Clinical and Experimental Research. (2) Here is the summary research:

Chronic musculoskeletal pain is highly prevalent in older adults, and individuals with musculoskeletal pain frequently report pain in two or more sites.
(This study is) to determine the prevalence and characteristics of multisite pain in relation to other geriatric syndromes and to evaluate whether multisite pain may represent a distinct geriatric syndrome.

The study enrolled 749 participants aged 70 and older.

The prevalence of multisite pain was 40% in this population of older adults.
Many participants had more than one geriatric syndrome, indicating a substantial overlap in the prevalence of these conditions.
Nearly half (48%) of participants with urinary incontinence or falls, 61% with ADL disability, and 49% of those with frailty also had multisite pain.
- Explanation point – ADL disability. This is your ability to do “Active Daily Living.” When you have ADL disability you have difficulty in:
  - Bathing, washing, and showering
  - Personal hygiene and grooming
  - The ability to dress yourself
  - Being able to use the toilet
  - Being mobily independent, being able to walk, or get in and out of a car or bed.

CONCLUSION: “Although prior studies have explored risk factors for chronic multisite pain, these findings reveal that multisite pain, often unexplained, bears many similarities to established geriatric syndromes. (urinary incontinence, falls, and frailty) Multisite pain warrants further consideration as a unique geriatric syndrome.”

“I had a knee replacement and now my ankle is killing me”

“Ankle bone connected to the shin bone, Shin bone connected to the knee bone.” There are many of you reading this article who may remember the old song “Dem Bones” and sang it when you were a child. The song gave the Biblical prophet Ezekiel instructions on how to put the dry bones the prophet was shown in the chapter of Ezekiel 37 back together so that they would become people again.

This often-used example of skeletal harmony in motion goes a long way to help you understand that if you “fix” one problem, you may be creating another. So is the case of ankle pain following knee replacement surgery.

“Now I need an ankle replacement”

In the medical journal Knee Surgery, Sports Traumatology, Arthroscopy, (3) Surgeons from the Department of Orthopaedic Surgery, College of Medicine, Kyung Hee University in South Korea published these findings:

“Changes in the parts of the lower extremity below the ankle joint following the correction of varus deformity of the knee (knee replacement) must be considered when Total Knee Replacement is planned and performed. Patients who have problems at the ankle, subtalar, and foot joints in addition to varus deformity (your knees point inward) of the knee are recommended to undergo knee joint correction first.”

Now there are some studies to suggest that ankle pain after knee replacement is “normal.” That your knee is operating in the correct way now and that your muscles just have to adjust. Maybe for some, but not for all.

Occasionally, patients experience new or increased ankle pain following total knee replacement and “a worse clinical outcome.”

Against the thinking that ankle pain following a knee replacement is normal and that the patient needs to have patience in regard to their rehabilitation, comes this study:

In the American Orthopaedic Association’s Journal of Bone and Joint Surgery, (4) surgeons from the Seoul National University College of Medicine in South Korea published these 2018 findings:

Occasionally, patients experience new or increased ankle pain following total knee arthroplasty (total knee replacement).
“A considerable proportion of patients who underwent (total knee replacement) had concomitant ankle osteoarthritis with reduced flexibility of the hindfoot. These patients experienced increased ankle pain following (total knee replacement) and a worse clinical outcome.”

We do understand that we point out a lot of problems with surgery. We have seen so many patients post-surgery who did not have the success that they had hoped for. The research from the surgical community confirms what we have seen clinically there are a lot of people who did not have a successful surgery. This does not mean you will not have a good surgery if you choose to go that route. People do have successful surgeries too.

What is pointed out in this research is simple. If you have significant ankle osteoarthritis and you have a knee replacement, you are at risk for “a worse clinical outcome.”

Treating your foot and ankle pain may help you avoid a knee replacement

In our article, The Evidence for Treating Ankle Osteoarthritis Pain and Loss of Function without Surgery, we suggest that: “Hopefully, you are at a stage where the damage to your ankle is not irreversible. If you have chronic ankle instability but a good range of motion in your ankle, we believe we can help you avoid future surgery and strengthen your ankle. The key is fixing the instability before the instability creates significant bone damage.”

To be clear, some patients have clear clinical deformities of their knee or their ankle that have progressed to a point that realistic assessments of treatments have to be made. When someone comes into our clinics and we do an examination, it is very rare that someone will be told surgery is the only way. But rare as it is, for some patients, their realistic option is surgery. Why? Because their situation has gone on too far and too long. Who are these people? The ones who usually were pain managed with conservative care until such time as their joint degeneration became “bad enough,” to “finally be approved for surgery.” These are the people whose joints continued to erode without a positive means of stopping that degeneration or regenerating or repairing the damaged tissue.

Patients with foot and ankle and knee pain over a four year period – if you stop the ankle damage you can save the knee

Here is a study from The University of Melbourne, which was published in the medical journal Osteoarthritis Cartilage (5) in May 2017. The researchers of this study examined patients with foot and ankle and knee pain over a four-year period. Here are the summary points::

“(our) study found that people with knee osteoarthritis who report foot/ankle (pain and instability) symptoms are at an increased risk of knee pain worsening compared to people without foot/ankle symptoms over the subsequent four years (of the study).
However, foot/ankle symptoms were not associated with worsening of symptomatic radiographic knee osteoarthritis. (Your knee hurt more but the MRI and scans did not reveal any more osteoarthritis damage.) Note: please see our article My knee hurts worse than my doctor believes it should – my doctor does not believe I have bad knee pain.
These (study) findings are important given that knee pain worsening has been shown to be an independent predictor of the future knee joint replacement surgery. Furthermore, both general and specific causes of foot pain can be treated using simple conservative interventions, suggesting foot/ankle symptoms may be a modifiable risk factor for knee osteoarthritis pain worsening.”

So here the researchers suggest non-surgical conservative care treatment of ankle and foot pain may lead to a lessening of knee pain and the need for knee replacement surgery.

Prolotherapy and regenerative medicine for knee, ankle, and foot

In our clinics, we offer non-surgical solutions to problems of joint pain. Above we discussed how we could treat foot, knee, and ankle at the same visit. Below are demonstrations of these treatments.

In this video, Danielle R. Steilen-Matias, MMS, PA-C, of Caring Medical demonstrates how we treat a patient with a primary complaint of knee osteoarthritis.

The person in this video is being treated for knee osteoarthritis as the primary complaint. The treatment takes a few minutes. The person in this video is not sedated and tolerates the treatment very well. For some patients, we do provide IV or oral medications to lessen treatment anxiety and pain.
The first injection is given to the knee joint. The Prolotherapy solution is given here to stimulate repair of the knee cartilage, meniscal tissue, and the ACL as well.
The injections continue over the medial joint line making sure that all the tendons and ligaments such as the medial collateral ligament are treated.
This patient-reported more pain along the medial joint line. This is why a greater concentration of injections is given here.
The injections continue on the lateral side of the knee, treating the lateral joint line all the tendon and ligament attachments there such as the LCL or lateral collateral ligament.

In this video a Prolotherapy treatment and PRP treatment is demonstrated.

If this article has helped you understand your knee, ankle, and foot pain and would explore options to avoid surgery, get help and information from our specialists

1 Keenan AM, Tennant A, Fear JO, Emery P, Conaghan PG. Impact of multiple joint problems on daily living tasks in people in the community over age fifty‐five. Arthritis Care & Research: Official Journal of the American College of Rheumatology. 2006 Oct 15;55(5):757-64. [Google Scholar]
2 Thapa S, Shmerling RH, Bean JF, Cai Y, Leveille SG. Chronic multisite pain: evaluation of a new geriatric syndrome. Aging clinical and experimental research. 2019 Aug 1;31(8):1129-37. [Google Scholar]
3 Jeong BO, Kim TY, Baek JH, Jung H, Song SH. Following the correction of varus deformity of the knee through total knee arthroplasty, significant compensatory changes occur not only at the ankle and subtalar joint, but also at the foot. Knee Surgery, Sports Traumatology, Arthroscopy. 2018 Nov 1;26(11):3230-7. [Google Scholar]
4 Chang CB, Jeong JH, Chang MJ, Yoon C, Song MK, Kang SB. Concomitant ankle osteoarthritis is related to increased ankle pain and a worse clinical outcome following total knee arthroplasty. JBJS. 2018 May 2;100(9):735-41. [Google Scholar]
5 Paterson KL, Kasza J, Hunter DJ, Hinman RS, Menz HB, Peat G, Bennell KL. Longitudinal association between foot and ankle symptoms and worsening of symptomatic radiographic knee osteoarthritis: data from the osteoarthritis initiative. Osteoarthritis Cartilage. 2017 Sep;25(9):1407-1413. doi: 10.1016/j.joca.2017.05.002. Epub 2017 May 13. PubMed PMID: 28506843; PubMed Central PMCID: PMC5565691. [Google Scholar]

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