CHAPTER SYNOPSIS:

Management of painful arthritis of the ankle is directed at reducing the pain and maintaining function. There are medications that can reduce pain, exercises that maintain motion, and braces that can help improve walking.

IMPORTANT POINTS:

Nonoperative treatment is primarily aimed at reducing pain; there is no evidence that the biology of the joint will improve. Oral medication, restriction of motion, and reduction of joint reaction force are first-line treatments. Corticosteroid injection is helpful for short-term relief. Use of newer agents such as hyaluronic acid may prove beneficial.

CLINICAL PEARLS:

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  The goal of bracing is to control the foot and ankle to immobilize the joint; additional weight-relief is possible with a patella tendon-bearing design leg piece. The heel height should be low.

  
  
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  Physical therapy is helpful early in the course of ankle arthritis to maintain range and strength.

CLINICAL/SURGICAL PITFALLS:

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  If treatment is causing pain, stop and determine the cause: braces may cause skin damage or create pain in proximal joints or the lower spine.

  
  
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  Pain medications have side effects that need to be considered when prescribing, and the patient should be alerted regarding what to look for.

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HISTORY/INTRODUCTION/SCOPE OF THE PROBLEM

The ankle functions as one of the most congruent weight-bearing joints in the human body. This biomechanical condition of congruence under high-level contact force may be the underlying reason that the reported incidence of primary arthritis of the ankle is very low. The leading factor in ankle arthritis is the degeneration that follows intra-articular or periarticular injury. Inflammatory arthritis is frequently a cause of ankle arthritis, but the prevalence of inflammatory ankle arthritis, such as classic rheumatoid disease, is far less than that of degenerative ankle arthritis associated with prior trauma. Several population events are creating an increase in the prevalence of ankle and foot arthritis: (1) increased survivorship of crash victims due to airbags and rapid transit to hospital means people with severe ankle injuries are now alive years later and need treatment, (2) increased longevity in patients with multiple medical problems, and (3) increasing numbers of obese people.

The hallmarks of ankle arthritis are pain, limitation of range of motion, limitation of function (e.g., walking), local swelling, and warmth. These features of ankle arthritis are elicited first in the patient’s self-reported history of the current complaint and physical examination, including observation of gait. Radiographs may show any of a number of common features: marginal joint osteophytes (spurs), cartilage space narrowing, subchondral sclerosis, and subchondral cysts. Malalignment, such as asymmetry of the cartilage space or tilting of the talus within the mortise, may also be noted on radiographs. Patients with rheumatoid arthritis often have multiple joint involvements, pronounced periarticular swelling, and radiographic evidence of local osteopenia.

The diagnosis of ankle arthritis is rarely difficult when in an advanced stage; early diagnosis and management are more daunting. Ankle joint pain may be the result of any number of conditions other than arthritis. When swelling, limitation of ankle motion, or local warmth occurs, then the pain is likely due to joint pathology. Modern advanced imaging studies such as magnetic resonance imaging or positron emission tomography may detect structural or metabolic disturbances ahead of classic radiographs. Worsening of symptoms, with or without treatment, is an indication that arthritis is likely. Prior injury, malalignment, or family history of rheumatic conditions places an individual at risk for ankle arthritis even if the original complaint is pain without supportive physical or laboratory findings.

CONSERVATIVE (NONOPERATIVE) TREATMENT

The goals of treatment are to reduce pain and to improve function. Pain, without arthritic change, may produce alteration in gait, muscle weakness, and decreased range of motion. Relieving pain and improving range of motion with a secondary goal of restoring muscle strength in the calf are reasonable approaches to the painful ankle. Pain-relieving nonsteroidal anti-inflammatory drugs (NSAIDs) plus exercise therapy may be all that is required, perhaps with temporary use of splinting or limited weight-bearing. It is likely that the painful condition is completely reversible by whatever natural “healing” occurs and the painful problem is self-limiting. This is similar in nature to a shoulder afflicted with adhesive capsulitis in a nondiabetic patient who fully recovers after physiotherapy.

Once there is an established physiologic or anatomic change in the painful joint, the likelihood of complete resolution of symptoms is possible but less likely than in the purely painful joint. The treatment goals remain the same—to provide relief of pain and to maintain overall limb function in the presence of a condition that will likely progress over time.

As arthritis becomes more advanced in the ankle, it will affect gait and the functioning of the proximal joints, as well as the lower back. Decreased dorsiflexion of the ankle is compensated by lifting the limb using the hip and trunk muscles plus flexing the knee using combined action of hamstring and gastrocnemeus muscles. This effect on gait may lead to symptoms in the knee, hip, or lower back. In addition to stiffness, the painful ankle leads to shortening of step length and rotation of the trunk away from the foot, to reduce the magnitude and duration of force (weight) on the ankle.

MEDICATION

NSAIDs have a long history in the treatment of arthritis. Aspirin has been available for more than 100 years and was the classic drug for early rheumatoid arthritis for generations until the synthetic drugs were created about 50 years ago and corticosteroids were used about 55 years ago. Newer drugs that have anti-inflammatory properties are alleged to be more selective at reducing inflammation without the side effects of upper gastrointestinal hemorrhage, fluid retention, renal failure, and tinnitus. It remains to be proved that the newer drugs do indeed have a lower risk profile than aspirin, indomethacin, or even ibuprofen. With worsening signs of inflammation around the ankle, a short course of oral corticosteroid is a reasonable treatment option. Long-term use of corticosteroids is reserved for patients with inflammatory arthritis rather than degenerative ankle arthritis. Topical use of anti-inflammatory medication blended into an ointment has been reported in case series but has not been compared with systemic medication.

Analgesia is often helpful at improving function. All the NSAIDs are also analgesic but have the additional benefit of reducing inflammation. Acetaminophen has become a first-line drug in the treatment of early knee osteoarthritis, but no designed studies have yet shown an effect in patients with early ankle osteoarthritis. Mild narcotic pain relievers such as propoxyphene (Darvon) or codeine have a role in keeping people active and employed without resorting to surgery.

Following some reports of improved symptoms in knee arthritis, patients and physicians have tried or recommended use of the neutraceutical glucosamine. There is no published evidence that glucosamine with or without chondroitin sulfate has improved symptoms in ankle arthritis. Since this is a nonprescription item considered by the U.S. Food and Drug Administration to be a nutritional supplement, it is not regulated and the prevalence of use for ankle or foot arthritis is not known.

Joint injection has considerable value in providing relief. The classic injection is a combination of local anesthetic such as lidocaine (Xylocaine) with a short-acting corticosteroid such as triamcinalone (Kenelog). The brief action of the anesthetic is helpful at breaking the “pain cycle” with the longer-lasting anti-inflammatory effect of the corticosteroid providing pain relief for several weeks, perhaps months. Frequent injection may accelerate cartilage destruction due to the action of both the anesthetic agent and corticosteroids on hyaline cartilage. Injections are associated with a slight risk of joint infection. Failure of a joint injection to relieve pain may indicate that the source of pain is somewhere other than the ankle joint, such as the posterior facet of the subtalar joint.

Human trial results indicate that intra-articular injection with hyaluronic acid may be helpful, with results similar to the pain relief from corticosteroids and relief lasting for several months. Whether hyaluronate injections have a protective effect on hyaline cartilage remains to be demonstrated, but this is one of the claims that manufacturers have made when used in the knee.

There is a great deal of hope regarding glucosamine, with and without chondroitin sulfate, as a treatment for osteoarthritis. The greatest reporting comes from the use in knee arthritis, with some reports claiming that glucosamine reduces the radiographic loss of cartilage space. There is no evidence that glucosamine is chondroprotective or effective at relieving ankle joint pain. It is worth asking patients if they have tried glucosamine as a “home remedy” and what, if any, relief they report.

Complications of medical management are often related to the route of administration. Oral medications may cause nausea, vomiting, or diarrhea. The NSAIDs may cause ulceration of the upper gastrointestinal tract, hypertension, peripheral edema, renal failure, and difficulty in adjusting warfarin anticoagulation. Corticosteroids for extended periods of time may induce addisonian suppression of adrenal function, myopathy, moon facies, and osteopenia, in addition to many of the problems associated with NSAIDs. Injections have a reported incidence of joint sepsis, about 1:10,000 in the knee, but the actual number is unknown. It is important when prescribing medication or performing injections to educate and alert the patient to the possible adverse affects of the substance or procedure and to have the patient communicate promptly with the surgeon if problems occur.