Ankle Arthritis

Ankle arthritis, or osteoarthritis, is pain in the ankle caused by long term wear and tear. In osteoarthritis the cartilage, the smooth lining of the joint, is rubbed away. The bone underneath is then irritated, inflamed and painful.

Ankle arthritis is very common, especially in older people. It is more likely if you have had an ankle injury, especially a fracture.

Often, arthritis can be managed with self care, pain medicines or supportive soft shoes. Occasionally, surgery is needed.

Symptoms

Osteoarthritis is associated with:

• Pain in one or both ankles. It is often worse at the end of the day after walking around. It may be eased by simple pain medicine from the chemist and ice.
• Some swelling
• Stiffness

Other symptoms, such as redness and warmth, may mean you have another condition that is sometimes mistaken for simple osteoarthritis:

• Rheumatoid arthritis – sometimes affects the ankle and feet, usually both sides together. It causes short episodes of mild to severe pain. This is different to osteoarthritis, which is usually a constant, slowly worsening process.
• Gout & pseudogout – similarly to rheumatoid arthritis, these affect different joints in the body with episodes of pain.
• Septic arthritis – several infections can affect joints. Often, but not always, fever, redness and swelling come with the pain.
• Neuropathic Arthritis

Causes

Ankle arthritis is caused by wear and tear on the cartilage in the joint.

If the ankle was injured earlier in life, for example by fractures, rheumatoid arthritis, gout or repeated sprains, the joint surfaces are likely to rub against each other abnormally. This makes arthritis more likely.

Other problems in the joint, such as infection or haemarthrosis (bleeding into the joint), can also damage the cartilage and lead to arthritis later in life.

If you have had surgery on the rest of your foot, for example fusion of the big toe or heel, you are more likely to develop arthritis because the forces through your ankle are unbalanced.

Risk Factors

Arthritis can occur at any age, but is more likely in older people. Other things that raise the risk include:

• Injury. Ankle fractures, dislocations and repeated sprains can all change the way the joint fits together. A poorly fitting joint rubs some areas of cartilage more than others, which starts the process of arthritis. This is so common it is called ‘post-traumatic arthritis’.
• Diabetes
• Obesity

Other foot surgery, in particular fusion operations across the heel and back of the foot, makes ankle arthritis more likely.

Investigations

Your doctor can assess your arthritis by listening to your symptoms and examining your ankle. Tests that may help include:

• X-rays.
• Rarely, more advanced images are required – CT scans and MRI.
• Blood tests.
• Needle aspirate of the joint. Gout and pseudogout can affect the ankle. If your doctor suspects one of these, they may take a sample of joint fluid with a needle.

Complications

Complications include pain and swelling in other joints, and inflammation spreading into the soft tissues around the joint (synovitis). This can make the joint hot, red, swollen and very painful.

Treatment

The treatment plan depends on how bad your pain is and how active you are.

There are three broad types of treatment: medicines and injections, physical therapy, and surgery. Splints, medicines, injections and minor surgery such as arthroscopy are often used together. When these begin to fail, you may need fusion surgery (arthrodesis) or ankle replacement.

While you wait to see a doctor, you can try these steps at home:

• Rest and avoid activities that aggravate your ankle. Try to wear wide, comfortable shoes. This does not mean complete bed rest. Gently move your ankle when it is not painful.
• If you notice swelling in your ankle, you can reduce this by applying ice and elevating your ankle.
  • Apply ice to the injured area for up to 20 minutes, several times a day. Ice packs, ice massage or ice water slush baths all can help. For an ice massage, freeze a plastic foam cup full of water so that you can hold the cup while applying the ice directly to the skin.
  • Keeping your ankle raised on several pillows while you sleep helps bring down swelling.

You can also try non-steroidal anti-inflammatory drugs (NSAIDs) such as aspirin and ibuprofen, or products that contain paracetamol, to ease pain.

Talk to your doctor if you need NSAIDs for a long time. Some of these drugs should only be used for short periods (about 7 to 10 days) to avoid complications.

Injections

Your doctor may suggest an injection of steroid and/or anaesthetic into the joint. This reduces inflammation, which eases pain and swelling and helps prevent further injury to your ankle.

Injections are often effective, but they need to be repeated every few months to keep working. So you may be referred for further treatment.

Physical Therapy & Orthotics

If self-care such as rest, ice and pain relief from the chemist is not working, your doctor may suggest other physical therapy:

• Shoe inserts – Orthotics.
• Shoe modifications.
  • Your orthotist, podiatrist or surgeon may recommend you try a special shoe design called a ‘rocker bottom‘ shoe. The sole of this type of shoe forms a smooth, soft curve along its bottom edge. It helps reduce the strain on the ankle by gently rolling the foot from heel to toe as you walk.
  • Shoes with a stiff sole and well-padded heel are also very useful for arthritis.
• Taping.
• Braces / splints. When shoe inserts do not help, a brace from the lower leg to the foot that stops the ankle moving too much can help. Your specialist may suggest you wear the brace for a number of weeks until the inflammation settles.
• Physiotherapy. Strengthening the muscles in your calf and leg can help balance the forces around your ankle.

Surgery

When these treatments do not control your symptoms, you may start to think about surgery.

There are several surgical options for severe arthritis:

• Arthroscopy. This is keyhole surgery that lets the surgeon see the inside of your ankle. The joint can be flushed and any damaged cartilage trimmed away. It treats the symptoms of arthritis very effectively. But it does not cure the arthritis, so repeat arthroscopy or bigger surgery may be needed in later years.
• Ankle Arthrodesis. Fusion of the ankle is a very effective way to stabilise the foot and relieve pain. The disadvantage is that all movement at the ankle is lost, which makes activities like running impossible. Despite this, most people are very happy with the results of fusion.
• Total Ankle Replacement. Replacing the ankle gives you a moving joint, but it is more likely to need revision surgery later in life.

Ankle distraction uses a frame outside the leg to take pressure off a worn ankle joint. Infection around the pins is common but can usually be treated.

Seeking Advice

If ankle pain is starting to make walking difficult, talk to your local healthcare provider.

In the meantime, you can use simple treatments such as rest, ice and keeping your foot raised at night. Medicines from the chemist, such as Panadol, can also ease pain.

Your Family Doctor (GP)

Your family doctor can diagnose your problem and help treat it. They can:

• tell you about your problem
• advise you of the best treatment methods
• prescribe you medications
• and if necessary, refer you to Specialists (Consultants) for further treatment

Prevention

Most ankle arthritis follows an earlier injury, not simple ageing. So prevention is mostly about looking after the ankle after an injury and reducing the load on it afterwards.

• Rehabilitate ankle injuries properly. A sprain that leaves the ankle weak and prone to giving way loads the joint abnormally for years. See chronic ankle instability.
• Have significant ankle fractures treated and followed up properly. A smooth, accurate joint surface matters more in the ankle than in most joints.
• Keep to a healthy weight. Each extra kilogram adds several times that load through the ankle when you walk.
• Wear comfortable, supportive shoes with a cushioned sole. A stiff or rocker sole reduces the movement a painful ankle has to make. See footwear in orthopaedics.
• Stay active with lower impact exercise such as cycling, swimming and walking on even ground, instead of stopping altogether. Strong muscles around the ankle protect the joint.
• If you smoke, stopping helps joint health in general and helps healing if you ever need surgery.

F.A.Q. | Frequently Asked Questions

Why do I have arthritis in my ankle when I’ve never had it anywhere else?

Unlike the hip and knee, ankle arthritis is usually caused by an old injury, not general wear. A fracture or repeated sprains decades earlier is the most common story. This is why it often affects one ankle only, and often in people who have no arthritis elsewhere.

Is a fusion or a replacement better?

They suit different people. An ankle arthrodesis (fusion) reliably relieves pain and is very durable, but you lose the up and down movement of the joint. An ankle replacement keeps movement and gives a more natural walk, but it is a newer operation with more chance of further surgery later. Your age, activity, the state of the neighbouring joints and how much movement you have left all help decide.

Should I stop walking on it?

No. Activity within comfortable limits maintains strength and function. Choosing lower-impact activity and even surfaces helps more than giving up.

Will it definitely get worse?

Not necessarily quickly. Ankle arthritis often stays stable for long stretches, and symptoms fluctuate. Many people manage for years with shoe modification, activity change and occasional injections.

What shoes help most?

A cushioned sole with a slight rocker takes work away from a stiff, painful ankle. A supportive boot that limits movement helps some people considerably. A podiatrist or orthotist can advise on what suits your foot shape.

Do injections work?

A steroid injection can settle a painful flare and often gives relief for weeks to months. It treats the symptoms, not the arthritis, and should not be repeated for ever. But it can help you through a bad patch or delay surgery.

References

1. Hollander JJ, Paget LDA, Dahmen J, Stornebrink T, Rikken QGH, Sierevelt IN, Kerkhoffs GMMJ, Stufkens SAS. Low annual revision rate in ankle distraction for ankle osteoarthritis. A systematic review and meta-analysis. Knee Surg Sports Traumatol Arthrosc. 2024, 32(2), 344-351. PMID 38294178.