Intra-Articular Injection of the Ankle Joint—Anteromedial Approach

Indications and Clinical Considerations

The ankle joint is susceptible to developing arthritis from a variety of conditions that all have the ability to damage the joint cartilage. Osteoarthritis of the joint is the most common form of arthritis that results in ankle joint pain. However, rheumatoid arthritis and posttraumatic arthritis also are common causes of ankle pain secondary to arthritis ( Fig. 174.1 ). Less common causes of arthritis-induced ankle pain include the collagen vascular diseases, infection, villonodular synovitis, and Lyme disease. Acute infectious arthritis usually is accompanied by significant systemic symptoms, including fever and malaise, and should be easily recognized by the astute clinician and treated appropriately with culture and antibiotics, rather than injection therapy. The collagen vascular diseases generally manifest as a polyarthropathy rather than a monoarthropathy limited to the ankle joint, although ankle pain secondary to collagen vascular disease responds exceedingly well to the intra-articular injection technique described later.

The majority of patients with ankle pain secondary to osteoarthritis and posttraumatic arthritis pain report pain localized around the ankle and distal leg. Activity, especially dorsiflexion, makes the pain worse; rest and heat provide some relief. The pain is constant and is characterized as aching and may interfere with sleep. Some patients note a grating or popping sensation with use of the joint, and crepitus may be present on physical examination.

In addition to the previously mentioned pain, patients with arthritis of the ankle joint often experience a gradual decrease in functional ability with decreasing ankle range of motion, making simple everyday tasks, such as walking and climbing stairs, quite difficult. With continued disuse, muscle wasting may occur and a “frozen ankle” caused by adhesive capsulitis may develop.

Plain radiographs are indicated for all patients with ankle pain (see Fig. 174.1 ). On the basis of the patient’s clinical presentation, additional testing may be indicated, including complete blood cell count, sedimentation rate, and antinuclear antibody testing. Magnetic resonance imaging of the ankle is indicated if joint instability, occult mass, or tumor is suspected.

Clinically Relevant Anatomy

The ankle is a hinge-type articulation among the distal tibia, the 2 malleoli, and the talus ( Figs. 174.2 and 174.3 ). The articular surface is covered with hyaline cartilage, which is susceptible to arthritis. The joint is surrounded by a dense capsule, which helps strengthen the ankle. The joint capsule is lined with a synovial membrane that attaches to the articular cartilage. The ankle joint is innervated by the deep peroneal and tibial nerves. The major ligaments of the ankle joint include the deltoid, anterior talofibular, calcaneofibular, and posterior talofibular ligaments, which provide the majority of strength to the ankle joint. The muscles of the ankle and their attaching tendons are susceptible to trauma and to wear and tear from overuse and misuse. There are a number of arteries that traverse the joint that can provide sources of bleeding when performing intra-articular injection of the ankle ( Fig. 174.4 ).