When you think of arthritis, you tend to think of creaky knees, swollen fingers, or a stiff hip. Arthritis in the ankle doesn’t get as much attention. While arthritis doesn’t affect the ankle as commonly as other joints, it can take a significant toll on your mobility and quality of life. “Ankle arthritis can cause significant disability and affect daily living,” says Saira Bilal, MD, assistant professor of medicine at the George Washington University in Washington, D.C.
Arthritis in the ankle can lead to pain, swelling, deformity, and instability in the ankle joint. Ankle arthritis affects the tibiotalar joint, which forms between the shin bone (tibia) and ankle bone (talus).
“The incidence of ankle arthritis is five to 10 times less than arthritis of larger joints like the hip and knee,” says podiatrist Krista A. Archer, DPM, who is on staff at Lenox Hill Hospital in New York City. “When I see it in advanced stages, it usually occurs after someone has experienced a prior injury. Ankle arthritis causes pain and can lead to changes in your gait, or the way you walk.”
Learn more about what causes ankle arthritis and how arthritis of the ankle is treated.
If you have ankle pain, it’s important to understand the type of arthritis that might be causing it, because some types of arthritis have very specific medications and treatments. Here are some of the more common types of arthritis that strike in the ankle.
Osteoarthritis (OA) is a degenerative joint disease where the cartilage that cushions the ends of a joint wears away gradually. Osteoarthritis often occurs because of typical wear and tear on a joint that happens with age. But many cases of ankle osteoarthritis are related to a previous ankle injury. Injury can damage the cartilage directly or change how the ankle joint works, leading to cartilage deterioration over time.
This type of arthritis develops in the foot as a result of injury, even one that happened a long time ago. For example, a sprain, fracture, or dislocation in the ankle may damage cartilage. That can lead to premature deteriorating of the joint. Symptoms may appear within a few years, or it can take decades for joint damage from an injury to cause pain.
Rheumatoid arthritis (RA) is a chronic inflammatory disease, in which the body’s immune system attacks itself. The joints of the ankles can be affected by RA. Difficulty with ramps, inclines, and stairs are the early signs that the ankle is involved with RA. Standing and basic walking can become painful as the RA in the ankle advances.
Other types of inflammatory arthritis such as psoriatic arthritis and peripheral spondyloarthritis can also affect the ankle joint.
For many people, pain and swelling in the big toe is the first symptom of gout, which is a type of arthritis that occurs because of elevated levels of uric acid in the blood accumulate in and aggravate joints. Gout attacks can affect other joints aside from the big toe, including the ankles. Lumps of uric acid, called gout tophi, may form underneath the skin around the ankles after you’ve had gout for years.
This chronic form of arthritis happens after an infection of the urinary, genital, or gastrointestinal systems. The ankles, along with knees and joints of the feet, are often the first joints affected by reactive arthritis.
If ankle arthritis is suspected, doctors will start with a medical history to determine a diagnosis. They’ll ask when you noticed your symptoms, where you feel pain, and how the symptoms affect your life. They’ll examine your ankle to check for signs of arthritis in the joints, such as swelling and tenderness.
Other tests can assess whether other types of arthritis may be responsible for the ankle pain, such as blood tests that measure inflammation and antibodies to rule out inflammatory arthritis, or testing of joint fluid for uric acid crystals if gout is suspected. Imaging tests such as X-rays can help confirm a diagnosis and determine the extent of the joint damage.
Ankle arthritis doesn’t have a cure. But many treatments are available that may help relieve pain and improve function.
“The goal with these treatments is to help patients function and do their daily activities with less pain,” says Narandra Bethina, MD, a rheumatologist at the University of Vermont Medical Center and assistant professor at the Robert Larner, MD College of Medicine at the University of Vermont in Burlington. “This can also result in better quality of life.”
Medications are an important part of treatment for arthritis in the ankle. They can help slow bone loss, relieve inflammation, and ease pain. Here are the types of medications used commonly in arthritis treatment.
Nonsteroidal anti-inflammatory drugs: Over-the-counter medications like ibuprofen (Advil) and naproxen (Alleve), as well as prescription NSAIDs, can help relieve pain and swelling in the joints. Even though many NSAIDs are available over the counter, they can have side effects (such as stomach ulcers and kidney dysfunction) especially when taken for the long term and/or in high doses.
Oral corticosteroids: These quick-acting drugs help stop inflammation and are often used to manage flares in rheumatoid arthritis and gout, says Rajat Bhatt, MD, a community rheumatologist with offices in Richmond, Pearland and Greater Heights, Texas. It’s best to use corticosteroids in the lowest possible dose for short periods of time, as they can cause a range of serious side effects, including bone thinning and high blood sugar.
Steroid injections: In certain cases, steroid injections into the ankle joint can help relieve inflammation. These shots shouldn’t be done repeatedly, though. “Frequent injections damage cartilage,” says Dr. Bhatt. “Also, we try avoiding tendon injections and tendon ligaments close to the joint.” An occasional shot, though, can offer temporary pain relief and reduce inflammation. “No more than three injections per year is the standard of care,” says Dr. Archer.
Analgesics: Analgesics such as acetaminophen (Tylenol) help with pain relief. That makes them good for people who can’t take NSAIDs if they’re allergic to them or have stomach issues. You can also combine analgesics and NSAIDs, Dr. Bhatt says.
Topical creams: Over-the-counter topical pain relievers (salves, rubs, or balms) are an alternative, says Dr. Bilal. They’re good if you can’t take oral medications or if medications aren’t helping with the pain. Examples include capsaicin cream (over the counter) and the prescription NSAID diclofenac (Pennsaid, Solaraze, Voltaren Gel), Dr. Bilal says.
Gout medications: Some gout medications help prevent future attacks of joint pain and inflammation. Others relieve an acute attack’s pain and inflammation. Some people take both types of gout medication.
DMARDs: Disease-modifying anti-rheumatic drugs include conventional immune-modifying drugs, such as methotrexate, as well as biologics, which are more targeted to certain immune system chemicals and pathways (these include such drugs as Humira and Enbrel) work slowly to change the course of inflammatory disease. They’re only used to treat inflammatory arthritis such as psoriatic arthritis and rheumatoid arthritis.
Lifestyle modifications are a big part of helping treat arthritis in the ankle. “The most important lifestyle change a patient can make is a commitment to healthy eating and exercise,” says Dr. Archer. “Unfortunately, pain from arthritis can force a patient to become more sedentary, which in turn can cause depression and overeating. Diet is 80 percent to 90 percent of the battle.”
Soothe with heat and ice: Stiff and sore ankles can be relaxed and soothed with heat therapy. Ice can help numb areas affected by joint pain and reduce inflammation. “Ice therapy is helpful for acute exacerbation of arthritis symptoms (swelling and redness), and heat is good for chronic pain symptoms,” says Dr. Archer.
Do ankle-friendly exercise: It’s important to control your weight with regular, low-impact aerobic exercise. “Keeping your weight close to your ideal BMI is the best thing you can do to control your pain and symptoms,” says Dr. Archer. As little as a 10-pound weight gain can increase stress on your ankle. This extra weight can weaken tendons and ligaments, which makes sprains and strains more likely.
Do gentle exercises that don’t stress the ankle joint, such as swimming or cycling. “Walking is one of the best exercises if done correctly with good shoes,” says Dr. Bhatt. Limit high-impact activities, such as running or tennis. Also stay away from soccer and kickboxing, says Dr. Bhatt.
Invest in your shoes: Cushioned shoe inserts can help create less pain in the ankle joint. A major cause of ankle arthritis is trauma. Reducing the amount of high-impact activity and providing cushion to the ankle joint helps prevent joint damage, says Dr. Bilal. “A rocker bottom added to the sole of your shoe can help decrease impact on your heel while standing or walking,” says Dr. Bilal. Here’s how to pick the right footwear when you have arthritis.
Go for physical therapy: Specific exercises can help your flexibility and range of motion and strengthen the muscles in your ankle. Your physical therapist can develop a program that’s right for you. Here are some range-of-motion exercises, including some for the ankle, you can try at home.
Get a supportive ankle brace: A brace called ankle-foot orthosis can help hold the ankle joint in position. It will support the joint, take pressure off the ankle, and prevent extra motion. It spans both the ankle and foot and looks like an ankle brace with a foot orthotic attached. Most people start with an over-the-counter brace, then if necessary, get a fitted one from a foot and ankle specialist or podiatrist. Most are worn inside the shoe though a new kind is worn outside the shoe.
“Custom-made orthotics are the best choice for ankle arthritis,” says Dr. Archer. “Usually ankle arthritis is asymmetrical. Prefabricated devices don’t provide as much relief. A custom device addresses all the issues specific to each foot.”
Eat a clean diet: As we shared above, maintaining a healthy weight helps reduce stress on the joints. Losing excess pounds leads to less pain and increased function. “Avoid processed foods and foods high in sugar, especially if you have gout,” says Dr. Bhatt. You especially want to eat healthfully since your exercise abilities may be limited, says Dr. Archer. “Diet becomes a huge factor in in weight control,” she says.
Use an assistive device: A cane or walker can help reduce stress on the affected joint and help improve mobility and stability, says Dr. Bilal. Holding a cane with the hand opposite the hurting ankle can help alleviate pressure off the affected ankle. However,Dr. Archer says a cane should be a last resort. “A cane can throw off gait and create hip problems,” she says. Learn more about using a cane with arthritis.
Your doctor may recommend surgery for your ankle arthritis if your pain causes disability and isn’t relieved with nonsurgical treatment. Your doctor may recommend more than one type of surgery. “Ankle surgery is complicated as it most commonly involves a fusion of the rearfoot or ankle joint or both,” says Dr. Archer. “If there is significant spurring of the ankle joint, the spurs can be resected via ankle arthroscopy first before fusion is attempted to try and restore ankle motion. However, all non-surgical measures should be attempted before surgery is planned.”
What’s right for you depends on the extent of your arthritis in the ankle. Here are some options.
Ankle arthroscopic repair: “Ankle arthroscopy is useful to clean up loose joint bodies, or small pieces of bone spurs in the joint that have broken off over time,” says Dr. Archer. It can lead to less pain and improved range of motion, says Dr. Bilal. Since the surgery can be done laparoscopically, your surgeon will make a few small incisions.
Ankle arthroscopic repair is helpful in the early stages of arthritis in the ankle and for those with limited ankle arthritis. It’s often ineffective in advanced ankle arthritis, says Dr. Bilal. That’s because when a significant amount of cartilage has worn away, the procedure won’t help the joint.
Ankle fusion surgery: This surgery, also called arthrodesis, is used in end-stage ankle arthritis. The procedure decreases movement of the worn-out portion of the joint/cartilage, which in turn decreases pain. The joint is then held in place with a rod or plates and screws, says Dr. Archer. The bones fuse together over time.
The surgery is ideal for those with excessive bone loss, poor ligaments, poor bone quality, or previous infection. It’s the most common surgical treatment for end-stage ankle arthritis, says Dr. Bilal. “Younger, heavy, physically active males might be better candidates for ankle fusion,” says Rashmi Maganti, MD, a rheumatologist who practices at the Baylor Clinic in Houston and an assistant professor at Baylor College of Medicine.
Ankle fusion isn’t a good option for everyone. “Sometimes the bones don’t heal and join together,” says Dr. Bhatt. Plus, you can develop arthritis at the adjacent joints of the ankle and foot from increased stress on those joints after this surgery, says Dr. Bethina.
Dr. Archer says that you shouldn’t expect to walk as you once did. “But if the pain is bad enough, you may welcome the chance to walk slightly differently without pain.”
Total ankle replacement: In this procedure, damaged cartilage and bone are removed and replaced with new metal or plastic joint surfaces to restore the joint’s function. This procedure helps preserve joint motion, says Dr. Bilal. Ideal candidates have good bone quality and normal tendons and ligaments. “Patients with pre-existing arthritis in smaller joints in foot or hip or knee impairment that would be worsened by loss of ankle joint motion might be better candidates for ankle replacement,” says Dr. Maganti.
This surgery is controversial, though, and has mixed results. “Joint replacement comes with its risks, including implant failures,” says Dr. Bilal. “And it’s not an ideal procedure for people who have deformity or prior infections leading to joint damage.”
The ankle joint gets a lot of stress and implants aren’t as good as natural bone, Dr. Bhatt says. It does preserve movement in the ankle joint, but you have to be off your foot for a while. “Outcomes for replacement for a weight-bearing, poorly supported joint like the ankle need a lot of surgical expertise,” says Dr. Maganti.
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