Osteoarthritis is the most common musculoskeletal pathology with 15% of the world’s population suffering from its effects (Hubbert et al, 2018). It is particularly debilitating when it affects a weight-bearing joint such as the hip, knee or ankle. Osteoarthritis of the hip and knee is very common but osteoarthritis of the ankle is much less, with only 1% of the population suffering from it (Nakamura et al, 2016).

The ankle is a complex region consisting of 3 separate joints which are responsible for producing movement (see image below):

  1. The talocrural joint (the ankle joint proper – blue arrow below) is formed by the articulation of the tibia, fibula and talus bones and is responsible for dorsiflexion (pulling your foot up) and plantarflexion (pointing your foot down).
  2. The inferior tibiofibular joint (red circle below) is formed by the articulation of the tibia and the fibula bones and is responsible for stabilising the lower shin and the ankle.
  3. The subtalar joint (green circle below) is formed by the articulation of the talus and the calcaneus bones and is responsible for inversion (turning your ankle in) and eversion (turning your ankle out).

The exact cause of osteoarthritis is unknown. There are some known genetic and environmental risk factors.

These risk factors include:

  • Age – the prevalence of osteoarthritis increases with age
  • Obesity – the increased pressure on the joints can lead to arthritic change.
  • Previous trauma – studies have shown ankle joint osteoarthritis to be present in 78% of ankles following traumatic injury such as an ankle sprain or a broken bone.
  • Altered biomechanics and muscle weakness – If your body weight and related forces are not evenly dispersed through the joint it may be more susceptible to developing osteoarthritis.
  • Sporting activities or physical occupations can put excessive forces through a joint over many years, resulting in arthritic changes.

If your ankle joint is subjected to one or more of the above risk factors it is more susceptible to developing osteoarthritis.  The ankle joint surfaces are lined with a layer of articular cartilage (see image below). Articular cartilage covers the bony surfaces of the ankle joint producing a protective shock absorbing layer for the bone surfaces beneath. It provides a smooth, friction free surface for the joint to glide during movement. Osteoarthritis occurs when the articular cartilage becomes thinner and the joint space is reduced. This results in morning stiffness, a reduction in your range of movement, pain and swelling.

The pain in the joint is thought to be from the sub-chondral bone (the bone underneath the articular cartilage) and the joint lining, known as the synovium. Inflammation of the synovium is called synovitis. Synovitis has been shown to be associated with disease progression and is responsible for the painful flareups that are associated with osteoarthritis.

How do you know if you have ankle joint osteoarthritis?

Ankle joint osteoarthritis can be very painful and may take many years of slow progressive change before becoming symptomatic.

Symptoms of ankle osteoarthritis include:

  • Deep nagging ache located within the ankle joint – this may start as an intermittent pain which slowly and progressively becomes more constant.
  • Intermittent periods of sharp pain – this may affect your sleep or cause you to limp.
  • Stiffness – your ankle may feel stiff when you get out of bed, when you start to walk after a period of sitting down or after exercise. This stiffness usually dissipates as you start moving. As osteoarthritis progresses the stiffness becomes more persistent resulting in a reduction in joint range of movement.
  • Swelling and/or bony deformity of the joint. As osteoarthritis progresses, the joint can get bigger or change shape – this is known as joint deformation.

How is osteoarthritis of the ankle diagnosed?

An accurate diagnosis of ankle osteoarthritis is critical. Correct diagnosis will allow your clinician to prescribe the most appropriate treatment option for you.

A definitive diagnosis is made using an x-ray. X-ray waiting lists in the NHS are typically very short and your GP can arrange this for you quickly and efficiently. If this is proving difficult, we can organise this for you.

Your GP may also ask you to have some blood tests. Blood tests are used to diagnose systemic arthritic pathologies such as rheumatoid arthritis or gout.  X-ray is a gold standard imaging technique for the diagnosis of osteoarthritis and also assessing the severity of joint damage.

It is common for patients to experience pain levels which do not correspond with the level of osteoarthritis seen on x-ray. Therefore, it is essential that an experienced clinician carried out a full clinical assessment of your ankle before further treatment decisions are taken.  The below image shows an x-ray of an ankle with osteoarthritis.

At your appointment with Complete we will carry put a comprehensive examination of your foot and carry out a diagnostic ultrasound scan. Diagnostic ultrasound is a quick and effective imaging modality commonly used to assess arthritic changes within the ankle joint. It is highly specific at picking up not only bony joint changes but also the presence of synovitis associated with osteoarthritis (Wakefield et al, 2000,  Kaeley et al, 2020). It is thought that the synovitis is responsible for a significant proportion of the pain associated with osteoarthritis.

How do we treat osteoarthritis of the ankle?

Osteoarthritis is a progressive degenerative disease of the joint. Treatment is therefore designed to improve or maintain the strength and range of movement at the joint. Research has shown that having good range of movement and strong musculature surrounding the joint is important in maintaining function and reducing pain in the presence of osteoarthritis. Your clinician will provide you with a progressive stretching and strengthening exercise program to help you maintain strength, flexibility and balance, allowing to you to continue the activities you enjoy. Your physiotherapist may also perform manual release techniques which involve manipulating and/or mobilising your ankle to improve range of movement. We will provide advice on how to look after your joint and how much activity you should be doing each day.

On occasion we will also use taping techniques and/or recommend a brace for you to wear during weight bearing activities such as hiking or prolonged walking.

Here are a few tips which you may like to try yourself:

  • Rest from activities which are painful. If this is not possible try to modify these as best as you can. This may include taking regular breaks.
  • If you are overweight, losing weight will reduce pressure through your ankle joint and will help reduce pain and increase function.
  • Try some gentle ankle stretches – such as simple calf stretches (see image above)
  • Calf strengthening exercises such as using an exercise band can be useful (see image above)
  • Over-the-counter oral medication such as paracetamol or ibuprofen, or a topical anti-inflammatory gel such as Voltarol can be effective at reducing pain associated with osteoarthritis. Speak to your pharmacist before taking any medication.

What if conservative management does not work?

Ultrasound-guided corticosteroid injection

If your ankle symptoms do not respond to conservative management and your pain remains then a corticosteroid injection may be suitable for you. A corticosteroid is a strong injectable, anti-inflammatory medication which has been routinely used in the management of osteoarthritis for decades and can be particularly effective in the following circumstances:

  • Pain that wakes you up at night
  • Pain that stops you completing your normal daily activities and/or is getting worse
  • Pain that stops you from taking part in your physiotherapy rehabilitation program.

At Complete, all injections are completed under ultrasound guidance. Current research shows ultrasound-guided injections are more accurate and more effective at reducing pain and increasing function than landmark guided injections (Finnoff et al, 2015).

The corticosteroid is injected directly into the ankle joint, using real time ultrasound imaging, where its anti-inflammatory effects can rapidly reduce the pain associated with ankle joint. Whilst ultrasound-guided steroid injections are highly effective in reducing pain, to achieve the best results, a course of physiotherapy should commence within 1-2 weeks after the injection.

Ultrasound-guided hyaluronic acid injection

Hyaluronic acid is a synthetically manufactured medication which mimics the ankle joint’s natural lubrication. Current evidence shows its effectiveness at reducing the pain and inflammation of arthritic joints, especially in active patients who are not overweight.  Hyaluronic acid injections are completed under ultrasound guidance using the same procedure as a corticosteroid injection and are commonly seen as an alternative treatment to corticosteroid injections. Once again, for best results, physiotherapy is highly recommended following injection.

All clinicians at Complete Injections are fully qualified physiotherapists, musculoskeletal sonographers and independent prescribers, experienced in treating osteoarthritic ankles. On your initial consultation your clinician will complete a full assessment including diagnostic ultrasound scan. If appropriate, you will be offered an injection on the same day. Your clinician is able to prescribe the correct medication so there is no need for a GP referral.

What if an injection does not work?

In some cases, where there is significant osteoarthritis in the ankle, an injection may not work. If this is the case you may be referred to an orthopaedic surgeon for consideration of surgical intervention. Your clinician can discuss this with you and help refer you to the most appropriate consultant.

If you would like more information or would like to book an appointment please contact us on 0207 4823875 or email injections@complete-physio.co.uk.

References

FINNOFF, J.T., HALL, M.M., ADAMS, E., BERKOFF, D., CONCOFF, A.L., DEXTER, W., SMITH, J. and AMERICAN MEDICAL SOCIETY FOR SPORTS MEDICINE, 2015. American Medical Society for Sports Medicine Position Statement: Interventional Musculoskeletal Ultrasound in Sports Medicine. Clinical Journal of Sport Medicine, 25(1), pp. 6-22.

HUBERT, J., WEISER, L., HISCHKE, S., UHLIG, A., ROLVIEN, T., SCHMIDT, T., BUTSCHEIDT, S.K., PÜSCHEL, K., LEHMANN, W., BEIL, F.T. and HAWELLEK, T., 2018. Cartilage calcification of the ankle joint is associated with osteoarthritis in the general population. BMC Musculoskeletal Disorders, 19(1), pp. 169-8.

KAELEY, G.S., BAKEWELL, C. and DEODHAR, A., 2020. The importance of ultrasound in identifying and differentiating patients with early inflammatory arthritis: a narrative review. Arthritis research & therapy, 22(1), pp. 1-10.

NAKAMURA, Y., UCHIYAMA, S., KAMIMURA, M., KOMATSU, M., IKEGAMI, S. and KATO, H., 2016. Bone alterations are associated with ankle osteoarthritis joint pain. Scientific Reports, 6(1), pp. 18717.

WAKEFIELD, R.J., GIBBON, W.W., CONAGHAN, P.G., O’CONNOR, P., MCGONAGLE, D., PEASE, C., GREEN, M.J., VEALE, D.J., ISAACS, J.D. and EMERY, P., 2000. The value of sonography in the detection of bone erosions in patients with rheumatoid arthritis: A comparison with conventional radiography. Arthritis & Rheumatism, 43(12), pp. 2762-2770.