Do you wake up with a swollen, stiff ankle? Can your ankle predict or respond to a change in the weather? Arthritis is the age related, degenerative changes that normally happen as we age. When these normal degenerative changes happen in the ankle you will be diagnosed with ankle arthritis.
Ankle arthritis causes largening of the joint, your affected ankle may look bigger than your unaffected ankle. Joint stiffness, swelling, and pain will be experienced regularly on your affected ankle.
There are different types of arthritis, which may affect you earlier in life too. A previous injury to your ankle increases your chances of developing ankle arthritis later in life.
How does the ankle joint work?
The ankle and foot have 28 bones forming 30 joints! A fine balance and interplay between these joints allow you to walk. The joints work less hard in supportive footwear and harder barefoot, on uneven surfaces, like sand and pebbles. That is why you may experience foot and ankle pain after walking on the beach. The forces generated over the joints are larger and more powerful when you run and jump. Have you ever balanced barefoot on one leg and noticed the sway from the ankle side to side, the way the toes play piano to grip onto the floor? That is the delicate interplay we are dependant on from day to day, that luckily supports you without you having to consciously think about it.
The ankle joint is formed where the bones of the lower leg, tibia and fibula, articulate with the talus. The tibiotalar joint allows dorsiflexion and plantarflexion. Dorsiflexion is the anatomical term for pulling your toes to your shin, and plantarflexion means pointing your ankle and toes like a ballerina. The subtalar joint, between the talus and calcaneus (heel bone), allows the inwards and outwards aim of the sole of the foot, supination and pronation respectively. Both these joints and the movements permitted through the joints are important for absorbing shock as you strike your heel down when you walk, and maintaining balance as you walk, run or jump.
Where these bone surfaces meet the joints are formed. The end of the bone is covered with articular cartilage, which allows smooth movement from the joint as the bone surfaces slide and rotate over each other. The joint is surrounded by a synovial sheath which supplies synovial fluid to the ankle joint. Synovial fluid feeds and lubricates the articular cartilage to maintain smooth movement.
Different types of ankle arthritis
- Osteoarthritis (OA)
OA is the normal degeneration that occurs with age, or rather with the use of the ankle joint. The smooth articular cartilage decays and the joint may feel stuck, stiff, or as though there are speed bumps inside the joint. With the thinning of the articular cartilage, the bones may experience more and more direct contact which is painful when loading. Osteophytes are bony protuberances that may start to develop as the body attempts to stabilize the joint.
- Rhumatoid arthritis (RA)
RA is an autoimmune disease that normally develops symmetrically. This means that RA would affect the same joints on both sides. The synovial membrane is affected when the body attacks its own cells, causing swelling and pain. The joint surfaces may also be affected, once this happens the joints may become deformed.
- Post traumatic arthritis
After a traumatic injury, like a fracture or dislocation, post traumatic arthritis may develop of the affected joint. This can happen many years after the initial injury. It is similar to OA in that the joint surface is affected.
- Psoriatic arthritis
Psoriatic arthritis is an inflammatory arthritis linked to the auto immune disease, psoriasis, which most visibly affects the skin and nails.
Causes of ankle arthritis
- previous traumatic injury (fracture or dislocation)
- repetitive training (long distance running)
- obesity
- poor biomechanics, your unique foot, and ankle anatomy and your choice of shoes influence the way your ankle joints functions on a day to day basis
- genetic predisposition to rheumatoid or psoriatic arthritis
- reaching advanced age
Does inflammation play a role in ankle arthritis?
Our understanding of osteoarthritis has evolved with time and with patient care. Because surely if ankle arthritis pain was caused solely by joint degeneration you will be in constant, unrelenting pain? Ankle arthritis pain fluctuates and that has led to understanding the pathophysiology better.
As osteoarthritis progresses and more and more articular cartilage is broken down, the ankle becomes inflamed. We used to think that cartilage breakdown causes joint inflammation. However, with MRI imaging of healthy looking cartilage, the synovial sheath may already be inflamed, known as synovitis. The inflamed synovial sheath can then release inflammatory cytokines into the synovial fluid. Inflammatory cytokines, like C-reactive protein and interleukin-6, are the markers of inflammation that will be present with blood tests. The more inflammation within the joint the more cartilage breakdown. This inflammatory cycle needs to be halted.
Does my weight affect my ankle arthritis?
Yes, your weight influences your ankle arthritis. Of course, the heavier load equals greater strain through the joint in its entirety. But extra weight changes your internal physiology too.
Fat cells, adipose tissue, store excess calories. These adipose cells secrete hormones. When you are round about your body’s ideal weight you have normal metabolic function, your adipose cells secrete equal amounts of pro-and anti-inflammatory cells. This balanced secretion means your stay within healthy limits of both the cells that fight and cause inflammation. The more adipose cells expand the more pro-inflammatory cells they secrete. This maintains inflammation throughout your whole body, not only within the ankle joint.
This explains why losing excess weight has a remarkable influence on pain intensity, even when the joint degeneration has not changed.
Can the weather influence my ankle arthritis?
This is not well understood or researched, but the folk tales of elderly or previously injured people “feeling” the change in weather may be due to changes in barometric pressure and humidity. Change in either or both barometric pressure and humidity have been found to increase pain. A drop or rise in barometric pressure or humidity can lead to increased intensity of pain.
How bad is my ankle arthritis?
The severity of OA of the ankle joint is classified with the Takakura Classification. This classification diagnoses the stage of ankle arthritis by using weight bearing X-rays of your ankle. Depending on the degeneration present on Xray, your ankle arthritis can be classified as:
- Stage I
Early sclerosis and osteophyte formation without joint space narrowing
- Stage II
Narrowing of medial joint space (innermost)
- Stage IIIA
Obliteration of joint space of medial malleolus with bone contact
- Stage IIIB
Obliteration of joint space of talar roof, with bone contact
- Stage IV
Obliteration of joint space with complete tibiotalar contact
Diagnosis of your ankle arthritis
As physiotherapists, we have the training and skill to diagnose your ankle arthritis with a thorough physical examination. We will ask detailed questions about the duration of your symptoms, your medical history and any contributing factors. Then we test your ankle joint by checking active and passive range, muscle strength and endurance and proximal stability of your hip and knee. After your clinical evaluation we will have a good idea of the severity of your ankle arthritis and any causative factors that we can address during your treatment.
X-rays
X-rays are the image of choice when we expect ankle arthritis. Weight bearing X-rays of a few different views can be ordered to confirm your ankle arthritis diagnosis. We will be able to see the joint surface, space and if any osteophytes have developed.
Diagnostic ultrasound
A sonar image shows us the soft tissue structures, like muscle, tendons and ligamaents that surround the ankle, but we cannot see what is going on within the joint. Therefore a sonar will not be able to diagnose ankle arthritis.
MRI
An MRI is a costly image that can only be ordered by your specialist doctor. With MRI images we can see what the bone and soft tissue looks like both outside and inside of your ankle joint. This is not necessary to confirm ankle arthritis diagnosis, a X-ray will be sufficient.
Why is my ankle arthritis pain not going away?
Ankle arthritis is aprogressive, degenerative condition. This means that although the symptoms are changeable with correct management, the changes that have already occurred within the ankle joint cannot be reversed. With the correct management, we can slow the degenerative process of your ankle arthritis and enable you to enjoy more of what you love doing, but we cannot take arthritis away.
Unfortunately, there is no quick fix or magic treatment. No medication or injection will reverse your ankle arthritis, please be wary of treatments that sound too good to be true.
You may experience phases or arthritic attacks of pain. This is completely normal and mostly due to load and activity or your body’s internal physiology. It is expected to feel more pain after spending more time on your feet or after you had a cold or flu.
A big problem we see with ankle arthritis
- Mismanagement
It is vitally important that you actively participate in your ankle arthritis treatment. The right advice is crucial for the long term management of this degenerative condition.
- Unrealistic expectation of treatment
Ankle arthritis is a degenerative condition. No treatment will take away your symptoms 100%. The aim of treatment is to understand what is happening in your body so that you can make informed decisions about your care. We aim to give you symptomatic relief of your ankle arthritis symptoms and educate you to pace your daily activities.
- Orthopedic devices
Crutches, canes and insoles should be used correctly. These devices can greatly decrease load and pain if used responsibly.
- Complete rest
Avoiding walking altogether is not the answer. This can lead to deconditioning, weakness and even more joint stiffness.
- Over the counter medication abuse
Please read the list of side effects of the medication you are currently taking. Rather consult with your pharmacist or GP before buying another packet of tablets.
Physiotherapy treatment for ankle arthritis
Once we have established the severity of your ankle arthritis we can determine which factors are contributing to your pain. Ankle joint range of motion, quality of motion, muscle strength and endurance, and your proximal stability will be tested. We will work as a team with you to set realistic goals and then endeavor to reach each goal in a determined timeframe. You will be supported every step of the way as we guide you on your journey to recovery.
Phases of rehabilitation
1st Phase: PEACE & LOVE protocol
Protection
Avoid activities that aggravate your symptoms for a few days. Active rest and use crutches to keep the load off of your ankle. The main aim is to prevent continuous inflammation which will cause continous pain.
Elevation
Elevate your affected ankle higher than your heart, that means lying down with your leg supported on pillows, as often as you can.
Avoid anti-inflammatory medication
Avoid continuous irresponsible use of anti-inflammatory medication. Oral medication can cause gastrointestinal side effects. Rather get treatment for pain relief than being dependant on medication to function.
Compression
Compression bandage or a tight, long sock can limit swelling and inflammation and therefore decrease pain.
Education
Make sure that you get information from the person that is treating you. Its important to understand what you should and shouldn’t do. You can make better decisions if you are informed. Your body knows best, so avoid too many types of treatments at once.
Load
Let pain guide you gradually to return to your normal activities. Initially, it is tricky to know if it is better to rest or to move, but finding a balance between the two is the best you can do. Letting your ankle carry some of the load is a good way to keep muscles and joints moving, without overdoing it.
Optimism
As Westerners, we have to long separated the body from the mind. Visualise your recovery, be confident and postive.
Vascularisation
Choose pain free cardiovascular activities, like cycling or swimming to increase circulation to the ankle and aid recovery. The endorphin release can help to stay positive too.
Exercise
This is where we will help you choose exercises that support your stage of healing.
2nd Phase: Establish pain free range of movement
During your examination, it will become clear what you are able to do, and what you should avoid. We identify factors that contribute to causing your pain, specific to your case and will address these factors as your treatment progresses. Keeping movements through a pain-free range will maintain the available range, improve circulation and keep muscles agile. The aim is that, with time pain with movements become less intense.
3d Phase: Tissue healing
We monitor the progress of joint inflammation. We can manipulate physiology with electrotherapy modalities, like LASER and ultrasound. This can speed up the current flare that you are experiencing. As inflammation settles, we want to see not only an improvement of your pain, but also an improvement in the quality of your ankle movement.
4th Phase: Muscle control and stability
We establish all the contributing factors that influence your ankle arthritis and start to address them early in your treatment. Muscle and joint stability from “upstairs”, your hip, knee, and back can influence the load you place through your ankle. We can lessen the load through your ankle by strengthening your major stabilising muscles. During this phase of treatment you may do core and hip strength exercises.
5th Phase: Pacing & activity modification
Ankle arthritis is a progressive degenerative condition. With the strength work you did in the previous phase we aim to modify contributing factors to slow the degenerative process. Once you start feeling better the true test is to pace your activities and avoid another flare up. Pacing your day to day chores, hobbies and work is very important.
6th Phase: Balance & return to activity
Now that you’ve worked through the different phases of your rehabilitation, we want to improve your balance too. The feet and ankles play a vital role in our ability to balance and reestablish balance if you walk on uneven surfaces.
Your physiotherapist will guide you to return to your normal activities, but with modifications. We are happy is by discharge you have learnt about ankle arthritis to make informed decisions and handle any flare of symptoms.
Other medical treatment for ankle arthritis
Your GP can prescribe analgesic and anti-inflammatory medication that is safe for long term use.
Biokinetic rehabilitation is a great adjunct to your physiotherapy treatment as you will strengthen any muscle weakness, stability and balance that is contributing to your ankle pain.
Infiltration of hyaluronic acid by your orthopaedic surgeon is an option for pain relief.
Insole prescription from your orthotist can aid load transfer and lessen pain.
Is surgery an option for my ankle arthritis?
Your unique case will determine if and what surgical intervention is a possibility. Surgery is only considered when conservative, nonsurgical treatment has made little change to your ankle arthritis pain. Please remember that surgery is not a quick fix, you have a long road to fully recover after your ankle surgery.
- Arthroscopic debridement
During this procedure, your surgeon will essentially clean your ankle joint from any osteophytes and damaged articular cartilage. The procedure is done through keyholes and is the least invasive of the surgical options.
- Arthrodesis
With arthrodesis, your ankle joint is fused with pins and screws. This means movement is severely limited in order to decrease pain.
- Total ankle replacement
Although this is not as common as a knee or hip replacement, recent advances have made this procedure a possibility. The decayed ends are removed and replaced completely with new hardware. Movement is maintained with a total ankle replacement, but you will not be able to fully walk on your “new” ankle for up to six weeks after the surgery.
What else could my ankle pain be?
An acute ankle sprain has a traumatic incident of rolling over your ankle, you will have immediate pain and swelling depending on the severity of your sprain.
- Gout
The big toe joint is mostly affected, but the ankle can get gout too. Extreme pain, swelling, and redness, usually after overindulging in rich dishes and alcohol lead to a build up of uric acid.
- Subtalar pronation / flat feet
Dropped arches may cause ankle pain because of the way load is transferred through the joint when the arch offers less support for shock absorbtion.
- Ankle fracture/dislocation
After a traumatic incident where you cannot take weight on the leg at all, it is advisable to get an X-ray to rule out a fracture of your ankle.
Pain on your heel that is worse when moving from rest and gets better as you move may be caused by Achilles tendinopathy.
- Infection
Redness, swelling and extreme pain after an insect bite or superficial wound when you were out hiking may cause a deep infection.
- Autoimmune diseases
Lupus and scleroderma may present with ankle pain, but will definitely have other symptoms too.
