Osteoarthritis – Ankle Arthritis

What is arthritis?

Arthritis refers to conditions that damage joints and cause pain. The commonest type is osteoarthritis which is a form of wear and tear involving the joint surfaces. The normal cartilage which forms the smooth lining of the joint surface wears away leaving exposed bone in the joint.  As the condition advances the joint is left with bone rubbing on bone. Sometimes there is no obvious cause for osteoarthritis but in other people it is caused by previous fractures or ligament injuries. In the ankle the instability resulting from a previous untreated ankle sprain can cause arthritis to develop. Arthritis in joints leads to pain, swelling and stiffness and sometimes deformity. 

Another form of arthritis is inflammatory arthritis, of which rheumatoid arthritis is the commonest form. In the majority of patients with inflammatory arthritis the condition is treated by a rheumatologist with medication to prevent the arthritis causing damage to joints. However in some people the condition does not fully respond to drug treatment and can lead to damage to the joints leading to pain, deformity, stiffness and loss of function.

Where can you get arthritis in the foot and ankle?

There are 26 bones in the foot and there is a joint between every pair of bones. Any of these can develop arthritis. Arthritis in the joints of the foot causes pain which for some people is minor but for others can become seriously debilitating. It is often not recognised and when it is it is very common for people to be incorrectly advised that there is no possible treatment.

How is the diagnosis made?

Your surgeon can carry out a physical examination to determine which joint is causing the problem. Sometimes there can be arthritis in more than one joint. The diagnosis can usually be confirmed with an ordinary x-ray but sometimes scans such as MRI, CT or ultrasound can be required.

What is the treatment?

There is currently no cure for arthritis. The damaged cartilage cannot be repaired. However not everyone with arthritis will require surgery. In particular in the early stages, simple measures such as modification of activities, simple pain killers and overall measures to improve general health can be effective at controlling symptoms. 

Our specialist podiatrists can advise whether a well made orthotic might help. Sometimes these effectively redistribute the load away from the painful area to give meaningful relief. They can also advise on general physical exercise regimens that help maintain movement in the joint and overall muscle strength, both of which are important in slowing progression of arthritis.

Sometimes injections can help. These may settle down inflammation in a joint and in situations where the joint surface damage is not extensive this can be effective. In some patients carefully targeted injections can be used to help confirm which parts of the foot are responsible for causing the pain – in this situation the pain relief from an injection is usually only temporary but can be very helpful for guiding further treatment. The commonest injections are steroid injections, but other injections including joint lubricants (known as viscosupplementation) can also be used. 

What about surgery?

Many people with arthritis in the joints of the ankle or foot will get to the point where the symptoms cannot be controlled with simple measures and the only means of relief is an operation. There are many different operations which can be performed for ankle arthritis with the aim of relieving pain and getting you back to your previous level of activity.

In mild arthritis, simple surgery to remove bone spurs can be helpful. Bone spurs, known as osteophytes, form as a part of the body’s healing process – the body cannot repair cartilage so it forms spurs of bone instead to try to protect a joint. These can themselves be a cause of pain. In arthritis of the ankle these can be treated with arthroscopy (keyhole surgery). Find out more about ankle arthroscopy.

Arthritis of the joint at the base of the great toe (first metatarsophalangeal joint) is known as hallux rigidus. Find out more about hallux rigidus and its treatments.

In the ankle there is often the option to replace the joint. For the other joints of the foot replacements are not available but fusion surgery can be very effective at controlling pain. Fusion involves fixing the two worn surfaces together and allowing the body to heal bone across between them – much in the same way as a broken bone heals. By turning the two separate bones into one solid bone the painful joint is removed. Because there are so many joints in the foot, fusion of a joint does not mean loss of all movement in the foot. With some joint fusions there can be a slight reduction in up-down or side-to-side movements of the foot. Find out more about fusion of the foot.

Should I have an ankle replacement or a fusion?

For more advanced arthritis of the ankle, the options are either ankle fusion or ankle replacement. There is often no right answer as to which option to choose and there are advantages and disadvantages to both. For some people there can be reasons why an ankle replacement cannot be performed but for most people both options are available.

Ankle fusion can often be carried out by keyhole surgery (arthroscopic ankle fusion). The advantage of an ankle fusion is that once the bones heal together the pain relief is excellent and long lasting. The disadvantage is that the recovery can be more lengthy and there is an increased load on the adjacent joints which can in turn wear out later on although this process usually takes several decades. People having an ankle fusion are often pleasantly surprised by how much movement they retain in the rest of the foot and the impact on gait is usually far less than might be expected. There are even professional footballers who have continued to play after an ankle fusion!

Ankle replacement has the advantage of preserving movement in the joint, relieving the strain on other joints and creating a more natural gait. The recovery is also quicker with usually only two weeks being required in cast. There are some drawbacks. Like any artificial joint it can wear out  – ankle replacements are good but 20% can be expected to fail before ten years. Some people (around 10%) will have some ongoing unexplained pain which is not always easy to treat. Some people will require additional minor surgery in future years, for example to tidy up the joint or to fill cysts that can form. Find out more about ankle replacement.

The decision about whether to have a fusion or replacement will depend on many factors including your own preferences as well as your age, activity level, overall health, and also the specific condition of your ankle joint. Our specialist surgeons can take all these factors into account and discuss which might be the better treatment option for you.