Arthritis of the ankle

What is ankle arthritis?

The ankle joint is formed by the lower end of the shin bone (tibia), the ankle bone below it (the talus) and the outer bone of the lower leg (the fibula). Smooth cartilage covers the surfaces so the joint glides. In arthritis this cartilage thins and the joint becomes painful, swollen and stiff.^[2]

Three types are most common:

• Post-traumatic arthritis, which develops after an injury such as an ankle fracture or repeated ligament injuries. Ankle arthritis is predominantly related to previous trauma.^[1]
• Osteoarthritis, the “wear-and-tear” type that develops slowly.
• Inflammatory arthritis, such as rheumatoid arthritis, which is autoimmune and often affects both sides.^[2,4]

Arthritis can also affect the joints of the hindfoot, the midfoot and the big toe (see hallux rigidus), so the location of the pain matters.

Symptoms

• pain with motion and weight-bearing, often after a period of rest
• swelling, warmth or redness around the ankle
• stiffness and a reduced range of motion
• difficulty walking, especially on uneven ground or stairs
• sometimes a noticeable change in the shape of the ankle or the way you walk^[2,4]

How it’s evaluated

The evaluation includes your injury history, an examination of ankle and hindfoot motion, alignment and walking pattern, and weight-bearing X-rays, which show how much joint space is left and how the bones line up. Blood tests may be used if an inflammatory type is suspected.^[2] CT scans, including weight-bearing scans, or MRI can show more detail about the cartilage, the neighboring joints, and the alignment of the leg and foot when surgery is being planned.^[5,6] See foot and ankle imaging.

Non-surgical care

Most people start with non-surgical treatment, and it can control symptoms for a long time in some.

• Activity changes and weight management to reduce load on the joint
• Physical therapy to strengthen the muscles that support the ankle and maintain motion
• Braces and custom orthotics that limit painful motion and support alignment
• Anti-inflammatory medicine and injections for pain and swelling^[2]

Traditionally, non-surgical measures — pain medicines, physical therapy and injections — have been used as a temporizing step until surgery is needed, and there is growing interest in more effective non-surgical and joint-preserving options.^[1]

When surgery is considered

Surgery is considered when pain and disability persist despite non-surgical care. The choice depends on how far the arthritis has progressed, the alignment of the leg and foot, your age, activity level and general health, and your goals.^[2,1]

• Arthroscopic debridement cleans the joint through small incisions and is used in selected, earlier cases, for example to remove bone spurs or scar tissue. See ankle arthroscopy.
• Joint-preserving realignment procedures can be considered in selected people when the leg or foot alignment is putting extra stress on one side of the joint.^[1]
• Ankle fusion (arthrodesis) joins the tibia and talus so that the painful joint no longer moves. It is meant to relieve pain and provide a stable ankle, and the foot and neighboring joints compensate for the lost motion.
• Total ankle replacement replaces the joint surfaces with an implant and aims to preserve motion.^[2]

Fusion and replacement have been compared in several reviews. A meta-analysis of recent studies found no significant difference in pain or alignment scores between them; replacement gave better function scores and range of motion, but a higher rate of complications and reoperations.^[3] A later meta-analysis that included large registry-based matched studies found no significant difference in total complication rates (moderate-certainty evidence).^[7] After ten years or more, uncemented total ankle replacements have shown improvements in pain and function scores.^[8]

There is also a concern that fusing the ankle may put more stress on the joints below it. A systematic review found no consensus on whether ankle fusion leads to arthritis in adjacent joints, and that imaging changes did not always match symptoms.^[9]

See foot and ankle joint fusion and replacement for a closer look at these operations. Full recovery from surgery for foot and ankle arthritis can take four to nine months.^[2]

When to seek care

Consider an evaluation if ankle pain and stiffness persist for more than a few weeks, especially after an earlier fracture or repeated sprains, or if pain limits walking, work or exercise.