Ankle osteoarthritis
- ankle arthritis has multiple causes, but osteoarthritis is the most common, and is post-traumatic in most cases
- ankle osteoarthritis affects 1% of the population and, unlike gonarthrosis or coxarthrosis, is secondary to previous trauma in more than 75% of cases (1)
- mechanical factors, such as incongruity, instability, malalignment, and impacts, which increase stress on isolated areas of the ankle cartilage, are associated with the development of osteoarthritis
- manage patients with ankle osteoarthritis in primary care initially using similar measures to those with hip or knee osteoarthritis
- in general, education, exercise and weight loss are recommended
- in the first instance, low doses of paracetamol in combination or not with topical nonsteroidal anti-inflammatory drugs (NSAIDs) or capsaicin may be used; however, if there is inadequate symptomatic relief, an oral NSAID or a cyclo-oxygenase-2 inhibitor could be added (2)
- referral for orthopaedic assessment is appropriate for
- ankle osteoarthritis that is refractory to medical management,
- end stage ankle osteoarthritis
- has a severe impact on quality of life (3)
Considerations in the clinical examination of a patient with suspected ankle osteoarthritis (3)
The examination begins from the first moment of meeting the patient by observing the gait and whether he/she uses any walking aids (4)
- the patient should be adequately exposed and ideally patients should wear shorts with bare feet.
- ask for chaperone if appropriate
- Look
- look from the side for the feet arches (is there any pes cavus or pes planus), any swelling or scars
- inspect for any big toe deformity (hallus valgus, hallux valgus interphalangeus or hallus varus), lesser toes deformity (mallet toe, hammer toes, claw toes) (4)
- consider (3):
- bony or soft tissue swelling, joint deformity, and effusion in advanced ankle osteoarthritis
- muscle wasting and weakness
- asymmetry-this is easier to identify on radiographs
- Feel
- ask the patient if there are any areas which are painful to touch, so you can try to avoid causing pain during the examination (4)
- then you start with gentle feel of the skin temperature, always comparing to the other side
- consider (3):
- joint warmth and/or tenderness (suggesting synovitis)
- integrity of the medial and lateral collateral ligaments
- tendon palpation to examine for tendonitis (Achilles, peroneal tendons, and tibialis posterior)- as they may be the cause of the ankle pain
- Move
- gait examination and consider (3)
- antalgic gait
- instability, and
- disruption of the stance phase in the gait cycle
- restricted and painful range of joint movement
- particularly restricted range of motion in ankle dorsiflexion and plantarflexion
- isometric testing (where the patient produces a maximum voluntary effort against fixed resistance) to look for pathology of surrounding contractile tissue
Reference:
- Herrera-Pérez M, González-Martín D, Vallejo-Márquez M, Godoy-Santos AL, Valderrabano V, Tejero S. Ankle Osteoarthritis Aetiology. J Clin Med. 2021 Sep 29;10(19):4489.
- Tejero S et al. Conservative Treatment of Ankle Osteoarthritis. J Clin Med. 2021 Sep 30;10(19):4561.
- McCarron L V, Al-Uzri M, Loftus A M, Hollville A, Barrett M. Assessment and management of ankle osteoarthritis in primary care BMJ 2023; 380 :e070573 doi:10.1136/bmj-2022-070573
- Alazzawi S, Sukeik M, King D, Vemulapalli K. Foot and ankle history and clinical examination: A guide to everyday practice. World J Orthop. 2017 Jan 18;8(1):21-29.