By Jamal Ahmad, MD
People are surprised that arthritis can affect the ankle because they’re used to hearing about it in the knees and hips. But think about it: The ankle bears four times the body’s weight, which makes it prone to injury, especially among active baby boomers. Several diseases can result in arthritis in the ankle, but trauma and rheumatoid disease are the most common causes.
Previous trauma includes previous fractures, joint dislocations, or severe ankle sprains, which can occur years before arthritis starts. These injuries can cause permanent damage to the ankle joint’s cartilage. With time, the bones in the ankle joint grind against each other with little or no cartilage left. This causes joint inflammation, swelling, and pain.
Rheumatoid arthritis (RA) is an autoimmune disease where the body’s immune system turns against itself. Rather than working to protect the joints, the body actually produces substances that cause joint inflammation and destruction. RA is a long-term disorder that causes inflammation of multiple joints and surrounding tissue throughout the body. Of those individuals who suffer from RA, nearly 90 percent develop symptoms at the ankle or foot. In most cases, these symptoms initially appear in the toes and then involve the rear portion of the foot and ankle.
Other inflammatory types of arthritis that can affect the ankle and deserve mention include gout, psoriasis, lupus (SLE), ankylosing spondylitis (AS), and Reiter’s syndrome.
In the ankle, the most common symptoms of arthritis include pain, swelling, stiffness, and deformity. When affected, the bones of the ankle may shift position in the joints. This can cause the arch on the bottom of the foot to collapse, which causes much pain and difficulty in walking.
The pain and symptoms of arthritis can often be controlled with exercise and medication. Some medications, such as ibuprofen and aspirin, help control the pain, but are not without side effects. Steroid injections into the joints can help relieve inflammation and swelling acutely. For patients with inflammatory arthritis (i.e., RA), medications like prednisone, methotrexate, and sulfasalazine can slow the course of the disease. Newer medications called tumor necrosis factor (TNF) inhibitors, such as Enbel™ and Remicade™ may actually slow the progression of the disease itself.
Over-the-counter and/or custom-molded ankle braces can be useful to externally control the joint, limit motion, and shift the stress away from the affected joints to help decrease pain. The brace will not correct the problem, but can help relieve symptoms. Additionally, a rocker-bottom soled shoe may help decrease the amount of stress at the ankle joint by limiting the amount of ankle motion required to walk.
With early or mild ankle arthritis, surgical treatments that preserve the joint can be effective. Ankle arthroscopy to clean or debride can be useful to treat small areas of degeneration or spurring. However, arthroscopy does not help much when arthritis advances to involve more of the joint.
Surgical treatments to treat more involved or severe ankle arthritis involve either an ankle fusion or joint replacement. Each has specific advantages and disadvantages. The ankle fusion locks the ends of the ankle joint together with internal hardware like screws. By eliminating motion, pain is improved. This option does not wear out with time, but the limited movement may affect walking and increase stress on the nearby joints in the foot.
Ankle joint replacement is amongst the newest form of joint replacements available for patients. This replaces the damaged cartilage and bone with an artificial hinge joint made of metal and plastic to replace the normal ankle joint function. While function after this procedure more closely resembles that of the normal ankle, the moving parts wear out with time and the procedure may need to be redone. Most modern ankle replacements are expected to last an average of 10-15 years after surgery in the appropriate patient.
Deciding the best treatment option for YOU depends on many factors. An orthopaedic foot and ankle surgeon well versed in the complexities of these procedures can help you greatly in navigating through these options.
Jamal Ahmad, MD, is an orthopaedic surgeon with NorthShore University HealthSystem
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