Ankle and Foot Arthropathies: Difference between revisions

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'''Original Editors ''' - &lt;a href="User:Ward Willaert"&gt;Ward Willaert&lt;/a&gt;
'''Original Editors ''' - [[User:Ward Willaert|Ward Willaert]] as part of the [[Vrije Universiteit Brussel Evidence-based Practice Project|Vrije Universiteit Brussel Evidence-Based Practice Project]]
 
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== Search Strategy ==
== Introduction ==
 
[[File:Foot.jpg|right|frameless|493x493px]]
Search terms: “Arthropathy”, “Haemophilic arthropathy”, “Osteoarthritis”, Rheumatoid arthritis”, Gout”, “psoriatic arthritis”, reactive arthritis”, Diabetic foot arthritis”, “Charcot neuropathic osteoarthropathy”<br>All these terms combined with: … AND “Diagnosis”, … AND “Epidemiology”, … AND “Treatment”, … AND “medical management”, … AND “Physical management”.
Any joint in the [[Ankle and Foot|ankle]], [[Foot Anatomy|foot]] and toes can be affected by an arthropathy (arthropathy is a general term for any disease of the joints).
 
* There are more than 100 forms of [[arthritis]], many of which affect the foot and ankle, causing [[Joint Classification|joint]] [[Pain Behaviours|pain]], swelling and stiffness.
Used databases: PubMed, Google Scholar, Web of Science, Pedro, VUB library<br>
* Arthritis in the feet can make standing and walking painful and the  feet and/or toes may change shape, making it harder to fit shoes and [[Activities of Daily Living]] may be affected.
 
* Athropathies of the foot and ankle are an important public health challenge due to their increasing incidence combined with their substantial negative impact on patients’ [[Quality of Life|quality of life]].
== Definition/Description&nbsp; ==
* Although arthropathy is less common in the ankle than the [[Hip Anatomy|hip]] and [[knee]], it can be just as disabling.<ref name="Stauffer">Stauffer RN: Intra-articular ankle problems. In Evarts CM (ed): surgery of the musculoskeletal system, vol. 4. New York, Churchill-Livingstone, 1990.</ref>
 
* Non-pharmacological treatments serve as the first line of treatment and are frequently used for patients with musculoskeletal conditions of the foot and ankle<ref name=":0">Rao S, Riskowski JL, Hannan MT. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3414868/ Musculoskeletal conditions of the foot and ankle: assessments and treatment options.] Best Practice & Research Clinical Rheumatology. 2012 Jun 1;26(3):345-68. Available from:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3414868/ (last accessed 1.7.2020)</ref>.
'''Arthropathy'''
Arthropathy is a blanket or global term for a wide range of joint presentations.
 
An arthropathy is a disease&nbsp;that effects&nbsp;a joint. So, in this case, “ankle and foot arthropathies” are diseases of the joints in the ankle and/or foot.<br>Although the terms "arthropathy" and arthritis have very similar meanings, the former is traditionally used to describe the following conditions:  
 
• Reactive arthropathy occurs as a reaction against an infection site elsewhere in the body. (1).  
 
• Enteropathic arthropathy is an arthropathy in association with, or as a reaction to, an enteric (usually colonic) inflammatory condition. (2)<br>• Crystal arthropathy is characterized by accumulation of tiny crystals in one or more joints.(3)<br>• Neuropathic arthropathy is a joint disease caused by diminished proprioceptive sensation, with gradual destruction of the joint by repeated subliminal injury. (4)<br>• Diabetic arthropathy is a neuropathic arthropathy occurring in diabetes. (5)<br>  
 
An arthropathy can be degenerative, such as osteoarthritis, or it can be associated with an inflammation, for example rheumatoid arthritis. A joint disease can also occur after a trauma.  
 
Although an arthropathy is distinctly less common in the ankle than in the hip and knee, it is an equally disabling condition. (6)


Because arthropathy of the ankle and foot is such a wide subject, it is difficult to explain it in general. We decided to discuss some arthropaties separately: osteoarthritis, rheumatoid arthritis, haemophilic arthropathy, diabetic foot arthropathy, gout, psoriatic arthritis and reactive arthritis.  
*Noninfectious arthritis eg [[Psoriatic Arthritis|Psoriatic arthritis]]; [[Ankylosing Spondylitis (Axial Spondyloarthritis)|Ankylosing spondylitis]]; [[Gout]]; [[Rheumatoid Arthritis]]; [[Osteoarthritis]]; Haemophilic Arthropathy (with severe haemophilia causes high levels of impairment) <ref name="Barg">Barg, A., et al. Haemophilic arthropathy of the ankle treated by total ankle replacement: a case series. Haemophilia 2010;16(4):647-655.</ref>; Post traumatic Arthritis.
*[[Reactive Arthritis|Reactive arthropathy]] occurs as a reaction against an infection site elsewhere in the body.<ref name="mayoclinic">Reactive Arthritis (Reiter’s Syndrome). www.mayoclinic.org. Retrieved May 16, 2011.(accessed  3 december 2016)</ref>
*[[Enteropathic Spondylitis|Enteropathic arthropathy]] Includes a group of rheumatic conditions such as arthritis caused by bacteria, parasitic infections and spondyloarthropathies. Other conditions that are included in this type of arthropathy are intestinal bypass arthritis, Whipple’s disease , collagenous colitis and [[Celiac Disease (Coeliac Disease)|celiac disease.]]<ref name="Björkengren">Björkengren A. G., Resnick D, Sartoris DJ. Enteropathic arthropathies. Radiologic Clinics of North America 1987: 189 </ref><ref name=":1" />
*Crystal arthropathy is characterised by accumulation of tiny crystals in one or more joints.<ref name="McGill">McGill, Neil W. Gout and other crystal-associated arthropathies. Best Practice &amp; Research Clinical Rheumatology 2000: 445-460 </ref>
*[[Charcot-Marie-Tooth Disease: A Case Study|Neuropathic arthropathy]] is gradual joint destruction when there is chronic damage of peripheral nerves and diminished proprioception (also called Charcot arthropathy and prominently affects patients with [[diabetes]])<ref name=":1">Scope heal [https://scopeheal.com/arthropathy/ Arthropathy] Available from:https://scopeheal.com/arthropathy/ (last accessed 1.7.2020)</ref> <ref name="Sanders (2013)">Sanders, L.J., Edmonds, M.E. & Jeffcoate, W.J. Diabetologia (2013) 56: 1873. https://doi.org/10.1007/s00125-013-2961-6 </ref>
*[[The Diabetic Foot|Diabetic arthropathy]] is a neuropathic arthropathy occurring in diabetic patients.&nbsp;<ref name="Medical dic">Medical dictionary. http://medical-dictionary.thefreedictionary.com/diabetic+arthropathy (Accessed 2 december 2016)</ref>
Be sure to look at all the links above for detailed information, this page is a general overview.


== Relevant Anatomy ==
[[File:Bones of the foot.png|right|frameless|485x485px]]
Each foot has 28 bones and more than 30 joints. The most common foot joints that arthritis affects are:
# The [[Ankle Joint|Ankle joint]]
# The 3 joints of the foot that involve the calcaneus, the navicular , and the cuboid bone.
# The !st MTP joint <ref>Cleveland clinic [https://my.clevelandclinic.org/health/diseases/13900-foot-and-ankle-arthritis Foot and ankle arthritis] Available from:https://my.clevelandclinic.org/health/diseases/13900-foot-and-ankle-arthritis (last accessed 1.7.2020)</ref>
More information about the anatomy of the ankle and foot can be found here: [http://www.physio-pedia.com/Biomechanics_of_Foot_and_Ankle Biomechanics of Foot and Ankle] and [http://www.physio-pedia.com/Ankle_Joint Ankle Joint].


== Signs and Symptoms ==
In general the symptoms are pain in the joints, reduction of the functions of the structure of connection or support and inflammation in the tendons, ligaments, joints, muscles and bones.
* Decreased range of motion, effusion, neumarthrosis, bone erosion.
* The symptoms are similar to rheumatic conditions and include pain, swelling and stiffness.
* Skeletal muscle is also affected by pain and inflammation of bones, structure, muscles, and is a type of joint disease<ref name=":1" />.
* Pain usually increases on activities such as standing, walking or running.
* “Start-up pain” is also a common complaint, where the patient experiences pain and stiffness in the ankle on moving after being asleep or sitting for a long period, which takes a few minutes of motion to settle.
* The affected joints will tend to increasingly swell as the day progresses, particularly with a higher level of activity.
== Assessment ==
[[File:OA_ankle.jpg|right|frameless|200x200px]]A clinical examination of the foot includes ‘traditional’ components such as history, palpation, and assessments of sensation, range of motion and strength, as well as special tests that provoke specific tissues. On observation, toe deformities and skin health (dryness, sweating, perfusion) should be noted.<ref name=":0" />


'''Osteoarthritis''' Osteoarthritic diseases are a result of both mechanical and biological events that destabilize the normal coupling of degradation and synthesis of articular cartilage chondrocytes, extracellular matrix and subchondral bone. Although they may be initiated by multiple factors, including genetic, developmental, metabolic, and traumatic, OA diseases involve all the tissues of the diathrodial joint. <br>Ultimately, OA diseases are manifested by morphologic, biochemical, molecular and biomechanical changes of both cells and matrix which lead to a softening, fibrillation, ulceration, loss of articular cartilage, sclerosis and eburnation of subchondral bone, osteophytes, and subchondral cysts. (7)
Salient Points of Examination include:
# Patients’ self-reported outcomes eg [[Visual Analogue Scale|VAS,]] [[Patient Specific Functional Scale|PSFS]]
# Static Foot Structure and Alignment eg [[Foot Posture Index (FP1-6)|the Foot Posture Index]]
# Joint Range of Motion - Quantified using a [[goniometer]], and note position tested in.
#[[File:Walk.jpg|right|frameless]]Muscle strength - Decreased toe flexor strength and foot pain are independently associated with fall risk. Strength deficits have also been reported in individuals with foot pain secondary to tibialis posterior tendinopathy<ref name=":0" />.
# Footwear assessment - Inspect for fit (length and width) and design features such as the presence of a heel cup, arch support, torsional and toe-break flexibility. Patterns of wear on the sole of the shoe and/or or scuffing should be noted. The Footwear Assessment Form is a simple and well-organized tool with established reliability and face-validity<ref name=":0" />.
# Dynamic Assessment of Foot Motion (including Gait Analysis) - Involves an observational or quantitative assessment of foot and lower extremity mechanics during a weight-bearing task (e.g., walking, running, single limb squat, step down). Particularly relevant in a clinical foot exam because evidence indicates that there is only a weak relationship between static and dynamic measures of arch height and large between-person variability<ref name=":0" />
# Dynamic Assessment of Plantar Load Distribution - When performing a clinical assessment, the plantar aspect of the foot should be inspected for patterns of calluses and weight-bearing.
# Provocational Tests - The final part of the clinical examination comprises provocational tests that provoke specific tissues. The [[Windlass Test]]<nowiki/>tstretcheshe plantar fascia and is considered positive if the patient reports pain when the 1st metatarso-phalanegeal joint is passively dorsiflexed. Limited extensibility in the gastrocnemius-soleus complex or the [[flexor hallucis longus]] can be assessed using passive muscle length testing. Symptoms related to the [[Sesamoiditis|sesamoids]] may manifest as plantar pain and localized tenderness to palpation.<ref name=":0" />


'''Rheumatoid arthritis'''
== Medical Treatment  ==
Management of ankle and foot arthropathies generally commences with conservative interventions, including analgesic or anti-inflammatory medications, therapeutic injections, physical therapy, footwear modifications and foot orthoses. If these treatments are ineffective, surgical options may be considered.<ref name=":2">Roddy E, Menz HB. [https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5871064/ Foot osteoarthritis: latest evidence and developments.] Therapeutic advances in musculoskeletal disease. 2018 Apr;10(4):91-103. Available from:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5871064/ (last accessed 2.7.2020)</ref>


According to previous studies, rheumatoid foot problems can be roughly categorized into forefoot, midfoot and hindfoot pathologies.(8) Most of the studies have focused on forefoot and hindfoot pathologies are less studies are conducted concentrating on the midfoot RA. (9) Rheumatoid arthritis is a multisystemic chronic progressive inflammatory disease. The joints become swollen, tenderness and painful. This can lead to severe disability.(9)(10)(11)(12)(13)  
The medications used to treat arthropathies vary depending on the diagnosis. Commonly used medications include:
#[[File:Methotrexate.jpg|right|frameless]][[Pain Medications|Painkillers]] eg paracetamol, For more-severe pain, opioids might be prescribed,  
# Oral non-steroidal anti-inflammatory drugs (NSAIDs) are the most widely used first-line pharmacological treatment. Some NSAIDs are also available as creams or gels, which can be rubbed on joints.<ref name=":3">Mayo clinic [https://www.mayoclinic.org/diseases-conditions/arthritis/diagnosis-treatment/drc-20350777 Arthritis] Available from:https://www.mayoclinic.org/diseases-conditions/arthritis/diagnosis-treatment/drc-20350777 (last accessed 2.7.2020)</ref>
# Counterirritants. Some varieties of creams and ointments contain menthol or capsaicin, the ingredient that makes hot peppers spicy. Rubbing these preparations on the skin over your aching joint may interfere with the transmission of pain signals from the joint itself.
# Disease-modifying antirheumatic drugs ([[DMARDs in the Management of Rheumatoid Arthritis|DMARDs]]). Often used to treat rheumatoid arthritis, DMARDs slow or stop your immune system from attacking your joints. eg methotrexate (Trexall, Rasuvo, others) and hydroxychloroquine (Plaquenil).
# [[BDMARDs in the Management of Rheumatoid Arthritis|Biologic response modifiers]]. Typically used in conjunction with DMARDs, biologic response modifiers are genetically engineered drugs that target various protein molecules that are involved in the immune response. eg Tumor necrosis factor (TNF) inhibitors are commonly prescribed. Other medications target other substances that play a role in inflammation eg interleukin-1 and certain types of white blood cells known as B cells and T cells.
# [[Corticosteroids in the Management of Rheumatoid Arthritis|Corticosteroids]]. This class of drugs, which includes prednisone (Prednisone Intensol, Rayos) and cortisone (Cortef), reduces inflammation and suppresses the immune system. Corticosteroids can be taken orally or can be injected directly into the painful joint<ref name=":3" />.
[[Therapeutic Corticosteroid Injection|Therapeutic Injections]]: Provide an effective alternative financially and some evidence exists that they are effective in pain alleviation (current evidence is limited and the benefit described from injection therapy has been short-lived in most cases)<ref>Urits I, Smoots D, Franscioni H, Patel A, Fackler N, Wiley S, Berger AA, Kassem H, Urman RD, Manchikanti L, Abd-Elsayed A. I[https://link.springer.com/article/10.1007/s40122-020-00157-5 njection Techniques for Common Chronic Pain Conditions of the Foot]: A Comprehensive Review. Pain and therapy. 2020 Feb 27:1-6. Available from:https://link.springer.com/article/10.1007/s40122-020-00157-5 (last accessed 2.7.2020)</ref>.  
* The most widely used are: corticosteroid injections and Viscosupplementation, the intra-articular injection of a lubricating fluid (hyaluronan) (aim of restoring the viscoelasticity of the synovial fluid).<ref name=":2" />
* Regenerative Injections are another option 1. Platelet-rich plasma (PRP) injections - these injections use your own blood and platelets to promote healing. Platelets contain growth factors and proteins that aid healing in soft tissues. Research shows PRP injections can alter the immune response to help reduce inflammation; 2. Placental tissue matrix (PTM) injections - injections of placental tissue  (obtained after a healthy baby is delivered from a healthy mother), there is a large number of growth factors in placental tissue that promote healing<ref>Clevelandclinic [https://health.clevelandclinic.org/4-injections-that-can-banish-joint-pain-for-months/ 4 Therapeutic injections] Available from:https://health.clevelandclinic.org/4-injections-that-can-banish-joint-pain-for-months/ (last accessed 2.7.2020)</ref>; 3. Mesenchymal Stem Cells (MSC) - Mesenchymal stem cells are usually collected from the patient’s fat tissue, blood, or bone marrow. When administering stem cell injections, many physicians use medical imaging, such as ultrasound, in order to deliver cells precisely to the site of cartilage damage.When administering stem cell injections, many physicians use medical imaging, such as ultrasound, in order to deliver cells precisely to the site of damage<ref>arthritis health [https://www.arthritis-health.com/treatment/injections/stem-cell-therapy-arthritis SCT]  Available from: https://www.arthritis-health.com/treatment/injections/stem-cell-therapy-arthritis (last accessed 2.7.2020)</ref>.


'''Haemophilic arthropathy'''
== Physiotherapy ==
[[File:Foot massage.jpg|right|frameless]]
The primary aim of treatment is to afford pain relief, restore mechanics (alignment, motion and/or load distribution) and return the patient to their desired level of activity participation. Individualised treatment is paramount taking into account clients diagnosis.


Haemophilic arthropathy is an important cause of morbidity in patients with severe haemophilia. The degenerative changes that occur in the joints of these patients are usually progressive and result from recurrent bleeding in ‘target’ joints. The ankle is one of the most frequent sources of pain in haemophilic patients. (14)
The plan of care should be designed with the goal of targeting impairments noted during assessment. Options include (see links also):
# [[File:ShoeCue insole.jpg|right|frameless]]Lifestyle Modifications
* In the early stages of arthritathies, limiting the amount of force being placed on the foot and ankle may relieve pain. For example, low-impact activities such as swimming and yoga can provide cardiovascular benefits without putting stress on the foot or ankle.
* Losing weight may decrease pressure on the joints. The foot and ankle support the entire body every time we stand and move, and being overweight increases this pressure and may cause arthritis to progress more quickly.
2. [[Introduction to Orthotics|Orthoses]] and [[Foot Orthoses|footwear]]


'''Diabetic foot arthropathy'''
3. [[Manual Therapy|Manual therapy]] examples include
* [[File:Standing Heel Rise.jpg|right|frameless]][[Massage]] – with sufficient pressure through the superficial tissue to reach the deep lying structures (used to increase blood flow, decrease swelling, reduce muscle spasm and promote normal tissue repair).
* Mobilisation –  joint and soft tissues are gently moved to restore normal range, lubricate tissues and relieve pain. eg Talar glides, Maitland mobilisations
4. [[Stretching]] and [[Exercise -Therapeutic|therapeutic exercises]], eg Stretches that target hamstrings, calves, foot arch and heel are particularly effective and complete range of motion exercises. Strengthening exercises like "small foot exercise", attempting to pick up pegs with toes, walking bare feet in sand. 


Charcot neuropathic osteoarthropathy of the foot is a devastating neuropathic complication of diabetes. (15)(16)(17)(18)(19)(20)
5. [[Cryotherapy]] or [[Thermotherapy]]


Charcot foot is a progressive and degenerative arthropathy of single or multiple joints that ultimately leads to destruction of normal foot architecture, collapse of the arch. (17) It also frequently leads to foot ulceration, gangrene and foot amputation. (18)(19)(20)
6. [[Therapeutic Ultrasound|Ultrasonic Therapy]] – to reduce tissue spasm, accelerates healing and pain relief.


The current accepted origin theory of Charcot neuropathic osteoarthropathy states that an unregulated inflammatory process is triggered in patients with peripheral neuropathy. The inflammatory process eventually stimulates the maturation of osteoclasts from osteoclast precursor cells. (18)(20)
7. I[[Interferential Therapy]] – used for differing treatment effects. E.g. pain relief, muscle or nerve stimulation, promoting blood flow and reducing inflammation.


'''Gout'''
8. [[Gait|Gait re-education]] – assess and treat appropriately with eg gait aides


Gout is a crystal-induced arthritis, in which monosodium urate (MSU) crystals precipitate within joints and soft tissues and elicit a highly inflammatory but localized response. The susceptibility to form MSU crystals is a consequence of excessive blood levels of soluble urate, one of the final products of the metabolic breakdown of purine nucleotides. Hyperuricemia is typically defined as occurring above the saturation point of MSU, at which point the risk of crystallization increases. Using this definition, hyperuricemia occurs at serum urate levels &gt;6.8 mg/dL (21).  
9. [[Taping]]
== Epidemiology /Etiology ==
*[[File:Ligaments_of_the_ankle_lateral_aspect_Primal.png|right|frameless]]Osteoarthritis - Approximately 1% of the world’s adult population is affected by ankle OA <ref name="Barg" />
* Rheumatoid Arthritis - The prevalence of foot pain in patients with RA has been reported at ranges from 60 to 94 % at some stage of the disease. <ref name="Lohkamp">Lohkamp M. et al. The prevalence of disabling foot pain in patients with early rheumatoid arthritis. The Foot  2006;16(4):201-207.</ref><ref name="Brenton">Brenton-Rule, Angela, et al. Foot and ankle characteristics associated with falls in adults with established rheumatoid arthritis: a cross-sectional study.BMC musculoskeletal disorders 2016;17(1):1.</ref>
* Diabetic Foot Arthropathy -  Charcot neuropathic osteoarthropathy are detected in up to 29% of diabetics, whereas under MRI the detection rate rises to 75%.<ref name="Kucera">Kucera, Tomas, Haroun Hassan Shaikh, and Pavel Sponer. Charcot Neuropathic Arthropathy of the Foot: A Literature Review and Single-Center Experience. Journal of Diabetes Research 2016</ref>
* Gout - The global prevalence of gout is substantial and is increasing in many parts of the world over the past 50 years. The distribution of gout is uneven across the globe, with prevalence being highest in Pacific countries. Developed countries tend to have a higher prevalence of gout than that of developing countries and incidence of the disease appears to be on the increase. <ref name="Kuo">Kuo CF, et al. Global epidemiology of gout: prevalence, incidence and risk factors. Nature Reviews Rheumatology 2015;11(11):649-662.</ref>
*  Psoriatic Arthritis - Prevalence of Psoriatic arthritis in psoriasis patients is between 6% and 39%. It is possible that the condition remains generally underdiagnosed, related to lack of awareness by both the patient and physician. <ref name="Mease">Mease P. Psoriatic arthritis update." BULLETIN-HOSPITAL FOR JOINT DISEASES NEW YORK 64.1/2 (2006): 25.</ref><u></u>
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*[[File:Ankle pumps.gif|right|frameless]]Ankle and foot arthropathies covers all joint disease types of the foot and ankle.
* Physical therapy can be effective in all cases of ankle and foot arthropathies
* Accurate differential diagnosis is important so that the most appropriate  management protocol is implemented for the specific disease.
* Recent studies show that individuals with foot and ankle pain have multiple co-existing impairments in alignment, motion, load distribution and muscle performance.
* A comprehensive assessment of the foot and ankle should include patients’ self-reported outcomes and measures of alignment, motion, strength and provocative tests.
* Increasing evidence highlights the importance of evaluating dynamic function and regional interdependence (advances in motion capture and plantar load distribution offer exciting opportunities to obtain precise, clinically relevant measures).
Non-surgical interventions are important factors to ease foot pain and slow the disease-related progression of foot and ankle conditions often seen with the rheumatic diseases. Increasingly, studies are showing that orthoses, footwear and other rehabilitation interventions may play an important role in rheumatology-related foot treatment<ref name=":0" />.  


'''Psoriatic arthritis'''
== References ==
 
<references />  
Psoriatic arthritis is an inflammatory arthritis which affects the skin and musculoskeletal system. (22)(23) If not diagnosed early and treated effectively it can result in joint deformity and disability. (22)
 
Psoriatic arthritis is a chronic condition which can cause considerable disability and pain if not recognized and treated properly. Approximately 15% of patients affected by psoriasis will develop associated joint disease. It was first recognized in 1964 and is now considered part of the spondyloarthropathy group of diseases. (22)<br>
 
'''Reactive arthritis'''
 
Reactive arthritis (ReA) is an infectious disease which may be initiated by several microbes in genetically susceptible hosts. (24) Reactive arthritis is one of the types known to primarily affect young men. Because it can be a complication of sexually transmitted infections.
 
ReA is classified as a type of spondyloarthritis. This group of joint diseases features mono- or oligoarthritis, often associated with extra-articular inflammatory manifestations involving the musculoskeletal, ophthalmologic, dermatologic, and genitourinary systems. These were previously referred to as seronegative spondyloarthritides because the rheumatoid factor is usually negative. (25)
 
== Clinically Relevant Anatomy  ==
 
We will discuss the most relevant anatomy for ankle and foot arthropathies: bones, joints and nerves.
 
'''Bones and joints'''<br>The two bones of the lower leg, the tibia and the fibula, come together and form the ankle joint together with the talus. They form a very stable structure, known as a mortise and tenon joint. The ankle joint allows the foot to bend up, flexion, and down, extension. (26)(27)
 
[[Image:Anatomy1.jpg]]
 
The two bones that make up the back part of the foot, sometimes referred to as the hindfoot, are the talus and the calcaneus. The talus is connected to the calcaneus at the subtalar joint. The subtalar joint allows the foot to rock from side to side. When the foot turns inward, it’s called inversion and when the foot turns outward, it’s called eversion. (26)(27)<br>
 
[[Image:Anatomy ankle and foot 2.jpg]]
 
Just down the foot from the ankle is a set of five bones called tarsal bones that work together as a group. They exist of 3 cuneiform bones (lateral, intermediate and medial), the navicular bone and the cuboid bone. These bones are unique in the way they fit together. When the foot is twisted in one direction by the muscles of the foot and leg, these bones lock together and form a very rigid structure. When they are twisted in the opposite direction, they become unlocked and allow the foot to conform to whatever surface the foot is contacting. The connection between these tarsal bones and the upper bones is called Chopart’s joint line. (26)(27)
 
[[Image:Anatomy ankle and foot 3.jpg]]
 
The tarsal bones are connected to the five long bones of the foot, called the metatarsals. The two groups of bones are rigidly connected, without much movement at the joints. Finally, there are the bones of the toes, the phalanges. The joints between the metatarsals and the first phalanx are called the metatarsophalangeal joints (MTP). These joints form the ball of the foot, and movement in these joints is very important for a normal walking pattern. Not much motion occurs at the joints between the bones of the toe, the interphalangeal joints. The big toe, or hallux, is the most important toe for walking, and the first MTP joint is a common area for problems in the foot. (26)(27)
 
'''Nerves'''
 
The main nerve to the foot, the tibial nerve, enters the sole of the foot by running behind the inside bump on the ankle, the medial malleolus. It divides into its terminal branches, the medial and lateral plantar nerves. (26)(27)
 
[[Image:Anatomy_ankle_and_foot_4.jpg]]
 
At the dorsal surface of the foot lies the peroneal nerve, divided into the deep peroneal nerve and the superficial peroneal nerve, the sural nerve and the saphenous nerve, divided into the intermediate and medial dorsal cutaneous nerve. (28)
 
[[Image:Anatomy_ankle_and_foot_5.jpg]]<br>
 
The tibial nerve, divided into medial plantar nerve (MPN) and lateral plantar nerve (LPN) supplies sensation to the toes and sole of the foot and controls the muscles of the sole of the foot. (26)(27)(28)


<br>  
<br>  


The deep peroneal nerve (DPN) provides motor innervation to the muscles of the anterior compartment and sensation to the big and second toe. The superficial peroneal nerve (SPN) reaches the dorsum of the foot and supplies the dorsal aspect of the toes, with the exception of the first web space. The sural nerve (SU) provides sensory innervation to the lateral aspect of the foot and fifth toe. The saphenous nerve (SA) to the medial aspect of the foot up to the first metatarsophalangeal joint. (28)
[[Category:Foot]]  
 
[[Category:Ankle]]  
More information about the anatomy of the ankle and foot can be found on the physiopedia page “[http://www.physio-pedia.com/Biomechanics_of_Foot_and_Ankle Biomechanics of Foot and Ankle]” and “[http://www.physio-pedia.com/Ankle_Joint Ankle Joint]”.<br>
[[Category:Foot - Conditions]]  
 
[[Category:Ankle - Conditions]]
== Epidemiology /Etiology  ==
[[Category:Vrije Universiteit Brussel Project]]
 
[[Category:Conditions]]
'''Osteoarthritis'''<br>Approximately 1% of the world’s adult population is affected by ankle OA,<br>which results in pain, dysfunction, and impaired mobility. The mental and physical disability associated with end-stage ankle OA is at least as severe as that associated with end-stage hip OA. Numerous clinical and epidemiologic studies have identified previous trauma as the most common origin of ankle OA. 79.5% of patients with ankle OA had a verified history of 1 or more joint injuries. (29)
[[Category:Osteoarthritis]]
 
'''Rheumatoid arthritis'''<br>The prevalence of foot pain in patients with RA has been reported in varying numbers within the published literature. The prevalence of foot pain depends on the stage of the disease. Ranging from 60 to 94 percent at some stage of the disease. (11)(12) In the early stages of RA the prevalence is lower: only 16 percent in one study and 32 in another study. (11)
 
'''Haemophilic arthropathy'''<br>It has been demonstrated that recurrent haemorrhages as occurred in haemophilia result in severe joint destruction. Many authors have reported changes in the synovial membrane and cartilage in chronic haemarthrosis. Repeated episodes of intra-articular bleeding cause damage to the joint, leading to deformity. <br>Several joint disorders, degenerative ones, such as osteoarthritis, inflammation-mediated ones, such as rheumatoid arthritis, and blood-induced ones, such as haemophilic arthropathy, result in cartilage damage and changes in synovial tissue. (30)
 
'''Diabetic foot arthropathy'''<br>Diabetes affects approximately 387 million people worldwide. Together with neuropathy, diabetes mellitus, is currently considered the main cause of Charcot neuropathic osteoarthropathy. The disease goes often undiagnosed among patients suffering of diabetes. The prevalence depends on the way of examination: changes diagnosed by X-ray and corresponding with Charcot neuropathic osteoarthropathy are detected in up to 29% of diabetics. Whereas when MRI is used as a diagnostic method the detection rate rises to 75%.(20)
 
'''Gout'''<br>The global burden of gout is substantial and seems to be increasing in many parts of the world over the past 50 years. The distribution of gout is uneven across the globe, with prevalence being highest in Pacific countries. Developed countries tend to have a higher burden of gout than developing countries, and seem to have increasing prevalence and incidence of the disease. (32)
 
In various geographic regions, men were more likely to report gout than women (33). Less than 10% of the cases occur in women. Most women with gout are 15 years or more postmenopausal. This arthropathy is rare in children. (34)
 
The results of several studies suggest that environmental, racial, and hereditary differences may influence the development of gout. For example, Tokelauan migrants to New Zealand have a greater prevalence of gout than nonmigrants, and certain populations, such as the Maori, have a greater frequency of gout than other New Zealand populations. (33)
 
Some ethnic groups are particularly susceptible to gout, supporting the importance of genetic predisposition. (32)
 
Hyperuricemia is the most important risk factor for gout (35) and is affected by both genetic factors and environmental factors (36). Factors that increase serum urate levels include hypertension, thiazide diuretic intake, obesity, alcohol use, and a high animal protein diet (37).
 
Socioeconomic and dietary factors, as well as comorbidities and medications that can influence uric acid levels and/or facilitate MSU crystal formation, are also important in determining the risk of developing clinically evident gout. (32)
 
The risk of gout is lower in men who are more physically active, maintain ideal body weight, and consume diets enriched in fruit and limited in meat and alcohol. (38)
 
'''Psoriatic arthritis'''<br>In comparison to most other rheumatic disorders genetic predisposition plays a major role in the development of Psoriatic arthritis. (39) Psoriasis is known to affect approximately 2% to 3% of the general population, and the prevalence of Psoriatic arthritis in psoriasis patients is between 6% and 39%. It is possible that the condition remains generally underdiagnosed, related to lack of awareness by both the patient and physician. (40)
 
It is still not clear what exact mechanism lies behind the development of psoriatic arthritis. It is thought to be multifactorial and secondary to environmental, genetic, and immunological factors. When compared with other inflammatory rheumatic conditions, psoriasis and psoriatic arthritis are strongly heritable. (22)
 
'''Reactive arthritis'''<br>Data indicate that approximately 50% of reactive arthritis and undifferentiated oligoarthritis cases can be attributed to a specific pathogen by a combination of culture and serology. The predominant organisms are Chlamydia, Salmonella, Shigella, Yersinia and Campylobactor species. The annual incidence of ReA was found to be 28/100.000 individuals in one study. This may exceed that of rheumatoid arthritis. (41)<br><br>
 
== Characteristics/Clinical Presentation  ==
 
The characteristics and clinical presentation of ankle arthropathies such as different forms of arthritis can be described as followed:
 
*Ankle pain
*stiffness
*swelling
*limited range of motion (ROM)
*Pain Mostly gets worse by activities such as standing, walking or running.
 
We can also speak of the so called “Start-up pain” such as when a patient has pain and stiffness in the ankle after sleeping or sitting in one spot for a while is also a common complaint.
 
When this happens/occurs it often takes the patient a few minutes (or longer) to “warm-up” the ankle. The ankle will tend to swell more as the day progresses particularly if there is increasing activity( patient is still doing sport activities, work activities,…).
 
Most of the time Pain is experienced throughout the ankle although it may be more noticeable in the front of the ankle if large bones spurs have formed. When there has been damage to the joint ankle, it’s often seen that arthritis will occur. Cartilage that normally covers the bones of the ankle joint can be lost leading to an ankle arthropathy.
 
== Differential Diagnosis  ==
 
Intra-articular pathologic lesions must be distinguished from surrounding <u>joint tendinitis </u>and <u>bursitis</u>. This can be achieved with diagnostic testing such as magnetic resonance imaging or with injection of local anesthetic.&nbsp;
 
<u>Primary osteoarthritis </u>is a diagnosis of exclusion. It has been addressed successfully with low tibial osteotomy<ref>Takakura Y, Tanaka Y, Kumal T, et al: Low tibial osteotomy for osteoarthritis of the ankle. J Bone joint surg Br 1995; 77:50.</ref>
 
<u>Post traumatic osteoarthritis </u>is the most common form of ankle arthritis. Post-traumatic disease can be present after intra-articular fractures or improper joint biomechanics after extra-articular fractures. Frequently, deformity is present in the joint. The extent of bone loss after trauma and joint space collapse can be assessed with weightbearing radiographs and CT scans.
 
<u>Avascular necrosis </u>must be considered in cases in which sclerosis of the talar dome is present. Patients may have a history of talar neck fracture, steroid or alcohol usage, or nonspecific injuries. Avascular necrosis of the talus can result in progressive segmental collapse and an increasing amount of particulate matter into the joint.
 
<u>Systematic inflammatory diseases </u>such as <u>rheumatoid arthritis </u>should be excluded prior to considering operative intervention. Ankle arthritis can be effectively treated with a medical regimen prior to considering surgical intervention, particularly during a flare of the disease. The majority of patients with rheumatoid arthritis test positive for rheumatoid factor. In addition, the diagnosis of rheumatoid arthritis requires the presence of certain other symptoms: morning stiffness, multiple joint swelling, rheumatoid nodules, and joint erosion on radiographs<ref>Geppert MJ, Mizel MS: Management of heel pain in inflammatory arthritides. Clin Orthop 1998; 349:93.</ref>
 
Patients with absence of rheumatoid factor in the serum, but manifestations of inflammatory arthritis are classified as having <u>seronegative arthropathy</u>. The four major disorders include <u>ankylosis spondylitis</u>, <u>psoriatic arthritis</u>, <u>Reiter’s syndrome</u>, and <u>inflammatory bowel arthritides</u>.
 
<u>Metabolic</u> and <u>infectious causes </u>of arthritis must be considered as well. This can include <u>gonococcal disease</u>, <u>Lyme disease</u>, and <u>gouty uricemia</u>. Patients should be questioned about possible exposure to disease sources for sexually transmitted diseases and insect bites.<br><br>H(a)emophilic arthropathy occurs by people who have haemophily, this is a desease which unables the blood from bleeding. When these bleedings occur within the joint it causes multiple defects to the joint, this is the result of a number of mechanisms affecting the synovial lining which becomes progressively fibrotic and the hyaline cartilage which disintegrates and is eventually lost. Mechanical and chemical processes cause degeneration of cells but enzymatic processes appear to be primairily responsible for the degradation of the matrix of the articular cartilage.<ref>J Bone Joint Surg Br. 1981;63B(4):601-9. The pathogenesis of chronic haemophilic arthropathy. Stein H, Duthie RB</ref>
 
Charcot osteoarthropathy or pedal neuropathic joint disease is a condition associated with peripheral neuropathy , it is a progressive deterioration of weight-bearing joints, usually in the foot or ankle, and is characterised in its early stages by acute inflammation that leads to bone and joint fracture, dislocation, instability and Gross deformaties. in patients with diabetes, Charcot osteoarthropathy is associated with a longstanding duration of diabetes and peripheral neuropathy. In the early stages of Charcot osteoarthropathy, the patient presents with a warm, erythematous and oedematous foot with or without associated pain or reported previous injury and can clinically mimic cellulitis or gout.<ref>Aust Fam Physician. 2010 Mar;39(3):117-9. Charcot osteoarthropathy of the foot. Perrin BM, Gardner MJ, Suhaimi A, Murphy D</ref>. It can lead to gross structural deformities of the foot and ankle, and subsequent skin ulceration and lower limb amputation from soft tissue or bony infection. The Charcot foot occurs most often in patients with diabetic neuropathy; other predisposing conditions include alcoholic neuropathy, sensory loss caused by cerebral palsy or leprosy, and congenital insensitivity to pain. However, it is often unrecognised, with deleterious consequences..<ref>Am Fam Physician. 2001 Nov 1;64(9):1591-8. Charcot foot: the diagnostic dilemma. Sommer TC, Lee TH.</ref><ref>J Diabetes Complications. 2009 Nov-Dec;23(6):409-26. Epub 2008 Oct 17. Charcot arthropathy of the foot and ankle: modern concepts and management review. Wukich DK, Sung W.</ref><br>
 
== Diagnostic Procedures  ==
 
'''Osteoarthritis'''
 
The diagnosis of osteoarthritic ankle joint starts with clinical assessment, and includes assessment of alignment and stability and measurement of range of motion. Different radiographic modalities may help to recognize and analyse the underlying reasons for ankle OA. Only weight-bearing radiographs of the foot and ankle should be performed. Additional imaging modalities such as MRI and SPECT-CT may help to evaluate the extent of degenerative changes and their biological activities. (29)<br>
 
'''Rheumatoid arthritis'''
 
Different imaging techniques, e.g. MRI, CT and ultrasonography (US), should help clinicians to detect early or subclinical foot problems, because clinical signs of foot disease in RA are often subtle. (9)(53)
 
When detecting joint inflammation ultrasonography and MRI have shown to be superior the clinical examination. (54) Sonography is being used more and more and has been found effective for the detection of erosions in patients with RA. Ultrasonography detected 6.5-fold more erosions in early disease than radiography. (53) Because US is easily available and less expensive than MRI it can be recommended as the first imaging method after plain radiography. (54)
 
'''Haemophilic arthropathy'''
 
Radiography remains the workforce horse in the diagnosis and follow-up of haemophilic arthropathy. The radiographical findings in arthropathy follow an expected sequence of events and are overall similar in different joints. Magnetic resonance imaging (MRI) has advantages over radiography based on its capability of visualizing soft tissue and cartilage changes in haemophilic joints. The recent development and standardization of MRI scoring systems for measuring soft tissue and cartilage abnormalities may enable the comparison of pathological joint findings in clinical trials conducted at different institutions across the world (55)
 
'''Diabetic foot arthropathy'''
 
The diagnosis is based on patient’s history, clinical examination, and imaging methods. As a result of their lowered perception of pain, patients are quite often not aware of any injury. (20)(31) Local inflammation is the main symptom which can lead to the diagnosis being suspected. (18)
 
In Charcot feet arthropathies it is very important that the disease is diagnosed quickly, because a delay can lead to worsening structural damage or even limb loss. (16)(56)(57)(58) Unfortunately the diagnosis is often missed at first presentation. A possible reason for the missed diagnosis is that Charcot feet are not emphasized in medical training. The result is that it is difficult to advocate the right choice of approach due to low evidence based information. (16)
 
Acute Charcot activity can be diagnosed if the temperature of the affected foot is 2°C or more than the contralateral unaffected foot. (58)(20)
 
'''Gout'''
 
Gout is ideally diagnosed through identification of characteristic negatively birefringent crystals under polarized light microscopy in fluid aspirated from end-organ deposits, typically from a joint (59). However, fewer than 10% of patients with gout see a rheumatologist, and most cases of gout are diagnosed in the primary care setting based on signs, symptoms, and serum uric acid level (60).
 
'''Psoriatic arthritis'''
 
A diagnostic test for psoriatic arthritis does not exist unlike in RA which is cyclic citrullinated peptide and rheumatoid factor positive. As in other inflammatory conditions, markers such as erythrocyte sedimentation rate and C-reactive protein can be raised in psoriatic arthritis. (22)
 
Scoring systems have been developed to try and identify psoriatic arthritis at an early stage and criteria have been developed to aid in classification of the disease from the other SPAs and inflammatory arthritides. Not only are they useful for identifying psoriatic arthritis earlier, they can also help identify cases of psoriatic arthritis which do not present in the typical manner. Some criteria include psoriatic arthritis with the SPA group. The classification for psoriatic arthritis (CASPAR) criteria was developed specifically for psoriatic arthritis. It has good sensitivity and specificity for those presenting with disease of &lt;2 years’ duration. Although primarily used for classification, it can be used for diagnostic purposes. (22)
 
Further imaging such as magnetic resonance imaging (MRI) can help to identify soft tissue involvement in further detail, particularly when a patient is suffering from enthesitis. Ultrasound has also become a useful tool in the investigation of arthritis; it can help to identify bony erosions in those patients where synovitis or dactylitis is not always evident clinically. Studies have shown that ultrasound scan and MRI are more sensitive for detecting inflammation than plain radiographs <br>in psoriatic arthritis. (22)<br>
 
== Outcome Measures  ==
 
(also see &lt;a href="Outcome Measures"&gt;Outcome Measures Database&lt;/a&gt;)
 
'''Osteoarthritis'''
 
The Ankle Osteoarthritis Scale (two subscales: pain and disability) (103) is a reliable and valid self-assessment instrument that specifically measures patient symptoms and disabilities related to ankle arthritis. (109)
 
More outcome measures of ankle osteoarthritis can be found on the physiopedia page “&lt;a href="http://www.physio-pedia.com/Ankle_Osteoarthritis#Outcome_Measures"&gt;Ankle Osteoarthritis Arthritis&lt;/a&gt;”
 
'''Rheumatoid arthritis'''
 
American College of Rheumatology (ACR) response criteria for RA. (104)<br>The ACR20 response criteria require a 20% improvement in both tender and swollen joint counts, and a 20% improvement in 3 of 5 items: patient global assessment (visual analog scale, VAS), physician global assessment (VAS), patient pain score (VAS), Health Assessment Questionnaire (HAQ), and either erythrocyte sedimentation rate or C-reactive protein (CRP). For some PsAstudies the joint count was increased to 78 to include distal interphalangeal (DIP) joints of the feet. To achieve an ACR50 or ACR70 response, the same guidelines apply but the level of response is 50% or 70% improvement, respectively. (104)
 
'''Haemophilic arthropathy'''
 
Visualization of bone or cartilage damage in index joints on MRI can be used as outcome measure<br>Tentative haemophilic arthropathy scales based on MRI findings have been developed in the last decade. In 2005, the International Prophylaxis Study Group (IPSG) presented a preliminary comprehensive scoring scheme that combined the pioneer Denver and European MRI scores. The use of such scales should result in a more consistent assessment of haemophilic joints and should facilitate the development of more targeted treatment to prevent or delay further destructive osteoarticular changes. (105)
 
'''Diabetic foot arthropathy'''
 
No research found.
 
'''Gout'''
 
Many different instruments can be used to assess the acute gout core domains. Pain VAS and 5-point Likert scales, 4-point Likert scales of index joint swelling and tenderness and 5-point PGART instruments meet the criteria for the OMERACT filter. (106)
 
'''Psoriatic arthritis'''
 
The Psoriatic Arthritis Response Criteria (PsARC) is recommended in the assessment and monitoring of PsA. It consists of four components: assessment of joint tenderness and swelling utilizing 68/66 joint counts respectively, the patient’s opinion of their global health and the physician’s global assessment. (104)(107)
 
'''Reactive arthritis'''
 
The outcome measures of reactive arthritis can be found on the physiopedia page “&lt;a href="http://www.physio-pedia.com/Reactive_Arthritis#Outcome_Measures"&gt;Reactive Arthritis&lt;/a&gt;”<br>
 
== Examination  ==
 
'''Osteoarthritis'''
 
The examination of osteoarthritis can be found on the physiopedia page “&lt;a href="http://www.physio-pedia.com/Ankle_Osteoarthritis"&gt;Ankle Osteoarthritis&lt;/a&gt;”
 
'''Rheumatoid arthritis'''
 
The examination of rheumatoid arthritis can be found on the Physiopedia page “&lt;a href="http://www.physio-pedia.com/Rheumatoid_Arthritis"&gt;Rheumatoid Arthritis&lt;/a&gt;”<br><br>
 
== Medical Management <br>  ==
 
'''Osteoarthritis'''
 
There is no cure of osteoarthritis. There are several treatments we can subdivide in pharmacologically, non- pharmacologically and surgical. The choice of treatment of ankle and foot osteoarthritis(OA) depends on the severity of the disease. (61) The goal of managing OA in foot and ankle includes the control of pain, improvement in function and quality of life. A number of different aspects like discomfort, comorbidity and radiologic damage need to be considered. (62-1A)
 
[[Image:OA ankle managment.PNG]][[Image:OA ankle managment2.PNG]]&nbsp;&nbsp;
 
'''Rheumatoid arthritis'''
 
[[Image:RA ankle managment.PNG]]  
 
 
'''Haemophilic arthropathy'''
 
[[Image:HA ankle managment.PNG]]<br>
 
 
'''Diabetic foot arthropathy'''
 
A multidisciplinary approach is recommended for the management of Charcot foot involving medical and allied health professionals. (19)
 
[[Image:DFA ankle managment.PNG]][[Image:DFA ankle managment2.PNG]]<br>
 
 
'''Gout'''
 
[[Image:Gout ankle managment.PNG]]<br>
 
 
'''Psoriatic arthritis'''
 
Treatments such as oral disease modifying anti-rheumatic drugs and biologic therapy are effective but have side effects which could limit their use in certain individuals. (22-1A)
 
[[Image:PsA ankle managment.PNG]]<br>
 
 
'''Reactive arthritis'''
 
The treatment of reactive arthritis comprises mainly non-steroidal anti-inflammatory drugs, intra-articular steroid injections, and physical treatment. (77-1B)
 
[[Image:ReA ankle managment.PNG]]<br>&nbsp;[[Image:ReA ankle managment2.PNG]]&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <br>
 
== Physical Therapy Management <br>  ==
 
add text here <br>
 
== Key Research  ==
 
add links and reviews of high quality evidence here (case studies should be added on new pages using the &lt;a href="Template:Case Study"&gt;case study template&lt;/a&gt;)<br>
 
== Resources  ==
 
<u></u><sub></sub><sup></sup><strike></strike>
 
== Clinical Bottom Line  ==
 
<br>
 
== Recent Related Research (from [https://www.ncbi.nlm.nih.gov/pubmed/ PubMed])  ==
 
see tutorial on "[http://www.physio-pedia.com/Adding_PubMed_Feed Adding PubMed Feed]"
<div class="researchbox">
<span>Feed goes here!!|charset=UTF-8|short|max=10</span>
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== References  ==
 
&lt;span class="fck_mw_references" _fck_mw_customtag="true" _fck_mw_tagname="references" /&gt;
 
&lt;a href="Category:Musculoskeletal/Orthopaedics"&gt;Orthopaedics&lt;/a&gt; &lt;a _fcknotitle="true" href="Category:Ankle"&gt;Ankle&lt;/a&gt; &lt;a _fcknotitle="true" href="Category:Rheumatology"&gt;Rheumatology&lt;/a&gt; &lt;a _fcknotitle="true" href="Category:Foot"&gt;Foot&lt;/a&gt;

Latest revision as of 16:47, 17 January 2023

Original Editors - Ward Willaert as part of the Vrije Universiteit Brussel Evidence-Based Practice Project Top Contributors - Anouck Leo, Admin, Arturo Quiroz Marnef, Evelien De Wolf, Scott Cornish, Kim Jackson, Lucinda hampton, Rachael Lowe, Ward Willaert, Yuli Borremans, 127.0.0.1, Gayatri Jadav Upadhyay, Cath Young, Maxim de Clippele, Mariam Hashem, Jan De Backer, Sai Kripa, Aminat Abolade, Fitim Cami and Veekhoven Laura  

Introduction[edit | edit source]

Foot.jpg

Any joint in the ankle, foot and toes can be affected by an arthropathy (arthropathy is a general term for any disease of the joints).

  • There are more than 100 forms of arthritis, many of which affect the foot and ankle, causing joint pain, swelling and stiffness.
  • Arthritis in the feet can make standing and walking painful and the feet and/or toes may change shape, making it harder to fit shoes and Activities of Daily Living may be affected.
  • Athropathies of the foot and ankle are an important public health challenge due to their increasing incidence combined with their substantial negative impact on patients’ quality of life.
  • Although arthropathy is less common in the ankle than the hip and knee, it can be just as disabling.[1]
  • Non-pharmacological treatments serve as the first line of treatment and are frequently used for patients with musculoskeletal conditions of the foot and ankle[2].

Arthropathy is a blanket or global term for a wide range of joint presentations.

Be sure to look at all the links above for detailed information, this page is a general overview.

Relevant Anatomy[edit | edit source]

Bones of the foot.png

Each foot has 28 bones and more than 30 joints. The most common foot joints that arthritis affects are:

  1. The Ankle joint
  2. The 3 joints of the foot that involve the calcaneus, the navicular , and the cuboid bone.
  3. The !st MTP joint [10]

More information about the anatomy of the ankle and foot can be found here: Biomechanics of Foot and Ankle and Ankle Joint.

Signs and Symptoms[edit | edit source]

In general the symptoms are pain in the joints, reduction of the functions of the structure of connection or support and inflammation in the tendons, ligaments, joints, muscles and bones.

  • Decreased range of motion, effusion, neumarthrosis, bone erosion.
  • The symptoms are similar to rheumatic conditions and include pain, swelling and stiffness.
  • Skeletal muscle is also affected by pain and inflammation of bones, structure, muscles, and is a type of joint disease[6].
  • Pain usually increases on activities such as standing, walking or running.
  • “Start-up pain” is also a common complaint, where the patient experiences pain and stiffness in the ankle on moving after being asleep or sitting for a long period, which takes a few minutes of motion to settle.
  • The affected joints will tend to increasingly swell as the day progresses, particularly with a higher level of activity.

Assessment[edit | edit source]

OA ankle.jpg

A clinical examination of the foot includes ‘traditional’ components such as history, palpation, and assessments of sensation, range of motion and strength, as well as special tests that provoke specific tissues. On observation, toe deformities and skin health (dryness, sweating, perfusion) should be noted.[2]

Salient Points of Examination include:

  1. Patients’ self-reported outcomes eg VAS, PSFS
  2. Static Foot Structure and Alignment eg the Foot Posture Index
  3. Joint Range of Motion - Quantified using a goniometer, and note position tested in.
  4. Walk.jpg
    Muscle strength - Decreased toe flexor strength and foot pain are independently associated with fall risk. Strength deficits have also been reported in individuals with foot pain secondary to tibialis posterior tendinopathy[2].
  5. Footwear assessment - Inspect for fit (length and width) and design features such as the presence of a heel cup, arch support, torsional and toe-break flexibility. Patterns of wear on the sole of the shoe and/or or scuffing should be noted. The Footwear Assessment Form is a simple and well-organized tool with established reliability and face-validity[2].
  6. Dynamic Assessment of Foot Motion (including Gait Analysis) - Involves an observational or quantitative assessment of foot and lower extremity mechanics during a weight-bearing task (e.g., walking, running, single limb squat, step down). Particularly relevant in a clinical foot exam because evidence indicates that there is only a weak relationship between static and dynamic measures of arch height and large between-person variability[2]
  7. Dynamic Assessment of Plantar Load Distribution - When performing a clinical assessment, the plantar aspect of the foot should be inspected for patterns of calluses and weight-bearing.
  8. Provocational Tests - The final part of the clinical examination comprises provocational tests that provoke specific tissues. The Windlass Testtstretcheshe plantar fascia and is considered positive if the patient reports pain when the 1st metatarso-phalanegeal joint is passively dorsiflexed. Limited extensibility in the gastrocnemius-soleus complex or the flexor hallucis longus can be assessed using passive muscle length testing. Symptoms related to the sesamoids may manifest as plantar pain and localized tenderness to palpation.[2]

Medical Treatment[edit | edit source]

Management of ankle and foot arthropathies generally commences with conservative interventions, including analgesic or anti-inflammatory medications, therapeutic injections, physical therapy, footwear modifications and foot orthoses. If these treatments are ineffective, surgical options may be considered.[11]

The medications used to treat arthropathies vary depending on the diagnosis. Commonly used medications include:

  1. Methotrexate.jpg
    Painkillers eg paracetamol, For more-severe pain, opioids might be prescribed,
  2. Oral non-steroidal anti-inflammatory drugs (NSAIDs) are the most widely used first-line pharmacological treatment. Some NSAIDs are also available as creams or gels, which can be rubbed on joints.[12]
  3. Counterirritants. Some varieties of creams and ointments contain menthol or capsaicin, the ingredient that makes hot peppers spicy. Rubbing these preparations on the skin over your aching joint may interfere with the transmission of pain signals from the joint itself.
  4. Disease-modifying antirheumatic drugs (DMARDs). Often used to treat rheumatoid arthritis, DMARDs slow or stop your immune system from attacking your joints. eg methotrexate (Trexall, Rasuvo, others) and hydroxychloroquine (Plaquenil).
  5. Biologic response modifiers. Typically used in conjunction with DMARDs, biologic response modifiers are genetically engineered drugs that target various protein molecules that are involved in the immune response. eg Tumor necrosis factor (TNF) inhibitors are commonly prescribed. Other medications target other substances that play a role in inflammation eg interleukin-1 and certain types of white blood cells known as B cells and T cells.
  6. Corticosteroids. This class of drugs, which includes prednisone (Prednisone Intensol, Rayos) and cortisone (Cortef), reduces inflammation and suppresses the immune system. Corticosteroids can be taken orally or can be injected directly into the painful joint[12].

Therapeutic Injections: Provide an effective alternative financially and some evidence exists that they are effective in pain alleviation (current evidence is limited and the benefit described from injection therapy has been short-lived in most cases)[13].

  • The most widely used are: corticosteroid injections and Viscosupplementation, the intra-articular injection of a lubricating fluid (hyaluronan) (aim of restoring the viscoelasticity of the synovial fluid).[11]
  • Regenerative Injections are another option 1. Platelet-rich plasma (PRP) injections - these injections use your own blood and platelets to promote healing. Platelets contain growth factors and proteins that aid healing in soft tissues. Research shows PRP injections can alter the immune response to help reduce inflammation; 2. Placental tissue matrix (PTM) injections - injections of placental tissue (obtained after a healthy baby is delivered from a healthy mother), there is a large number of growth factors in placental tissue that promote healing[14]; 3. Mesenchymal Stem Cells (MSC) - Mesenchymal stem cells are usually collected from the patient’s fat tissue, blood, or bone marrow. When administering stem cell injections, many physicians use medical imaging, such as ultrasound, in order to deliver cells precisely to the site of cartilage damage.When administering stem cell injections, many physicians use medical imaging, such as ultrasound, in order to deliver cells precisely to the site of damage[15].

Physiotherapy[edit | edit source]

Foot massage.jpg

The primary aim of treatment is to afford pain relief, restore mechanics (alignment, motion and/or load distribution) and return the patient to their desired level of activity participation. Individualised treatment is paramount taking into account clients diagnosis.

The plan of care should be designed with the goal of targeting impairments noted during assessment. Options include (see links also):

  1. ShoeCue insole.jpg
    Lifestyle Modifications
  • In the early stages of arthritathies, limiting the amount of force being placed on the foot and ankle may relieve pain. For example, low-impact activities such as swimming and yoga can provide cardiovascular benefits without putting stress on the foot or ankle.
  • Losing weight may decrease pressure on the joints. The foot and ankle support the entire body every time we stand and move, and being overweight increases this pressure and may cause arthritis to progress more quickly.

2. Orthoses and footwear

3. Manual therapy examples include

  • Standing Heel Rise.jpg
    Massage – with sufficient pressure through the superficial tissue to reach the deep lying structures (used to increase blood flow, decrease swelling, reduce muscle spasm and promote normal tissue repair).
  • Mobilisation – joint and soft tissues are gently moved to restore normal range, lubricate tissues and relieve pain. eg Talar glides, Maitland mobilisations

4. Stretching and therapeutic exercises, eg Stretches that target hamstrings, calves, foot arch and heel are particularly effective and complete range of motion exercises. Strengthening exercises like "small foot exercise", attempting to pick up pegs with toes, walking bare feet in sand.

5. Cryotherapy or Thermotherapy

6. Ultrasonic Therapy – to reduce tissue spasm, accelerates healing and pain relief.

7. IInterferential Therapy – used for differing treatment effects. E.g. pain relief, muscle or nerve stimulation, promoting blood flow and reducing inflammation.

8. Gait re-education – assess and treat appropriately with eg gait aides

9. Taping

Epidemiology /Etiology[edit | edit source]

  • Ligaments of the ankle lateral aspect Primal.png
    Osteoarthritis - Approximately 1% of the world’s adult population is affected by ankle OA [3]
  • Rheumatoid Arthritis - The prevalence of foot pain in patients with RA has been reported at ranges from 60 to 94 % at some stage of the disease. [16][17]
  • Diabetic Foot Arthropathy - Charcot neuropathic osteoarthropathy are detected in up to 29% of diabetics, whereas under MRI the detection rate rises to 75%.[18]
  • Gout - The global prevalence of gout is substantial and is increasing in many parts of the world over the past 50 years. The distribution of gout is uneven across the globe, with prevalence being highest in Pacific countries. Developed countries tend to have a higher prevalence of gout than that of developing countries and incidence of the disease appears to be on the increase. [19]
  • Psoriatic Arthritis - Prevalence of Psoriatic arthritis in psoriasis patients is between 6% and 39%. It is possible that the condition remains generally underdiagnosed, related to lack of awareness by both the patient and physician. [20]

Clinical Bottom Line[edit | edit source]

  • Ankle pumps.gif
    Ankle and foot arthropathies covers all joint disease types of the foot and ankle.
  • Physical therapy can be effective in all cases of ankle and foot arthropathies
  • Accurate differential diagnosis is important so that the most appropriate management protocol is implemented for the specific disease.
  • Recent studies show that individuals with foot and ankle pain have multiple co-existing impairments in alignment, motion, load distribution and muscle performance.
  • A comprehensive assessment of the foot and ankle should include patients’ self-reported outcomes and measures of alignment, motion, strength and provocative tests.
  • Increasing evidence highlights the importance of evaluating dynamic function and regional interdependence (advances in motion capture and plantar load distribution offer exciting opportunities to obtain precise, clinically relevant measures).

Non-surgical interventions are important factors to ease foot pain and slow the disease-related progression of foot and ankle conditions often seen with the rheumatic diseases. Increasingly, studies are showing that orthoses, footwear and other rehabilitation interventions may play an important role in rheumatology-related foot treatment[2].

References[edit | edit source]

  1. ↑ Stauffer RN: Intra-articular ankle problems. In Evarts CM (ed): surgery of the musculoskeletal system, vol. 4. New York, Churchill-Livingstone, 1990.
  2. ↑ 2.0 2.1 2.2 2.3 2.4 2.5 2.6 Rao S, Riskowski JL, Hannan MT. Musculoskeletal conditions of the foot and ankle: assessments and treatment options. Best Practice & Research Clinical Rheumatology. 2012 Jun 1;26(3):345-68. Available from:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3414868/ (last accessed 1.7.2020)
  3. ↑ 3.0 3.1 Barg, A., et al. Haemophilic arthropathy of the ankle treated by total ankle replacement: a case series. Haemophilia 2010;16(4):647-655.
  4. ↑ Reactive Arthritis (Reiter’s Syndrome). www.mayoclinic.org. Retrieved May 16, 2011.(accessed 3 december 2016)
  5. ↑ Björkengren A. G., Resnick D, Sartoris DJ. Enteropathic arthropathies. Radiologic Clinics of North America 1987: 189
  6. ↑ 6.0 6.1 6.2 Scope heal Arthropathy Available from:https://scopeheal.com/arthropathy/ (last accessed 1.7.2020)
  7. ↑ McGill, Neil W. Gout and other crystal-associated arthropathies. Best Practice & Research Clinical Rheumatology 2000: 445-460
  8. ↑ Sanders, L.J., Edmonds, M.E. & Jeffcoate, W.J. Diabetologia (2013) 56: 1873. https://doi.org/10.1007/s00125-013-2961-6
  9. ↑ Medical dictionary. http://medical-dictionary.thefreedictionary.com/diabetic+arthropathy (Accessed 2 december 2016)
  10. ↑ Cleveland clinic Foot and ankle arthritis Available from:https://my.clevelandclinic.org/health/diseases/13900-foot-and-ankle-arthritis (last accessed 1.7.2020)
  11. ↑ 11.0 11.1 Roddy E, Menz HB. Foot osteoarthritis: latest evidence and developments. Therapeutic advances in musculoskeletal disease. 2018 Apr;10(4):91-103. Available from:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5871064/ (last accessed 2.7.2020)
  12. ↑ 12.0 12.1 Mayo clinic Arthritis Available from:https://www.mayoclinic.org/diseases-conditions/arthritis/diagnosis-treatment/drc-20350777 (last accessed 2.7.2020)
  13. ↑ Urits I, Smoots D, Franscioni H, Patel A, Fackler N, Wiley S, Berger AA, Kassem H, Urman RD, Manchikanti L, Abd-Elsayed A. Injection Techniques for Common Chronic Pain Conditions of the Foot: A Comprehensive Review. Pain and therapy. 2020 Feb 27:1-6. Available from:https://link.springer.com/article/10.1007/s40122-020-00157-5 (last accessed 2.7.2020)
  14. ↑ Clevelandclinic 4 Therapeutic injections Available from:https://health.clevelandclinic.org/4-injections-that-can-banish-joint-pain-for-months/ (last accessed 2.7.2020)
  15. ↑ arthritis health SCT Available from: https://www.arthritis-health.com/treatment/injections/stem-cell-therapy-arthritis (last accessed 2.7.2020)
  16. ↑ Lohkamp M. et al. The prevalence of disabling foot pain in patients with early rheumatoid arthritis. The Foot 2006;16(4):201-207.
  17. ↑ Brenton-Rule, Angela, et al. Foot and ankle characteristics associated with falls in adults with established rheumatoid arthritis: a cross-sectional study.BMC musculoskeletal disorders 2016;17(1):1.
  18. ↑ Kucera, Tomas, Haroun Hassan Shaikh, and Pavel Sponer. Charcot Neuropathic Arthropathy of the Foot: A Literature Review and Single-Center Experience. Journal of Diabetes Research 2016
  19. ↑ Kuo CF, et al. Global epidemiology of gout: prevalence, incidence and risk factors. Nature Reviews Rheumatology 2015;11(11):649-662.
  20. ↑ Mease P. Psoriatic arthritis update." BULLETIN-HOSPITAL FOR JOINT DISEASES NEW YORK 64.1/2 (2006): 25.


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