Ankle and Foot Arthropathies

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Original Editors - Ward Willaert

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Key-words: ankle and foot arthropathies, ankle arthritis, tibio-talair arthritis, tibio-talair joint, Ankle diagnosis and management.

Information found at the university’s library ( books and scientific magazines) and websites such as Pubmed, web of knowledge, British medical journal, PEDro (physiotherapy evidence database), Medicine, The IOWA orthopaedic journal, The journal of bone and joint surgery.

Definition/Description

An arthropathy is a disease of a joint.
Although the terms "arthropathy" and arthritis have very similar meanings, the former is traditionally used to describe the following conditions:
• Reactive arthropathy is caused by an infection, but not a direct infection of the synovial space.
• Enteropathic arthropathy is caused by colitis and related conditions.
• Crystal arthropathy involves the deposition of crystals in the joint.
o In gout, the crystal is uric acid.
o In pseudogout/chondrocalcinosis/calcium pyrophosphate deposition disease, the crystal is calcium pyrophosphate.
• Diabetic arthropathy is caused by diabetes.
• Neuropathic arthropathy is associated with a loss of sensation

Although an arthropathy is distinctly less common in the ankle than in the hip and knee, it is an equally disabling condition.[1]

Clinically Relevant Anatomy

The most important relevant anatomy is the bone structures and joints of the foot and ankle.
The skeleton of the foot begins with the talus, or ankle bone, that forms part of the ankle joint. The two bones of the lower leg, the large tibia and the smaller fibula, come together at the ankle joint to form a very stable structure known as a mortise and tenon joint. The two bones that make up the back part of the foot (sometimes referred to as the hindfoot) are the talus and the calcaneus, or heelbone. The talus is connected to the calcaneus at the subtalar joint. The ankle joint allows the foot to bend up and down. The subtalar joint allows the foot to rock from side to side. Just down the foot from the ankle is a set of five bones called tarsal bones that work together as a Group, they excist of 3 cuneiform bones (lateral, intermediate and medial), the navicular bone and the cuboid bone. There are multiple joints between the tarsal bones. The connection between these tarsal bones and the upper bones is called the transverse tarsal joint of the line of Chopart. The tarsal bones are connected to the five long bones of the foot called the metatarsals, this connection is calles the tarsometatasal joint or the line of Lisfranc. Then there are the bones of the toes, the phalanges. The joints between the metatarsals and the first phalanx is called the metatarsophalangeal joint (MTP). These joints form the ball of the foot, and movement in these joints is very important for a normal walking pattern.
A knowledge of the surrounding muscles, ligaments and nerves and vesels is of course also very important when looking at the human anatomy or for pathologies.
more information on the human anatomy you can by clicking on the link below.

Epidemiology /Etiology

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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 joint tendinitis and bursitis. This can be achieved with diagnostic testing such as magnetic resonance imaging or with injection of local anesthetic. 

Primary osteoarthritis is a diagnosis of exclusion. It has been addressed successfully with low tibial osteotomy.[3]

Post traumatic osteoarthritis 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.

Avascular necrosis 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.

Systematic inflammatory diseases such as rheumatoid arthritis 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.[4]

Patients with absence of rheumatoid factor in the serum, but manifestations of inflammatory arthritis are classified as having seronegative arthropathy. The four major disorders include ankylosis spondylitis, psoriatic arthritis, Reiter’s syndrome, and inflammatory bowel arthritides.

Metabolic and infectious causes of arthritis must be considered as well. This can include gonococcal disease, Lyme disease, and gouty uricemia. Patients should be questioned about possible exposure to disease sources for sexually transmitted diseases and insect bites.

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.

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.. 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..

Diagnostic Procedures

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Outcome Measures

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Examination

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Medical Management

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Physical Therapy Management

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Key Research

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Resources

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Clinical Bottom Line

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Recent Related Research (from Pubmed)

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References

1. Stauffer RN: Intra-articular ankle problems. In Evarts CM (ed): surgery of the musculoskeletal system, vol. 4. New York, Churchill-Livingstone, 1990, p 3868

2. Charles L Saltzman, MD, Professor, Michael L Salamon, MD, G Michael Blanchard, MD, Thomas Huff, MD, Andrea Hayes, Joseph A Buckwalter, MD, and Annunziato Amendola, MD : Epidemiology of ankle arthritis : Report of a consecutive series of 639 patients from a tertiary orthopaedic center. Iowa Orthop J. 2005; 25: 44–46.

3. Takakura Y, Tanaka Y, Kumal T, et al: Low tibial osteotomy for osteoarthritis of the ankle. J Bone joint surg Br 1995; 77:50.

4. Geppert MJ, Mizel MS: Management of heel pain in inflammatory arthritides. Clin Orthop 1998; 349:93.