Ankle Osteoarthritis

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Top Contributors -Scott Buxton, Rachael Lowe, Kim Jackson, Aminat Abolade, Admin, Maarten Cnudde, Thijs Van Liefferinge, Nupur Smit Shah, Lukas Van Orshoven, Caroline Akst, Arne Van De Winkel, Uchechukwu Chukwuemeka, Shaimaa Eldib, Simisola Ajeyalemi, Vidya Acharya, Rucha Gadgil, 127.0.0.1, Abbey Wright, Lauren Lopez, Lucinda hampton, Jess Bell, Khloud Shreif, Evan Thomas, Olajumoke Ogunleye and Ammar Suhail  

Search Strategy

- Main information: VUB (Free University of Brussels) library (books) and websites: Pubmed, Web of Knowledge, PEDro.

- Keywords used: (ankle) osteoarthritis, ankle, etiology, exercise, surgery, physical therapy.

Definition & Description

Ankle osteoarthritis is the occurrence of osteoarthritis (OA) in the ankle joint. The ankle joint consists of two synovial joints, namely the talocrural joint and the subtalar joint. In both joints osteoarthritis can be diagnosed in the medial and the lateral compartment. (1)

Clinically Relevant Anatomy

Osteoarthritis occurs in the two synovial joints of the ankle. (2) (9)
This figure shows damage in the talocrural joint. You can see that both compartments are affected.

Epidemiology & Etiology

Epidemiology

OA is the most common joint disorder in the world. Of all persons with OA, there are about 1% persons with OA of the ankle (Peyron J.G. (1984) The epidemiology of osteoarthritis. In: Moskowitz R.W. et al. Osteoarthritis. Diagnosis and treatment. Philadelphia WB Saunders, 1984: 9-27. Level of Evidence: C).
Ankle OA has a multi-factorial etiology and can be considered the product of an interplay between systemic and local factors. Older age, female gender, overweight and obesity, repetitive use of joints, muscle weakness and joint laxity all play roles in the development of primary OA. Ankle injuries play a role of developing secondary OA.  (4) (11)

Etiology

There are 2 types of osteoarthritis: primary OA and secondary OA: see osteoarthritis

Compared with results reported for knee and hip, there is a substantially lower rate of primary ankle OA. Although early cartilage degeneration occurs, progression to severe grades of degeneration is not frequently observed (Meachim and Emery, 1974; However, 1975; Koepp et al., 1999). This phenomenon is thought to be caused by the unique anatomic, biomechanical and cartilage characteristics of the ankle. Specifically it has been reported that the ankle has a smaller contact area than the hip or knee (Kimikuza et al. (1980) Load-bearing pattern of the ankle joint; contact area and pressure distribution. Arch Orthop Trauma Surg 96: 45-49). There is also a relative higher cartilage resistance in the ankle, which might protect it from degenerative changes leading to primary OA. This higher cartilage resistance in the ankle is due to the fact that the ankle is primarily a rolling joint with congruent surfaces at high load, which allows it to withstand large pressures (Wynarsky and Greenwald, 1983). Although the ankle cartilage is thinner compared with knee or hip cartilage, it shows higher compressive stiffness and proteoglycan density, lower matrix degradation and less response to catabolic stimulations. So the ankle is not generally a site of primary OA (This occurs only in approximately 7% of all ankle OA cases: Peyron and Mann, 1984).

In most of the cases ankle OA is developed secondary to trauma. Traumatic ankle injuries that may result in OA include fractures of the malleoli, the tibial plafond, the talus and ankle ligament injuries. This reflects the notion that fracture of the malleoli is the most severe risk factor to develop ankle OA. The underlying pathomechanisms causing secondary OA in ankle sprains might be twofold: either an acute osteochondral lesion, as in single severe ankle sprains, or chronic change in ankle mechanics leading to repetitive cartilage degeneration, as in recurrent or chronic instable ankles.
Patients with secondary OA are preferentially younger than patients with primary OA. Patients with ankle OA predominantly have varus alignment.  (4) (12)

Characteristics & Clinical Presentation

- Pain: experiencing pain around the ankle during movement (after a period of inactivity). The intensity of pain is variable. It is depending on the type and the grade of OA.
- Limited range of motion: this is the result of changes in the artical spaces with incongruention of joint surfaces. To assess the range of motion, we measure degrees (with a goniometer) of plantarflexion, dorsiflexion, inversion and eversion of the ankle and compare these with the results of the healthy ankle.
- Crepitus: due to irregularities in the articulating joint surfaces and assessed using active and passive movement.
- Instability of the ankle: lateral and medial instability of the ankle.
- Muscle atrophy: clear muscle atrophy around the ankle and the leg.
- Swelling of the ankle: due to changes in ratio between joint surfaces.  (13)

Outcome Measures

- Visual Analogue Scale (VAS) to determine pain of the ankle due to OA.
- Goniometer to determine the range of motion of the two synovial joints of the ankle.
- The Intermittent and Constant Osteoarthritis Pain index (ICOAP)
- The Algofunctional Index (AFI)
- The Western Ontario and McMaster universities osteoarthritis index (WOMAC)
The last three are questionnaires to determine ankle OA.  (5)

Examination

The examination of ankle OA consists of inspection, palpation and examination of basic functions.
- Inspection: the physiotherapist observes potential swelling of the ankle (and grade of this swelling), crepitus, gait, inflammation and instability of the ankle. He also looks at potential muscle atrophy (muscles around the ankle and the leg). Range of motion inspection is needed. With a goniometer it is possible to measure the degrees of plantarflexion, dorsiflexion, inversion and eversion of the ankle and compare these with the results of the healthy ankle. The physiotherapist also pays attention to the location of the experienced pain. Varus and valgus position of the ankle need to be observed by the physiotherapist.
- Palpation: the physiotherapist assesses the presence of swelling, thickening, temperature differences and muscle tonus.
- Examination of basic functions: the physiotherapist tests muscle power, mobility, balance, coordination and stability of the joint. These factors can be tested by active/functional tests, like standing on one leg, walking on various surfaces, sitting down and getting up, getting up from lying position, climbing stairs and also by passive manual tests. There is also another important factor which is proprioception. When testing proprioception, it is important to make a difference between ‘the joint position sense’ and ‘the joint motion sense’. (3) (5) (13)

Medical Management

Depending on the type and the severity of OA, there are several medical nonsurgical treatments:
- Anti-inflammatory medication to counter periodic inflammation.
- An intra-articular injection of corticosteroids, a drug that reduces inflammation.
- An injection of hyaluronic acid in the joint. This viscosupplementation refers to the concept of synovial fluid replacement with intra-articular injections of hyaluronic acid for the relief of pain, associated with OA. (3) (6) (7)

There are also medical surgical treatments. What surgical treatment is required depends on the location of OA, how severe the joint is affected and the degree of experiencing the condition. Sometimes more than one type of surgical treatment is needed. (3)
The most common surgical procedures in ankle OA are:
- cleaning the joint with keyhole surgery: arthroscopy.
- securing the joint: arthrodesis.
- replacing of the joint: ankle prosthesis. (8)

Physical Therapy Management

Recent studies suggest that moderate exercise (physical activity) is safe and effective for the treatment of ankle OA. This physical activity leads to less experienced pain (relief of pain), stronger muscles around the ankle (M. Gastrocnemius, M. Soleus, M Tibialis Anterior, Mm. Peronei), improvement of range of motion (degrees of plantarflexion, dorsiflexion, inversion and eversion of the ankle improve) and less instability of the ankle (improved balance, coordination and stability of the ankle), which improves physical function on short therm. These exercises have to take place under supervision of a physiotherapist. (Level of Evidence A2, D, B) (5) (10) (14)

- Exercise: is most effective when it consists of a combination of:
- Strength training: muscle strengthening exercises for M. Gastrocnemius, M. Soleus, M. Tibialis Anterior and Mm. Peronei (repeated exercises with theraband).
- Endurance training: exercises to increase aerobic capacity. Run training and cycling are recommended.
- Mobilizing exercises: range of motion exercises. Exercises including plantarflexion, dorsiflexion, inversion and eversion of the ankle are recommended.
- Balance and proprioceptieve training if there is instability of the ankle joint. Exercises (plantarflexion, dorsiflexion, inversion and eversion of the ankle) with airex cushion and wobble board are recommended.
Functional exercises like standing on one leg, walking on various surfaces, sitting down and getting up, getting up from lying position, climbing stairs are also recommended because these exercises include several components simultaneously. (Level of Evidence A2, D)  (5) (10)
- Hydrotherapy: is recommended in international guidelines. It can be useful in cases where the pain is too severe to exercise on dry land. Some studies suggest that swimming and water exercises (including plantarflexion, dorsiflexion, inversion and eversion of the ankle) are excellent for OA patients. It provides relaxation (in case of a warm bath), a decreased pain level and improved mobility. (Level of Evidence: A2, D)  (5) (9)

- Passive mobilisation: this includes mobilisations for plantarflexion, dorsiflexion, inversion and eversion of the ankle. It has proved to be effective to eliminate pain and joint immobility. It is only effective in combination with active exercise therapy. (Level of Evidence A2)  (5)

- Massage: of the muscles around the ankle. This is not effective for ankle OA. However careful and progressive massage of a pain point can lead to temporary waiver of localized pain. (Level of Evidence A2)  (1) (5)

- Thermotherapy: can be effective to warm up tissues (in case of very stiff joints) before exercise. It is also useful for patients with problems to relax. In case of inflammation of the joint, the application of cold ice packs is designated. (Level of Evidence A2)  (5)

- Electrotherapy: has not proved to be effective for ankle OA. It may be considered if there is severe pain and it serves then to support exercise. (Level of Evidence A2)  (1) (5)

- Ultrasound: is not advised in the treatment of ankle OA. (Level of Evidence A2)  (1) (5)

- External support devices: have not proved to be effective for ankle OA. However bracing, taping and shoe inserts may be take away the pain. (Level of Evidence A2)  (5)

Key Research

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References

1.  Crielaard J.M., Dequeker J., Famaey J.P., et al. (1985). Osteoartrose. Brussel: Pfizer. p. 148-167.
Level of evidence: D
2. Parkway Physiotherapy. (2009) Osteoarthritis of the Ankle. http://www.parkwayphysiotherapy.ca/article.php?aid=122.
Level of evidence: E
3. Patientenbelangen. (2008) Voet- en enkelartrose. http://www.patientenbelangen.nl/docs/File/Folders/Voet-en-enkelartrose.pdf.
Level of evidence: C
4. Valderrabano V., Horisberger M., Russell I., et al. (2009). Etiology of ankle osteoarthritis. Journal Clin Orthop Relat Res  467: 1800-1806.
Level of evidence: D
5. Peter W.F.H., Jansen M.J., Bloo H., et al. (2010). KNGF-richtlijn Artrose heup-knie. Supplement Nederlands Tijdschrift voor Fysiotherapie 120 (1).
Level of evidence: A2
6. Sun S.F., Chou Y.J., Hsu C.W., et al. (2009). Hyaluronic acid as a treatment for ankle osteoarthritis. Curr Rev Musculoskelet Med 2: 78-82.
Level of evidence: C
7. Conduah A.H., Baker C.L., et al. (2009) Managing joint pain in OA: safety and efficacy of hylan G-F 20. Journal of Pain Research 2: 87-98.
Level of evidence: A2
8. Saltzman C.L., Kadoko R.G., Suh J.S. (2010). Treatment of isolated ankle OA with arthrodesis or the total ankle replacement: a comparison of early outcomes. Clinics in Orthopedic Surgery 2: 1-7.
Level of evidence: C
9. Reginster J.Y., Pelletier J.P., Martel-Pelletier J., Henrotin Y. (1999). Osteoarthritis: Clinical and Experimental Aspects. Berlin: Springer. p. 1-17.
Level of evidence: D
10. van Nugteren K., Winkel D. (2009). Onderzoek en behandeling van artrose en artritis. Houten: Bohn Stafleu Van Loghum. p. 453-479.
Level of evidence: D
11. Zhang Y., Jordan J. (2010). Epidemiology of Osteoarthritis. Clinical Geriatric Medicine 26(3): 355-369.
Level of Evidence: C
12. Muehleman C., et al. (2002) Bone density of the human talus does not increase with the cartilage degeneration score. The Anatomical Record 266: 81-86.
Level of Evidence: C
13. Cibere J., et al. (2004) Reliability of the knee examination in osteoarthritis. Arthritis and Rheumatism 50(2): 458-468.
Level of Evidence: C
14. Mc Gibbon C., Krebs D., Scarborough D. (2003) Rehabilitation effects on compensatory gait mechanics in people with arthritis and strength impairment. Arthritis and Rheumatism 49(2): 248-254.
Level of Evidence: B