Skip to main content

Table 5 Findings, illustrations, categories and synthesised findings of the qualitative data

From: Psychological factors associated with foot and ankle pain: a mixed methods systematic review

Author, Year

Findings

Illustration

Categories

Synthesised findings

McAuliffe 2017

Participants described uncertainty in the causal factors associated with the condition.

“I don’t know. It’s a question people often ask. Definitely people would say to you it’s an overuse. And well I’m not doing enough for it to be overuse. That’s what wrecks me.”

1.1 Perceptions of the cause

1.0 Participants report variability but also uncertainty about factors associated with the development of Achilles tendinopathy, plantar heel pain and ankle osteoarthritis. Fear avoidance behaviours appear common and might be associated with the belief that exercise may worsen pain and cause further injury or tendon rupture.

McAuliffe 2017

Participants described mechanical factors that might associated with the condition.

“Obviously there’s some weakness there I suppose. Or some, or is it down to running style or something. Footwear yeah.”

Turner 2020

Nearly all participants noted that over training was probably the cause of their Achilles tendinopathy.

So I feel that I probably over trained. Not so much leading up to the run, it was more I didn’t recover and allow myself time to recover afterwards and I just pushed it a little bit too far.”

Turner 2020

Some participants believed that the lack of overall fitness was the key cause for the development of Achilles tendinopathy.

“I just assume that I’ve become slightly unfit and that I always had tight muscles in my legs

and it’s kind of a consequence

always had tight muscles in my legs

and it’s kind of a consequence of decades of not really exercising.”

Turner 2020

There was confusion or lack of understanding as to why their condition had not resolved.

“I don’t actually know what’s going on. When I feel the pain, I mean I feel it in the base of my

Achilles, but I don’t know what’s going on.”

Cotchett 2020

Numerous causes were proposed by participants including being overweight, a change in the level of activity, standing for long periods, walking on hard, soft and uneven surfaces, and walking barefoot.

“Probably I was overdoing it. I increased my walk because I used to do around the three to four kilometres, pushing every now and then. But since I retired, I’ve been going five and at times eight (kilometres), and then walking on both hard surface and the sand.”

“I just thought it was because I put on a lot of weight during that time.”

“Well I really don’t know. I didn’t understand what it was. I knew it had something to do with the plantar fascia.”

Ceravolo 2018

Some participants were fearful of re-injury. Which prevented wanting to exercise.

“There is the fear of it reoccurring ... the fear of triggering an attack prevents you from doing stuff.”

1.2 Activity beliefs

McAuliffe 2017

Participants noted that they were fearful of doing further damage (e.g., tear) if they continued to exercise and or failed to complete their exercise program.

“Yeah it could like. It probably ... I’d be thinking that like. By running on it as it is, I think it would. It might get to the stage where it will rupture ... If I don’t get it fixed like.”

Turner 2020

Nearly all participants reported having significantly reduced or completely ceased certain physical activities due to fear of further injury, damage, and/or pain.

“I often just pull out earlier then. I never let it get that bad, if you know what I mean? I don’t really go in as hard. I’ve got that kind of doubt niggling in the back of my mind about it. That I need to protect it, rather than let it get too bad. So I’m not someone who would take it that far to the edge. I think that’s probably more of it, it just hinders me from going further or harder, or any of those things really.”

Yeowell 2021

Participants described fearing the experience of pain if they undertook physical activity.

“I can get away with doing it, it’s afterwards, when I stop, it doesn’t, it’s endless... but wow the pain I felt over the following days. It’s like we’d go to the park and I don’t want to risk it. I don’t want to risk it and then it affect me; not moving tomorrow.”

“If I want to play golf I just go out in a buggy [golf buggy to avoid walking], but you do a lot of twisting … … …”

Ceravolo 2018

Participants described variable experiences related to living with their Achilles tendinopathy. Some were resigned to living with it.

“I expect it’s something I’ll be managing forever, by the sounds of it, from those people who seem to have it.”

“So I just got back to that stage where I’m like—yeah, it’s almost like accepting you’ve got cancer.”

2.0 Living with the condition

 

Ceravolo 2018

Some participants reported minimal impact on quality of life.

“An Achilles is not an epic thing where you can’t live a normal life

or anything like that; I can’t say that it overly affected my

quality-of-life.”

Ceravolo 2018

Participants previous experiences and beliefs about their condition influenced their coping mechanism and approach.

“The attitude in my case, because having 40 years of chronic back pain off and on, you tend to say absorb it into the normality of things … Adopt a more practical and stoic approach to it I think.”

Turner 2020

Nearly all participants reported that the Achilles tendinopathy impacted on their running, either having reduced or completely stopped running.

“It just means altering, I guess, my training regime that I’m used to, to kind of fit in with the injury. So, when there’s the running aspect in that, I just don’t even bother trying anymore.”

Turner 2020

Those who expressed poor prognosis stated chronicity, pathology, and genetic disposition as reasons.

“It can be relieved, but there’s nothing you can do about flat feet. I’m born like that. That’s

how life is. I’m not gonna [sic] play tennis again. I’m not sure that I’ll be able to play table tennis.”

Turner 2020

Participants stated they were motivated to seek treatment for their pain and fear of disability and further deterioration of both the condition and physical activity.

“And there are still things I want to do in the future, like with running and more marathons, … ... So, I don’t have a choice but to keep it strong

and keep doing those exercises.”

Ceravolo 2018

Participants noted having to adapt their lifestyle due to their Achilles tendinopathy which impacted on social connections.

“There are things that you can do, whereas I don’t know about you guys, but when I had the Achilles, it was like being in jail, that real restriction of your freedom for things that you enjoy doing.”

3.1 Impact on activity and participation

3.0 The impact of Achilles tendinopathy, plantar heel pain and osteoarthritis of the ankle is individual presenting with emotional, physical challenges and a loss of self.

Turner 2020

All participants reported that their daily routines and activities were affected by their Achilles tendinopathy.

“I think it restricts me in a lot of things that I would be able to do. I don’t think I can go out and kick the footy with my son, or... You know, I manage to... in pain, to go for a walk with the dog in the evening, if you know what I mean?”

Turner 2020

Nearly all the participants reported having reduced or completely stopped running due to their Achilles tendinopathy.

“It just means altering, I guess, my training regime that I’m used to, to kind of fit in with the injury. So, when there’s the running aspect in that, I just don’t even bother trying anymore.”

McAuliffe 2017

Some participants reported disruption at work, depending on the demands of work.

“Aww, it’s just when you have to go anywhere, walk around the office, walking to go get a coffee. You get up; you’ve forgotten about it sitting down … once you get up it’s like ouch. Then you’re almost limping everywhere. It’s noticeable enough in that

people would say are you all right, what are you limping for.”

McAuliffe 2017

The physical disruption varied based on participants symptoms, however morning pain was more common.

“But in the morning times in particular, very sore in the mornings. You’re literally hobbling around the place until you get moving as such.”

Cotchett 2020

Most participants described a negative impact on physical function.

“I don’t feel as strong in my whole body. I have a bit more trouble lifting, trouble walking, especially down slopes or downstairs, not so bad going up stairs or up slopes but activity has certainly been slowed right down.”

Yeowell 2021

The symptoms experienced impacted on participants function and social life.

“I get no enjoyment out of it [dancing] like I used to. and that means I’ve stopped doing that, because I’m not sufficiently ‘macho’ that I will force myself to do it if it hurts.”

“We tend to go the climbing centre and I’m very limited to where I can go. My friend was into his hiking and we went on loads of walks and I just can’t go.”

“I’m sat in the house, I can’t do nothing. I have no social life. My friends, they all say come and have a pint, but what’s the good in going for a pint when I’m sat there, I can’t move, I can’t go to the bar, I can’t get to the toilet.”

“… I’m not living well with this right ankle. It’s just stopping the living of life, I can’t live my life with it, it’s crazy.”

Yeowell 2021

Negative impact on strength and stability.

“My ankle just doesn’t feel strong. I don’t like walking on cobbles or uneven surfaces as it feels I will go over on my ankle.”

Ceravolo 2018

Some participants noted the negative impact on their mental health including feeling depressed, stressed and reduced self-esteem.

“I don’t want to overstate the cranky and anger stuff, but there’s definitely a general feeling of—it’s almost depression, but not clinical depression, but you just don’t feel good about yourself or the world.”

3.2 Pain impacts emotions

Ceravolo 2018

Achilles tendinopathy limited exercise which negatively impacted on mental health. Exercise relieves stress and increases energy.

“So I rely on exercise heavily to maintain my mental health. The endorphins that I get from training are vital to my mental well- being. To not be able to train would be a devastating impact I think on my mental health.”

Turner 2020

A majority of participants described frustration and/or annoyance with their condition and its limitations on activity.

“Well, I think it’s just like there’s things that I enjoy doing and if I can’t do them, now I get a bit frustrated and it’s part of what makes me happy and makes me satisfied with things. Yeah, I think it’s part of those basic sort of … You know, you do a nice, long run and you feel quite good after it. I’m not having that experience. I think that satisfaction, the challenge, and all that sort of stuff, I’m just not being able to do and expose myself to and I kind of struggle to find that in other modes when I’m not running.”

“It’s disappointing and it’s pretty frustrating, really, because it feels like it’s something that will never go away, but yeah, it’s just very frustrating is probably the biggest thing, really.”

Turner 2020

There was a feeling of a lack of control over their condition.

“I no longer feel that I am in control now.”

“I failed to go to the gym this morning, because I was feeling fed up with myself and so I’m not really in control of any of these things.”

Cotchett 2020

A reduction in physical activity was associated with negative emotions and feelings including hopelessness and frustration.

“I’m a mouse on a wheel. I can’t seem to get off. I don’t know what to do. I don’t know how to lose weight without moving, and how do you move without the pain? So yeah, sometimes I’m a bit exasperated by it”.

“But honestly, if someone told me to mix up a special drink cause that’s what was gonna fix it that’s probably what I’d do as well. So, I probably am trying anything. It’s a bit like spin the wheel and try your luck. I’ll try it all.”

Yeowell 2021

Participants described a negative impact on mood due to their experience of ankle osteoarthritis.

“I got quite depressed with it all. I didn’t realise that there was such an adverse effect that the pain grinds you down and gives you that low self-esteem and no self-confidence. You can see other people your age doing things but you’re not able to. It wears you down mentally and makes you very depressed at times. What you don’t realise is it’s not just physical, it very much affects you mentally.”

“It’s just always there and it just hurts. If it was just one or two blasts of tooth ache then you’d be ok; “ooh that’s not nice”, but when it’s there every time you walk, it just gets you down.”

Yeowell 2021

Pain is the central issue.

“The pain is horrific. It’s just terrible, I wish someone could. .. you know what, I would have it cut off and a false one there if they could. It’s horrendous pain, it’s terrible. It’s driving me round the bend. I’d go for anything to get rid of this pain, I’d try anything now.”

 

Ceravolo 2021

Participants who identified as physically fit described a negative impact on self-image and self-esteem. Quality of life appeared to be more negatively impacted for those whose self-image was affected.

“I’d also say that, in some respects, it (running) defines who I am, and so, if I can’t do that, it’s taking who I am away from me. That’s tough... Well the self-esteem certainly goes down, because you’re not who you were.”

3.3 Loss of self

McAuliffe 2017

Participants noted a negative effect on the ability to undertake activities that are enjoyable and contribute to their social life and sense of self.

“Seeing my peers going to races, winning races or getting PBs. Progressing ... and I’m stuck here. That has been horrendous I have to say. Now, I know there are worse things in life that can happen. But it’s been horrible.”

Yeowell 2021

Participants felt that they had experienced a change in their self-identity and perceived this as a loss of self-worth.

“I was like the leader, and them the handbrakes because they were slower than me; now I’m the handbrake.”

“I’m just useless, just because of a daft ankle. It’s unbelievable that isn’t it. It makes me feel as if I’m good for nothing, I might as well just turn it in, you know, just go for a couple of tablets and I’ll call it a day. Just a waste of time. I’m good for

nothing at the minute. I feel like crying. It’s horrible. Every day of my life; it gets a bit upsetting. You just wanna give in, in the end, you get sick of it.”

“…. I didn’t realise that there was such an adverse effect that the pain

grinds you down and gives you that low self-esteem and no self-confidence … ..”

McAuliffe 2017

Participants noted frustration with the treatment process and the uncertainty of professional opinion.

“For me there were a lot of grey areas. Everybody was giving me, like telling me different things. So like nobody knew 100% everything about Achilles and it was varying, you know people opinions were varying.”

4.1 Perceptions of the management process by health professionals

4.0 External factors from health professionals can affect participants’ experience of Achilles tendinopathy, plantar heel pain and ankle arthritis. Participants described unmet needs regarding a clear diagnosis and management plan. Opinions from health professionals were often conflicting or lacking in detail to obtain an understanding of the condition and the treatment pathway or options. Exercise (strengthening) was considered important although adherence was problematic for people with Achilles tendinopathy. Passive treatments were considered important for positive treatment outcomes in people with plantar heel pain.

Ceravolo 2018

Participants previous experiences and beliefs about their condition influenced their decision on treatment options.

“So they tell you never to stop activity, but I think you really need to do that with Achilles.”

Turner 2020

Frustrations and/or dissatisfaction with healthcare providers and the education they received was a common theme and was reported by several participants.

“Sometimes when you talk to your doctor, or the specialist, it’s very limited time, and they don’t have the time to explain it properly, and they speak in technical terms. I thought the physio spent a bit more time with you to talk to you about it.”

Cotchett 2020

Gathering information from various sources to understand and improve PHP was variable.

“I did actually go to the doctor once and described it to him, but – yeah, he just said massage the foot. The GP didn’t look in the slightest bit interested, really.”

Cotchett 2020

Needing better understanding of PHP, and seeking better management.

“If I had a better idea, better understanding of what was actually happening with it. I think that would have guided me a lot better in what I was doing about it.”

Cotchett 2020

Need for a better explanation and justification of the treatment plan.

“A lot of explanation is being well “Do this or do that” but without really explaining what it is that you’re doing and why you’re doing it and what you’re supposed to observe.”

Cotchett 2020

Participants expressed frustration with conflicting information regarding the best approach to manage PHP with a spectrum of messages being delivered by clinicians and resources available online.

“I mean there’s so much conflicting information on the internet, trying to put that into context with what doctors told me, what my physio friend at work told me and reading different things on the internet, trying to relate that to my condition, and work it all out” (Participant 3).

Cotchett 2020

A strong theme emerged regarding the importance of seeking early diagnosis and advice from a health professional.

“Get a good diagnosis and someone who knows what they’re doing. I suppose looking back, getting a firmer diagnosis at the beginning maybe, trying to get some information that seemed to relate more specifically to your own condition because I found that I was never really quite clear on what advice I was getting really related to what I had because of confusion over what it was” (Participant 3).

Yeowell 2021

Participants described not being taken seriously in the early stages of the disease.

“They x-rayed it, and they said it’s not too bad. They said you can see it, but it’s not bad. .. but I can barely walk on it [in the mornings] until it wakes itself up a bit.”

“In some sense, it seems that it’s not being treated seriously, and if I physically couldn’t walk, I’d be referred to people. Actually, it matters. Long before people are physically incapacitated, because it’s affecting my mental health, it’s affecting my physical health, but it’s not extreme enough with the level of funding the NHS has at the moment for it to be treated seriously. With ankle pain, the pain doesn’t have to be that bad to have a massive impact on your quality of life.”

Turner 2020

Nearly all of the participants were prescribed or sought passive treatment for management of their Achilles tendinopathy.

“So, acupuncture tends to... I respond really well to that and pretty quickly as well. Obviously, massage, anything to loosen up my calf, really. So, massage work or acupuncture on my calves.”

4.2 Individual experiences with treatment.

Turner 2020

Several of the participants believed strength training was the most effective treatment in Achilles tendinopathy.

“I failed to really maintain it properly. I should have done more of those exercises prescribed.”

McAuliffe 2017

Participants expressed the belief that forceful passive treatments were required.

“He wore a kind of a knuckle duster and really rubbed them hard. And I think that’s the only thing that got rid of the morning stiffness.”

McAuliffe 2017

Participants noted the expectation of exercise but were either non-adherent or did not find the principle plausible.

“There was a therapy that was recommended to me maybe at the start of the year, it was called heel drops or painful heel drops? They’re on the edge of the steps and you basically flex, you basically flex down and flex up ... Was it 10 min a night every night for 12 weeks but in my head that was crazy.”

“There was a therapy that was recommended to me maybe at the start of the year, it was called heel drops or painful heel drops? They’re on the edge of the steps and you basically flex, you basically flex down and flex up ... Was it 10 min a night every night for 12 weeks but in my head that was crazy.”

Cotchett 2020

Prefabricated foot orthoses had been explored by participants but with mixed success.

“Well, talk about painful, they were dreadful and then most of my shoes, I couldn’t wear because my instep is too high, and I couldn’t get the foot in the shoe with the orthotics in it” (Participant 5).

“The thing I’ve had the most success with is some orthotic inner soles that are very rigid and seem to hold my foot still. That seems to give me the most support” (Participant 18).

Cotchett 2020

Footwear played a key role in alleviating pain with participants highlighting the importance of wearing supportive shoes with a small degree of heel elevation, and caution was expressed when walking in flat unsupportive shoes.

“Go invest in a good pair of shoes firstly. Never walk barefoot or in thongs and even if you get up in the middle of the night, make sure you put a shoe on to walk around” (Participant 7).

Cotchett 2020

Tension existed in participants’ responses relating to the role of modifying activity and or rest. While some participants modified their behaviour by limiting or eliminating an activity, others questioned the importance of rest.

“I didn’t realise that this would help but I’ve started running and I’ve stopped eating sugar and I don’t think the sugar has a relationship but what it has done is help me lose weight and get healthy” (Participant 17).

“Maybe I just didn’t give it long enough, but I did have a week of total rest and it didn’t help my foot and my brain nearly went into a massive meltdown” (Participant 18).

McAuliffe 2017

Participants noted that rest was often a treatment decision made by the health professional or the patient themselves although there were conflicting opinions about the value of rest.

“I’ve gone to a lot of physios and they tell me it’s an overuse injury but I don’t think it is ‘cause I’ve stopped. People say stop and don’t do anything for 6 or 8 weeks but if I did stop and went back even for a jog a couple of miles after not doing anything for a period of time id still be in pain like it never stopped.”

Yeowell 2021

Mixed experiences with non-surgical management.

“It was gentle exercises, which helped the stiffness in the joint. Doing any kind of mild exercise was unbelievable and the manipulation stuff helped because it kept the joints from freezing up. So, they definitely helped.”

“I have an ankle brace, it’s really good. .. off course in the summer time they’re not great..That’s because it is hot and your feet start sweating more. You get sores on your feet with them, so I take them off.“

“The physio gave me some exercises which, quite frankly, didn’t really help. .. it was just movement exercises and strengthening – the idea being to strengthen the joint.”