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By Nathan Wei
Ankle arthritis is one of the most common problems seen in a rheumatology office. While it is a relatively small joint complex, it is subjected to a great deal of stress because of the weight-bearing required with standing and walking.
Throw in the need to make forward and backward movements as well as side to side movements, it becomes clear that the stress placed on the bones, ligaments and tendons is tremendous. And that doesnt even account for the twisting and [pivoting motions that are often required during a typical day.
Because of this responsibility and location, ankles are probably injured more than any other joint complex.
Many different kinds of arthritis can affect the ankle. The most common are osteoarthritis. Osteoarthritis is a wear and tear type of arthritis. The cartilage that cushions the joint begins to wear away prematurely as a result of trauma and localized inflammation. This type of osteoarthritis that occurs following injury is referred to as post-traumatic osteoarthritis. A common scenario is someone who sprains their ankle as an adolescent or young adult and then develops ankle arthritis years later.
Rheumatoid arthritis comprises about 15 per cent of ankle arthritis. Rheumatoid arthritis is a chronic systemic autoimmune disease that affects virtually all joints. The chronic inflammation leads to progressive deterioration of cartilage, bone, and ligaments.
Other types of arthritis that can attack the ankle include psoriatic arthritis, Reiters disease, gout, pseudogout, sarcoidosis, juvenile arthritis, and ankylosing spondylitis.
Treatment of ankle arthritis first consists of making the correct diagnosis. That takes a careful history and physical examination. Laboratory testing and imaging studies such as x-ray, ultrasound, and magnetic resonance imaging are useful.
Treatment for mild discomfort is straightforward. Limit activities that cause pain. That means high impact sports like running, soccer, and basketball. If excess weight is an issue, then weight loss is mandatory. Over-the-counter anti-inflammatory medicines can also provide symptomatic relief.
Various ankle braces can be a lifesaver. These come in different varieties and shapes. They can fasten using laces or Velcro. Braces may be soft or may contain a hard synthetic shell. It is best to consult with your rheumatologist or orthopedist before purchasing a brace.
Orthotics are shoe inserts that tilt the ankle and relieve pain by altering the direction of stress forces. These should be custom-made for optimal results.
Rocker bottom shoes reduce pain with walking because they limit the amount of motion the joint has to go through. People who have had ankle fusion surgery 9where the joijt is fused together) often find rocker bottom shoes helpful.
When ankle pain is severe due to inflammation and/or fluid accumulation, then aspirating the joint with a needle and injecting a long-acting glucocorticoid (steroid) may be very useful. Following a procedure like this, it is a good idea for the patient to have their ankle braced for at least three days to rest the joint.
Physical therapy is also an excellent adjunctive therapeutic approach. The therapist can help the patient with different modalities that can reduce edema (soft tissue swelling0 as well as inflammation and also teach a patient exercises to strengthen and stabilize the ankle so that future ankle sprains and strains are less likely.
Patients who have severe ankle arthritis due to osteoarthritis may benefit from viscosupplementation. This is a procedure where a lubricant is injected into the joint. Viscosupplements have been used successfully in many joints including the knee, hip, and shoulder, as well as the ankle.
Surgery is an option for patients who have failed more conservative measures. Arthroscopy, which is a procedure where a small telescope is inserted into the ankle joint through a tiny incision. Small instruments are used to remove loose pieces of cartilage. This procedure can also be incorporated with simultaneous cartilage transplant where healthy cartilage is inserted in place of damaged cartilage at the time of the procedure. Cartilage transplant procedures are very time intensive and require limited weight bearing for several weeks to months afterward.
Joint realignment is a procedure where a wedge of bone is removed from one side of the ankle so that stress forces are transferred to the healthy part of the ankle. While this is a temporary fix, it is useful for some patients.
Ankle fusion is a surgical procedure where the tibia (leg bone) is screwed to the talus (upper ankle bone). This restores alignment and reduces pain. Unfortunately, the patient loses about half of the plantar and dorsiflexion (toe down and toe up) movement in the ankle. The ability to walk without pain is restored to the ankle; however, there is more stress placed on other weight-bearing joints such as the knee, which can lead to the development of osteoarthritis in these joints.
Ankle replacement is an increasingly popular option. In the past, ankle replacements werent that effective but technological advances have improved their success. Good candidates for ankle replacement are those who are older than 55 years of age, in good medial condition, have their weight in the normal range, and who dont engage in high impact activities either at work or during their leisure time.
About the Author: Nathan Wei, MD FACP FACR is a rheumatologist and Director of the Arthritis and Osteoporosis Center of Maryland. He is a Clinical Assistant Professor of Medicine at the University of Maryland School of Medicine. For more info: