Osteoarthritis of the Ankle
The ankle joint is a commonly injured joint in the body. While ankle fractures and ankle sprains heal pretty well, they can lead to problems much later in life. This is due to the wear and tear that occurs for years after the injury. This condition is called osteoarthritis, or post-traumatic arthritis. The term trauma means injury, and the term post-traumatic arthritis is used to describe the condition of the arthritis after injury.
Degeneration is a term that describes a condition where something wears out over time. The term degenerative arthritis is used by doctors to describe a condition where a joint wears out, usually slowly over a period of many years. The term arthritis means inflammation of a joint, so the term degenerative arthritis means inflammation of a joint due to wear and tear. You may also hear the term degenerative arthrosis used. Some doctors believe that degenerative arthritis isn’t a true arthritis and confuses people. The term arthrosis is used to describe the condition of a worn out joint. The term arthritis is used to describe the true inflammatory conditions such as gout, infection and rheumatoid arthritis.
Osteoarthritis is usually considered a type of degenerative arthritis, or wear and tear arthritis. Doctors usually consider osteoarthritis pretty much the same whether it appears years after an injury to the joint or whether it simply appears without any history of injury. Over the past several years, there has been increasing evidence that osteoarthritis is genetic, meaning that it runs in families. Research suggests that osteoarthritis that occurs without any injury may be related to differences in the chemical makeup of the articular cartilage with which people are born.
Injury to a joint, such as a bad sprain or fracture, can cause actual damage to the articular cartilage. The cartilage can be damaged by bruising when too much pressure is exerted on the cartilage surface of a joint. This damages the cartilage, although if you look at the surface it may not appear to be any different. The injury to the material doesn’t show up until months later. Sometimes the cartilage surface is damaged even more severely and pieces of the cartilage are ripped from the bone.
These pieces do not heal back and usually must be removed from the joint surgically. If not, they may float around in the joint causing the joint to catch and be painful. These fragments of cartilage may also do more damage to the joint surface. The areas where these pieces of cartilage are ripped from do not normally grow back. Unlike bone, the holes in the surface are not simply replaced by the cartilage tissue around the hole. Instead the defects are filled with scar tissue. The scar tissue that forms is not nearly as good a material for covering joint surfaces as the cartilage it replaces. It just can’t support weight bearing like true articular cartilage.
An injury to a joint, even if it does not injure the articular cartilage directly, can alter how the joint works. This is true for a fracture where the bone fragments heal slightly different from the way they were before the break occurred. It is also true that when ligaments are damaged it leads to instability in the joint. When an injury results in a change in the way the joint moves, the injury may increase the forces on the articular cartilage. This is very similar to any mechanical device or machinery. If the mechanism is out of balance, it wears out faster.
Over many years this imbalance in the joint mechanics can lead to damage to the articular surface. Since articular cartilage cannot heal itself very well, the damage adds up. Finally, the joint is no longer able to compensate for the increasing damage and it begins to hurt. The damage is occurring well before the pain begins.
Degenerative arthritis may come from differences in how each of us is put together based on our genes; a condition best described as osteoarthritis. Or degenerative arthritis may come years after an injury has occurred that leads to slow damage to the joint surfaces; a condition probably best described as post- traumatic arthritis. Either way the joint is worn out – and it hurts.
Rheumatoid Arthritis: Symptoms, Causes and Treatments of Rheumatoid Foot and Ankle
Rheumatoid arthritis is the most common form of inflammatory arthritis, affecting about two to three million Americans. Rheumatoid arthritis is a symmetric disease, meaning that it will usually involve the same joints on both sides of the body.
Approximately 90 percent of people with rheumatoid arthritis will have arthritis of the foot or ankle. The pain may prevent sufferers from walking and can even lead to deformity if left untreated. The human foot is prone to developing rheumatoid arthritis because it contains such a large number of joints and is put under a lot of pressure. The ankle, which is a hinge joint linking the shin bone to the fibula, is a little less likely to develop rheumatoid arthritis but is also put under immense pressure daily.
About 8 out of 10 Americans will suffer foot or ankle problems at one point in their lives. On average, people will walk about 100,000 miles during their lifetime. That distance is equivalent to four trips around the world. Studies have found that women walk about 10 miles a day while men walk only seven. In addition, the average person’s foot absorbs 500 pounds of pressure with each step. In one day, that total comes to about 5 million pounds. Perhaps it comes as no surprise that the foot and ankle are at risk for developing rheumatoid arthritis.
Causes of Rheumatoid Foot and Ankle
The exact cause of rheumatoid arthritis is unknown. However, there are several views about what could cause it. A sudden and traumatic injury, such as an ankle sprain, may cause the injured joint to become arthritic in the future.
Some experts think rheumatoid arthritis is an autoimmune disease, meaning that the body tissue is the victim of an immune response against itself. The body creates antibodies that actually attack the joints causing the swelling and redness. Excess fluid will be produced in the joint space.
Many doctors believe that a virus or bacteria may prompt rheumatoid arthritis to develop in those people who have a genetic predisposition to it. Seven out of ten people who have rheumatoid arthritis have an inherited chemical marker on their cells leading doctors to believe that there is a correlation.
Symptoms may develop as the result of many other factors as well, including:
- the use of prescription and/or illegal drugs
- contact with certain chemicals
- bowel disorders such as iletis and colitis
- obesity, which often aggravates arthritic conditions
- severe stress
Assistive Devices for Patients with Ankle Arthritis and Arthritis Pain
If you have ankle arthritis, you may find it is becoming increasingly difficult to walk. Fortunately, there are products or assistive devices designed to give support to the ankle, assisting you to walk more comfortably, and help ease your arthritis pain.
Your doctor or occupational therapist can speak with you about solutions for your particular situation. He or she may suggest that you use an elastic bandage wrapped around your ankle to provide support. Your physician may also suggest purchasing new shoes that provide the necessary support. In some cases, you may need a specially designed ankle brace.
For ankle arthritis, proper footwear can be an essential assistive device in supporting your ankle. Look for shoes that have a low heel, cushioned sole, firm arch, and side support. You may also need to buy inserts for old shoes you already own. If regular store-bought shoes do not help, you may need to purchase specially designed shoes or orthotics.
If you are experiencing severe arthritis pain from ankle arthritis, crutches may be needed to help you move around. It is important to have your crutches measured by a qualified professional. For a long-term solution, a cane may help. There are many different types of canes so you should look for one that gives you the best balance. The use of a walker may help you if you are too weak or need more stability than crutches or canes can provide. Frequently, these assistive devices have wheels on the front and rubber tipped legs in the back.
You can buy most of these assistive devices in department stores, medical supply stores, through specialized mail-order catalogs, or through medical assistance web sites.
Before you use any assistive device, please consult with your doctor or physical therapist to discuss the options available to you.
- Heel Spurs
- Lisfranc (Midfoot) Injury
- Osteochondritis Dissecans of the Ankle
Osteochondritis dissecans is a condition that causes ankle pain and stiffness. Osteochondritis dissecans can affect all age groups and usually follows a twisting injury to the ankle such as an ankle sprain. Osteochondritis dissecans is a loss of blood supply to a segment of bone and cartilage in the ankle and may result in a small fracture or collapse of the joint surface.
The talus is one of the large foot bones that help form the ankle joint. Osteochondritis dissecans occurs at the top of the talus. Depending on how the ankle injury happened, the condition can occur on the sides of the talus.
The top of the talus is part of the ankle joint and is covered with articular cartilage. Articular cartilage is the white, slippery material that covers all joint surfaces. The articular cartilage on the talus is about one-eighth of an inch thick and allows the bones of the ankle joint to slide against each other without much friction.
Most cases of osteochondritis dissecans are caused by actual chip-type fractures. These fractures often occur with severe ankle sprains. The side of the talus the chip is on depends on how the ankle was twisted during the initial injury.
The chip fracture can vary in size and severity. If the bone underneath the cartilage is crushed or cracked and the articular cartilage is left intact, the fragment is less likely to move. However, if the articular cartilage is broken, bone chip fragments may move out of position hindering the healing process.
Because the bone chip is separated from the rest of the talus, blood vessels traveling to the chipped fragment are torn and the blood supply to fragment is lost. If the fragment displaces, these blood vessels cannot grow back. The fragment looses its blood supply and dies. This makes healing less likely.
Osteochondritis dissecans includes symptoms similar to ankle sprain injuries. You may feel swelling and pain and have difficulty placing weight on the ankle. Continued problems with the fragment may cause more swelling and a generalized ache in the ankle. You may also feel a catching sensation with the ankle in certain positions. This is caused by the chip getting caught in the ankle joint as it moves. Over time, osteochondritis dissecans can result in severe arthritis.
The diagnosis of osteochondritis dissecans may be suggested by your medical history and physical examinations. X-rays of your ankle will usually show a problem on the top of the talus (sometimes called the talar dome). Special tests such as computerized axial tomography (CAT scan), or magnetic resonance imaging (MRI) may be necessary to determine the full extent of the area involved.
Treatment for osteochondritis dissecans depends on when the problem is discovered. If discovered immediately after a twisting injury to the ankle, immobilization in a cast for six weeks may be suggested to see if the bone injury heals. You may need to keep weight off the foot and use crutches during this period of immobilization.
If osteochondritis dissecans is not recognized early, the bone fragment may not heal and may continue to cause problems. Surgery may then be required to treat your symptoms.
Surgery usually involves removing the loose fragment of cartilage and bone from the ankle joint and drilling small holes in the injured bone. When the fragment is removed, a defect shaped like a small crater is left in the talar dome (Fig. 5). Holes are drilled in this area allowing new blood vessels to grow and helping scar tissue to form to fill in the area. Eventually this new scar tissue smoothes out the defect and allows the ankle to move more smoothly.
The surgery can be performed in several ways. In some cases the surgery can be done using an arthroscope. An arthroscope is a special miniature camera that can be inserted into the joint through a very small incision. Through other small incisions, special instruments can be inserted into the ankle. While the surgeon watches on a TV screen, the fragment can be removed and the defect drilled.
The ankle is a small joint, and the arthroscope may have difficulty getting into certain areas of the joint. If the defect is difficult to reach with the arthroscope, an open incision may be required. This incision is usually made in the front of the ankle to allow the surgeon to see into the joint. Again, special instruments are used to remove the bone fragment and drill the injured area.
If your surgeon recommends nonsurgical care using a cast or cast boot, you may be on crutches for up to six weeks. During follow-up office visits, X-rays will probably be taken so that the surgeon can follow the healing of the fragment and determine whether surgery will be necessary.
If surgery is required, it will take about eight weeks before the bones and soft tissues heal. You will be placed in a cast or cast boot during this period to protect the bones while they heal. You will probably need crutches as well. A physical therapist may help you learn to use your crutches.
You will probably wear a dressing for a week following the procedure. The stitches will be removed 10 to 14 days from surgery. If your surgeon used dissolvable stitches, these will not need to be removed.
Treating Arthritis of the Ankle
Your First Visit to Physical Therapy
On your first visit, your physical therapist will want to gather some more information about the history of your ankle problem. You may be given a questionnaire that helps you tell about the day-to-day problems you are having with your ankle. The information you give will help measure the success of your treatment. You may also be asked to rate your pain on a scale of one to ten. This will help your physical therapist gauge how much pain you have now and how your pain changes once you’ve had treatment. Your physical therapist will probably ask some more questions about your ankle problem to begin zeroing in on the source and location of your pain and to know what will be needed to help relieve it. Here are some questions your physical therapist may ask you:
- How long have you had ankle pain?
- Where do you feel the pain?
- What makes the pain better or worse?
- How do your symptoms affect your daily activities?
- Do you have pain in your lower leg, knee or hip?
- Does your ankle swell?
- Does your ankle ever feel like it’s going to give out?
- Do you have any numbness or tingling?
Physical Therapy Evaluation
Once all this information has been gathered, your condition will be evaluated.
Posture: Your physical therapist will begin by checking your overall posture, including your foot and leg alignment. Imbalances in the position of your foot and leg can put extra pressure on your ankle. If alignment is a problem, your therapist may take some measurements to see if a special shoe insert, or orthotic, will be needed to take away the pressure and pain.
Observation: Your therapist will note if there is any swelling in or around the ankle joint. If so, measurements will be taken to get an idea of how much swelling is present. Volumetric testing is done by placing your foot and lower leg in a container of water and measuring how much water is displaced. The results of each ankle and leg are compared. Another way to measure swelling is to use a tape measure and compare several measurements around one ankle and then the other. These measurements can be rechecked later on to get an idea if the swelling is going away.
Gait Analysis: By watching you walk back and forth, your therapist can see if how you walk may be linked with your condition. Even subtle changes in your stride, foot and knee position, or hip movement can create problems like ITB syndrome. Range of motion (ROM): Next, your physical therapist will check the ROM in your ankle. This is a measurement of how far you can move your ankle in different directions. Ankle movements include bending the ankle up and down (dorsiflexion/plantarflexion) as well as in and out (inversion/eversion). Your therapist may also want to get an idea of how other joints around the ankle are moving, including the lower leg, knee, and possibly even your hip. Your ROM is written down to compare how much improvement you are making with the treatments.
Strength: Your therapist will then test the strength of your muscles. You’ll be asked to hold against resistance as your therapist tests the muscles around the ankle. Other areas that may be checked include the muscles of the knee and hip. These measurements are compared to your other leg. Weakness in key muscles of the leg or ankle will be addressed with a strengthening program. Trained muscles can help control your sore ankle, which eases pain and keeps the joint healthy for as long as possible.
Manual Examination: Your therapist will then test the strength of your muscles. You’ll be asked to hold against resistance as your therapist tests the muscles around the ankle. Other areas that may be checked include the muscles of the knee and hip. These measurements are compared to your other leg. Weakness in key muscles of the leg or ankle will be addressed with a strengthening program. Trained muscles can help control your sore ankle, which eases pain and keeps the joint healthy for as long as possible.
Palpation: The evaluation usually ends with palpation. Palpation is when your physical therapist feels the soft tissues around the joint. This is done to check the skin for changes in temperature, areas of soreness, and whether you have swelling. Palpation is also done to find whether there are tender points or spasm in the muscles around the ankle. This can help your therapist get a good idea about which treatments will help you the most.
Treatment Plan: Once the examination is done, your therapist will put together a treatment plan. The treatment plan lists the types of treatments that will be used for your condition. It gives an indication of how many visits you will need and how long you may need therapy. The plan also lists the goals that you and your therapist think will be the most helpful for getting your activities done safely and with the least amount of soreness. Finally, it will include a prognosis, which is how your therapist feels the treatment will help you improve.
Physical Therapy Treatment
Your therapist may choose from one or more of the following tools, or modalities, to help control the symptoms caused by ankle osteoarthritis:
Heat: Heat makes blood vessels get larger, called vasodilation. This action helps to flush away chemicals that are making your ankle hurt. It also helps to bring in nutrients and oxygen that help the area heal. True heat in the form of a moist hot pack, a heating pad, or warm water whirlpool or bath is more beneficial than creams that merely give the feeling of heat. Hot packs are usually placed on the sore area for 15 to 20 minutes. Special care must be taken to make sure your skin doesn’t overheat and burn. It’s also not a good idea to sleep with an electric hot pad at night.
Ultrasound: An ultrasound machine produces high frequency sound waves that are directed toward the sore area. Passing through the body’s tissues, these waves vibrate molecules. This causes friction and warmth as the sound passes through the tissue. The rest of the sound changes to heat in the deeper tissues of the body. This heating effect helps flush the sore area and brings in a new supply of nutrient and oxygen-rich blood. Ultrasound treatments are a way for your therapist to reach tissues that are over two inches below the surface of your skin.
Phoresis: This means to “carry or transmit.” There are two methods that therapists can use to transmit substances across the skin. Phonophoresis uses the high frequency sound waves of ultrasound to “push” a steroid medication (cortisone) through the skin. Iontophoresis uses a small machine that produces a mild electrical charge, which is used to carry medicine, usually a steroid, through the skin. The steroid is a very strong anti-inflammatory medication that actually stops the pain-causing chemical reaction within the cells of the sore tissue in your body. Either type of phoresis may be used in place of a cortisone injection.
Electrical Stimulation: This treatment stimulates nerves by sending an electrical current gently through your skin. Some people say it feels like a massage on their skin. Electrical stimulation can ease pain by sending impulses that are felt instead of pain. This procedure is based on the Gate Theory which says that when you feel a sensation other than pain, like rubbing, massage, or even a mild electrical impulse, your spinal column will actually “close the gate” and not let pain impulses pass to the brain. In the case of electrical stimulation, the electrical impulses speed their way across the skin and on to the central nervous system much faster than pain. By getting there first, the electrical information “closes the gate” to pain, blocking its passage to the brain. Once the pain eases, muscles that are in spasm begin to relax, letting you move and exercise with less discomfort. Other settings on the machine can be used to help your body release endorphins. These are natural chemicals formed within your body that behave like a strong drug in reducing the perception of pain for up to eight hours at a time.
Soft Tissue Mobilization/Massage: Physical therapists are trained in many different forms of massage and mobilization when treating the neck. Massage has been shown to calm pain and spasm by helping muscles relax, by bringing in a fresh supply of oxygen and nutrient-rich blood, and by flushing the area of chemical irritants that come from inflammation. Soft tissue treatments can help tight muscles relax, getting them back to a normal length. This will help you begin to move with less pain and greater ease.
Joint Mobilization: These are graded pressures and movements that are done by skilled physical therapists. Gentle graded pressures help lubricate joint surfaces, easing stiffness and helping you begin moving with less pain. Pain that is left unchecked can quickly escalate to an uncomfortable “cycle of pain and muscle guarding.” In other words, the pain can make your muscles go into spasm, in which your muscles try to guard the sore joints, keeping you from wanting to move your ankle at all. When movement stops, your brain gets an uninterrupted flow of pain sensation. Ouch! This leads to a cycle of even more muscle spasm and pain because your muscles try to “protect” you from painful movement. By applying gentle pressures, or mobilizations, your therapist will begin to halt the flow of pain information, which helps muscles relax. Once your muscles begin to relax, you will begin to feel other sensations than pain. As your pain eases, more vigorous grades of mobilization may be used to lengthen tissues around the joint helping restore better movement in your ankle.
Topical Agents: Certain topical ointments (such as Capsaicin(r)) have been shown to ease pain by blocking chemicals that cause pain.
Improving Range of Motion: When movement of a joint is limited, pain and other problems may worsen. Improving ankle movement can help keep the joint surfaces healthy, while helping to control soreness. Getting more motion can give you the relief you need to do your day-to-day activities. If you don’t have full range of motion, your therapist has several ways to get more movement in the ankle. Your therapist can use graded joint mobilization, manual stretching, and select exercises. Active movement and stretching either as part of a home or pool therapy program can also be helpful.
Strengthening: In the early stages, strengthening may be done by using isometric exercise. These are exercises where the muscles around the joint are worked, but the joint stays in one position. Isometrics help restore strength while protecting you from further pain and irritation. As your muscles gain strength, you may notice less pain while experiencing a sense of ease with walking and other activities.
Joint Protection: These are ways to give your joint the edge it needs to stay healthy for as long as possible.
Muscular Control: Sometimes the ankle gets an extra jolt when you suddenly miss a stair or stub your toe. Untrained leg muscles are slow to respond in protecting the ankle joint, and these jolting forces can do more damage to the softer bone under the cartilage. A trained muscle will generate force quickly. Conditioning exercises help ankle and leg muscles generate forces more quickly, preparing them to act as shock absorbers to protect your ankle joint.
Shock Absorption: A good pair of shoes will also help reduce shock. If walking is one of your primary exercises, choose a soft walking surface like cinder or grass. Avoid cemented or other hard surfaces. Limit your walking speed, especially if you find that increasing your walking speed irritates your ankle pain. Other types of exercise that prevent high impact on your joints include stationary biking and swimming.
Walking Aids: In cases of severe pain or joint wear and tear, you may need to use a cane or walker until your condition is stabilized. Using a walking aid can take some of the pressure off the ankle joint, protecting it from undue stress and strain.
Alignment: When the leg and ankle are not properly aligned, you may be getting extra pressure around the foot and ankle. In these cases, a special shoe insert, or orthotic, can help relieve pressure and pain. Sometimes a small heel lift or cushion can be placed in your shoe to limit pressure on a stiff ankle joint, helping you to enjoy walking longer distances without a limp.
Exercise Progression: Your exercise program will be advanced cautiously to include strengthening, balance, endurance, and other exercises that mimic your daily activities. Your program will address key muscle groups of the hips, thighs, calves, and foot. You will be trained in exercises that help stabilize and control the ankle. Other exercises can be used to simulate day-to-day activities like raising up on your toes, stepping off a curb, or descending a ramp. Specific exercises may also be used to simulate your work or hobby demands.
Daily Exercise: Your joint surfaces can remain healthier by consistently working your ankle through a full range of motion and using safe, load-bearing exercises. Do exercises as prescribed to keep the hip, knee, and ankle muscles strong. Avoid pain by exercising with pain-free movements, by limiting walking speeds, and by not overdoing it. If you feel pain, you may need to back off and do gentle range of motion and isometric exercises.
General Fitness The Surgeon General recommends that everyone get at least 30 minutes of moderate activity a day for as many as seven days a week. Along with reducing the risk of heart disease, lowering stress, managing body weight, and prolonging life, a general fitness program can also assist you in managing ankle osteoarthritis. Moderate activity can include walking, swimming, stationary biking, or low impact aerobics. Before undertaking such a program, consult your physician.
Long-Term Management: Here are some long-term solutions to help manage your ankle condition:
Control pain and inflammation with heat, cold and medication (as prescribed by your doctor)
Reduce shock by using a walking aid, wearing good shoes, choosing soft surfaces and keeping the leg muscles conditioned for unexpected stresses
Exercise often to maintain range of motion, strength, and cardiovascular fitness
Use a shoe orthotic in cases where leg and foot alignment is a problem
Take precautions with daily activities to avoid stressing the ankle
Home Program: Once your pain is controlled, your range of motion is improved, and your strength is returning, you will be progressed to a final home program. Your therapist will give you some ideas to help take care of any more soreness at home. You’ll be given some ways to keep working on the range of motion and strength too. Before you are done with physical therapy, more measurements will be taken to see how well you’re doing now compared to when you first started in therapy.
Symptoms of Osteoarthritis of the Ankle
Pain is the main problem with osteoarthritis of any joint. At first, the ankle joint pain occurs only related to activity. Once the activity gets underway there is not usually much pain, but after resting for several minutes the ankle pain and stiffness increase. Later, when the condition worsens, pain may be present even at rest. The pain may interfere with sleep. There may be a swelling around the ankle joint and it may fill with fluid and feel tight, especially following increased activity. When all the articular cartilage is worn off the joint surface there may be a squeaking sound when the ankle joint moves. Doctors refer to this sound as crepitance. Osteoarthritis will eventually affect the motion of the ankle joint and it will become stiff and lose the ability to move.
Certain motions can become painful, and it may become difficult to trust the ankle joint to hold your weight in certain positions. The body has a pain reflex to ensure that, when a joint is put into a position that causes pain, the muscles around the joint may stop working without warning. This reflex can lead to falls when arthritis affects the leg joints. When osteoarthritis has reached a very severe stage, the bone under the articular cartilage may become worn away. This can lead to increasing deformities around the ankle joint. In the final stages, the alignment of the joints can begin to form odd angles where they meet to form the joint.