Aches and pains in a variety of joints are common throughout pregnancy. Low back pain is typically the most prevalent, but any joint can be affected for a variety of reasons, including the feet and ankles.
How common is ankle pain in pregnancy?
Low back pain represents the most common form of joint pain during pregnancy, but ankle and foot pain can also be quite prevalent. A study conducted by Kesikburun et al (2018) assessed musculoskeletal pain sites across the duration of pregnancy in 184 women. This study identified that 6.5% of the women had foot and ankle pain in the first trimester, 9.2% had foot and ankle pain in the second trimester, and 19.6% of women experienced foot and ankle pain in the third trimester.
In other words, while the majority of women in this study did not report ankle pain during pregnancy, almost 1 in 5 women did report ankle pain in the third trimester, making it a fairly common symptom that can be quite distressing when there’s already a lot going on.
What causes ankle pain in pregnancy?
The cause of ankle pain in pregnancy is multi-factorial and not fully understood. A study conducted by Francisco et al (2018) assessed foot posture during pregnancy with the hopes of understanding its influence on pain. They found that Foot Posture Index, which is a valid and reliable way to examine foot posture in clinical studies, varied throughout pregnancy, but did not appear to be associated with the onset of foot and ankle pain.
Additionally, pronation increased over the course of pregnancy, and while this is usually associated with various musculoskeletal ailments, the authors stated they could not say with confidence that it significantly influenced pain in the lower limbs, at least in this study cohort. However, this result should be taken with a grain of salt, as other studies focusing on a combination of factors suggest that over-pronation should not be overlooked (more on that later).
Lastly, while foot size did not significantly increase from the first to third trimester in this study, body weight and body mass index (BMI) did change significantly, suggesting the increased force from general weight gain that is being placed on the foot and ankle may have a role in the development of foot and ankle pain in pregnancy.
Why does foot pronation increase during pregnancy?
In the information above, we suggested that weight gain and BMI may play a role in the development of foot and ankle pain during pregnancy, but the study cited was unable to confirm this directly. What else could be going on? After all, physiological and hormonal changes during pregnancy are abundant, and it’s difficult to imagine that doesn’t play a role in how one feels on multiple fronts.
Specifically, the main endocrine change during pregnancy that is often deemed an important consideration by physiotherapists is the increased secretion of relaxin. Often considered one of the pregnancy hormones, it naturally exists in the body prior to pregnancy, but the increased secretion helps to relax connective tissue in preparation for child birth, on top of other physiological functions it facilitates throughout pregnancy. This hormone effectively loosens connective tissue throughout the body in order to accommodate body changes and facilitate the birthing process.
Unfortunately, relaxin isn’t completely specific to pregnancy-related functions, and it will loosen a variety of connective tissues throughout the body, including ligaments in the foot and ankle. Given concurrent postural and weight changes that occur during pregnancy, this excessive stress being placed on the foot and ankle joints is not as well supported by loose ligaments and fascia, which can lead to excessive foot pronation or flat feet. In summary, excessive foot pronation can play a role in the development of ankle pain in pregnancy when considered alongside other contributing factors.
Plantar Fasciitis in Pregnancy
While increased foot pronation was not found to be directly associated with onset of foot and ankle pain in the Francisco et al (2018) study cited above, other studies do suggest that this, in combination with other factors, can lead to the development of plantar fasciitis in pregnant women (Gianakos et al 2022). While plantar fasciitis is typically felt as heel pain or foot pain, it can continue to alter biomechanics of the ankle joint as well, thus indirectly increasing vulnerability of the ankle joint. This means that plantar fasciitis can lead to foot pain, ankle pain, or both.
In the study by Gianakos et al (2022), currently available data from previous research was combined and analyzed. They found that pregnant women who develop plantar fasciitis benefit from conservative therapies, particularly when addressed early on. Physiotherapy is a primary treatment method for plantar fasciitis, and by developing a specific strengthening program aimed at foot intrinsics and other surrounding musculature, such as the calf muscles, one can reduce the pain associated with plantar fasciitis while also preventing secondary problems in the ankle.
Furthermore, a physiotherapist can also determine if any modalities or manual therapy could be indicated as an adjunct to activity-based treatment and resolve the symptoms associated with plantar fasciitis in the short term.
Ankle Swelling in Pregnancy
Given the pregnancy-related endocrine changes (some of which were mentioned above), combined with increased circulating blood volume, an enlarged uterus, and increased body weight, it can be expected that most women are prone to developing lower leg swelling during pregnancy. In fact, it was found that approximately 40% of women develop varicose veins and 80% develop swollen feet and ankles during pregnancy, both of which can cause discomfort especially in the second and third trimesters (Gianakos et al., 2018 – further information in this section largely cited form this same study).
Therefore, while it’s entirely possible that one can develop ankle pain during pregnancy without swelling, it’s definitely one of the more common changes to be reported. Foot and ankle swelling tends to be focused around the top of the foot and the ankle, and is more likely to occur with lack of activity, increased blood pressure, and venous return (i.e. blood circulation). Symptoms of swollen ankles in pregnancy include pain, soreness, a sensation of tightness, and reduced joint mobility.
Treatment for foot and ankle swelling in pregnancy is similar to swelling that appears after suffering an ankle sprain, but with a couple considerations in mind. Extremes of temperature are sometimes avoided, such as ice, but this is typically a precaution for those with vascular issues to begin with. Other strategies include water immersion, whereby the water provides external pressure on the limbs similar to compression stockings. Compression stockings can also help reduce the ankle swelling in pregnancy, but results are a little more variable with this one.
Elevation, which involves keeping the legs elevated above heart level, can be effective in reducing swelling, as the force of gravity will assist in venous and lymphatic return. Other modalities, such as massage and reflexology, have shown some promising results, but again this is a little more variable.
To a physiotherapist’s delight, one effective method for pregnant women to prevent and reduce swelling in the ankle is through exercise! Therapeutic exercise has been consistently recommended for most women during and after pregnancy, and this can even be combined with some other methods to reduce swelling, such as aquatic exercise (exercise + water immersion). This can assist with proper blood flow helping to reduce fluid retention, as well as strengthening muscles that are required for foot and ankle support.
That said, most people understandably don’t know where to start, or require some guidance in order to confidently and safely exercise during pregnancy. Therefore, it’s always a good idea to consult with a healthcare professional who has specific expertise in this field, such as physiotherapists and obstetric health professionals.
Ankle pain in pregnancy is quite common, but given the source of this pain can vary and is often multifactorial, it is highly recommended to consult with an obstetric health professional or physiotherapist at any point during pregnancy, as information provided by these professionals can give you the confidence you need to safely manage any ankle discomfort that arises during this time.
Francisco Javier Vico Pardo, Andres López del Amo, Manuel Pardo Rios, Gabriel Gijon-Nogueron, Cristina Castro Yuste (2018). Changes in foot posture during pregnancy and their relation with musculoskeletal pain: A longitudinal cohort study. Women and Birth. Volume 31, Issue 2. Pages e84-e88. ISSN 1871-5192. https://doi.org/10.1016/j.wombi.2017.08.114.
Arianna L. Gianakos, Adam Abdelmoneim, Gino M. Kerkhoffs, Christopher W. DiGiovanni (2022). The Pregnant Patient – Why Do My Feet Hurt? The Journal of Foot and Ankle Surgery. Volume 61, Issue 6. Pages 1357-1361. ISSN 1067-2516. https://doi.org/10.1053/j.jfas.2022.04.004.
Kesikburun S, Güzelküçük Ü, Fidan U, Demir Y, Ergün A, Tan AK (2018). Musculoskeletal pain and symptoms in pregnancy: a descriptive study. Therapeutic Advances in Musculoskeletal Disease. Volume 10, issue 12. Pages 229-234. doi:10.1177/1759720X18812449
The content here is designed for information & education purposes only and is not intended for medical advice.