Nonsurgical Treatments for Ankle Arthritis
Degenerative arthritis is a common condition in the general population and in many cases can be attributed to some antecedent injury earlier in life. Such injuries may include ankle sprain or more severe trauma, like ankle fracture, and has been demonstrated in female ballet dancers.1 However, development of degenerative arthritis is considered an ordinary disease of life, and when occurring at the level of the ankle joint complex can often be associated with changes in the normal function of the foot. Muehleman et al showed in 1,060 adult cadaveric specimens greater propensity for knee degeneration than ankle; however, they observed no cases of ankle degeneration that did not have more severe degeneration, or degeneration at all, of the ipsilateral knee joint.2 Because of ankle joint mechanics and pressure distribution, degenerative joint disease of the ankle is relatively minimal compared to the knee.3 It has also been suggested that cartilage degeneration can result from aberrations in the metabolism of the extra-cellular matrix.4
Patients who present with general ankle pain need to be closely worked up for accurate diagnosis because “ankle” as a term is a relatively unspecific anatomical term, and to the patient can mean virtually anything in the region of the joint including the subtalar joint, peroneal tendon complex, and/or Achilles insertion—whereas to the practitioner it usually denotes pathology of the talo tibiofibular articulation.
For those providers who routinely deal with lower extremity pathology, “ankle pain” is at best a nebulous complaint, and gives them only an area to start the examination. It is more common than not to have simultaneously more than one pain generator in play, which can result in more complex treatment decision-making. Sadly, patients with degenerative changes presenting on x-ray are often only given a diagnosis of “arthritis,” when in fact that may or may not contribute to the overall “joint” pain or any of it.
As we can see in Table 1, there are myriad conditions frequently described by patients as “ankle pain.” Too many times we evaluate patients who have been diagnosed with degenerative joint disease of the ankle, based solely on a radiographic examination, and are currently being treated with a non-steroidal anti-inflammatory drug (NSAID), when in fact they have subtalar joint dysfunction, sinus tarsi syndrome, or frequently, stenosing tenosynovitis of the peroneal tendons. Accurate diagnosis is essential to eliminate these other possible generators, as many patients aged 50 to 70 years will have some radiographic evidence of degeneration, and their treatment is considered unsuccessful because they have been given the usual treatment regimen for “arthritis,” when in fact their real etiology of pain still lies unrecognized.
Most ankle sprains are of an inversion type, with the primary injury to the lateral collateral ligaments, and contribute to a significant amount of emergency room visits, previously estimated at an incidence of 2.15 per 1,000 person-years between 2002 and 2006.5 Most often, these sprains or strains are mild, with injury involving partial or complete rupture of the anterior talofibular ligament (ATFL), and the injured patient will heal in 6 to 8 weeks without sequelae. In one study evaluating 113 patients who had suffered 133 sprained ankles, 6.5% ended up with damage to the cartilage of the talus resulting in an osteochondral lesion.6 These types of lesions do not show up radiographically at the time of injury, most often present with symptoms greater than 3 months after the time of injury, and then can rarely be seen with plain film radiography. Computed tomography scans or magnetic resonance imaging (MRI) are definitive, objective tests to rule out this injury.
Because there are so many different tissues that can be injured at the time of an ankle sprain, it is imperative that the provider be aware of them, and understands that rarely is there an isolated pathology with a severe injury.
Figure 1. In this x-ray, a well-maintained joint space is consistent from medial to lateral in the AP view, with no incongruity of the joint surfaces. AP, anteroposterior
Figure 2. From the lateral view of the same ankle seen in Figure 1, there is no evidence of arthritis, and there is a normal joint space from posterior to anterior. There is no evidence of anterior talotibial impingement.
Figure 3. This example represents a severe degenerative ankle joint with joint space only noted on a small aspect of the medial gutter. This ankle requires fusion or total joint replacement and will not respond to adjuvant treatments.