Ankle Arthritis

Pain is the most common presenting symptom and is characteristically deep in the anterior ankle or dorsal foot.

History should include any previous trauma or infection, history of systemic disease, such as diabetes or inflammatory arthritis, previous treatments, shoewear, use of orthotics, and tobacco use.

Physical examination should include areas of tenderness, alignment, and range of motion.

• Assessment of alignment of the ankle and hindfoot is particularly important.

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    The presence of severe deformity changes treatment options.

• Most patients with severe arthritis will have lost the majority of ankle motion.

The presence and location of calluses may point to underlying deformity or malalignment, while scars are evidence of previous trauma or surgery.

Observation of the appearance of the soft tissues, palpation of pulses, and monofilament sensory testing provide additional information about healing potential.

• If pulses are not palpable, vascular assessment is needed.

• If any signs of neuropathy are found, the source of the neuropathy must be identified.

Examination of the foot, as well as the ankle, can yield additional useful information.

• Hindfoot flexibility, stability, and alignment should be noted.

• Arthritis at adjacent joints may require concurrent treatment to obtain relief of symptoms.

Gait analysis in patients with ankle arthritis typically shows decreased velocity, stride length, and cadence and more time in double-limb stance.

• However, a formal gait analysis is generally not required in the work-up of ankle arthritis.

Radiographs should include weight-bearing anteroposterior, lateral, and mortise views of the ankle as well as anteroposterior, lateral, and medial oblique views of the foot.

• Radiographs should be assessed for joint space narrowing, alignment, and bone quality.

• The location and size of osteophytes should also be noted, especially when impingement is suspected.

• Obtaining a weight-bearing film is critical to assess true deformity and joint space narrowing.

Alignment should be evaluated on both sagittal and coronal views.

• A procurvatum or recurvatum deformity may be noted by examining the relationship of the tibia to the talus, which should be centrally located with its lateral process under the midline of the tibia.

• In the coronal plane, varus-valgus alignment should be at ~ 0°, measured by the intersection of the midtibial line and the talar dome.

Specialized views may be useful in certain patients.

• The weight-bearing hindfoot alignment view shows coronal alignment of the hindfoot.

• The Harris view shows axial alignment of calcaneus.

• The Broden view shows the subtalar joint.

Other imaging modalities are generally not needed for diagnosis and surgical planning unless diagnosis is in doubt.

• Bone scans may identify occult arthritis, stress fracture, infection, or reflex sympathetic dystrophy.

• Computed tomography (CT) can be used to identify a subtle syndesmosis injury and for complex fractures.

• Magnetic resonance imaging is most useful for investigating the soft tissues, such as in cases of infection and tumor.

Selective diagnostic injections of local anesthetic, such as lidocaine, may be injected in the ankle and adjacent joints to determine relative contributions to symptomatology.

• For example, pain from subtalar arthritis may be confused with ankle-related pain and may be clarified with selective injections to aid surgical planning and improve outcome.

Laboratory data are generally not helpful in diagnosing ankle arthritis.

• However, if there is concern for infection, complete blood count, erythrocyte sedimentation rate, and C-reactive protein are sensitive indicators.

Activity modification may minimize the pain of ankle arthritis.

• Steps include recommending low-impact activities, such as swimming and stationary bicycle, over high-impact exercise, such as example jogging, and sedentary work over occupations that require prolonged standing.

Weight loss may also alleviate symptoms by decreasing force across the joint and may improve results of future surgical procedures.

A cane carried in the contralateral hand may partially offload the joint.

Shoe modifications, orthotics, and braces can also be used to temper the pain of an arthritic ankle.

• A shoe with a rocker sole may allow more comfortable gait by decreasing the amount of ankle motion needed.

• A high-top shoe, boot, or lace-up ankle brace can provide some support and immobilization of the ankle.

• An ankle-foot orthosis also immobilizes the ankle joint, improves axial alignment, and can improve gait.

• An offloading brace that transfers load away from the ankle and to the patellar tendon and proximal tibia can be used in extreme situations.

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    However, these braces are bulky and cumbersome.

Casting may be viewed as the ultimate brace for the ankle and offers pain relief by immobilizing the ankle joint.

• A short leg walking cast can be used for 6 weeks to reduce inflammation and pain, although postimmobilization stiffness should be expected.

Medications may also be used to relieve the pain and inflammation of ankle arthritis.

• Nonsteroidal antiinflammatory drugs act by blocking cyclooxygenase to limit prostaglandin production and thus inflammation.

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    They also have a central effect, which is responsible for their analgesic action.

Glucosamine is a building block of proteoglycans, the primary component of cartilage matrix.

• Although data are limited and primarily addresses osteoarthritis of the knee, it has been shown to offer some pain relief to patients and result in decreased inflammation in arthritic joints.

Glucosamine is commonly coupled with chondroitin, another cartilage matrix protein, and sold as an over-the-counter supplement in a largely unregulated fashion.

• Quantity and bioavailability of the active agents in these preparations is largely unknown.

Steroid injections may be used in the ankle and adjacent joints to decrease inflammation and alleviate pain.

• The ankle joint is injected via the medial or lateral gutter with the needle directed posteriorly.

Steroid injections have been shown to be beneficial for short-term pain reduction but are no different from placebo in the long term.

• Repeated injections separated by several months continue to be effective in some patients but often show diminishing returns.

• Complications include a low risk of infection and skin depigmentation.

• There is evidence from hip and knee arthroplasty that recent steroid injection can increase the risk of infection during subsequent joint arthroplasty.

Hyaluronic acid injections in the ankle may be helpful for pain relief, although the evidence is not strong.

There is no clinical evidence to support the use of platelet-rich plasma injections for ankle arthritis, although that is being explored by some physicians.