Ankle Arthritis

Ankle arthritis is wear and damage of the cartilage that lines the ankle joint, causing pain, stiffness, swelling and difficulty walking. Unlike hip and knee arthritis, it most often follows an earlier injury such as a fracture or repeated sprains. Treatment starts with activity changes, supports and injections, with surgery if these fail.

The ankle joint is where the shin bones (tibia and fibula) meet the talus, a bone at the top of the foot. Its surfaces are covered with smooth cartilage. In ankle arthritis, this cartilage is damaged, which can expose and damage the bone beneath. Ankle arthritis is much less common than arthritis of the hip or knee.

What are the symptoms?

• Pain and stiffness in the ankle, especially in the morning or after rest
• Swelling around the joint
• A grinding or catching sensation during movement
• Difficulty walking or standing for long periods
• Pain that worsens with activity and improves with rest
• In advanced cases, visible swelling, deformity or instability

What causes ankle arthritis?

• Post-traumatic arthritis following ankle fractures, dislocations or repeated sprains
• Chronic ankle instability
• Osteoarthritis, from age-related cartilage degeneration
• Inflammatory arthritis, such as rheumatoid arthritis
• Infection, gout, or avascular necrosis (loss of blood supply to the bone)

Primary osteoarthritis of the ankle (arising without an earlier cause) is uncommon. Common causes include previous fractures of the ankle or talus, long-term ligament instability, previous infection, inflammatory arthritis, avascular necrosis of the talus and Charcot joint.

A study of 406 ankles in 390 patients with painful end-stage ankle arthritis at a Swiss specialist centre (Valderrabano and colleagues, Clinical Orthopaedics and Related Research) found that the arthritis was post-traumatic in 78% of ankles, secondary to another condition in 13% and primary in 9%. Patients with post-traumatic arthritis were younger than those with primary osteoarthritis.

How is it diagnosed?

Diagnosis is by clinical assessment, confirmed with X-rays. These show narrowing of the joint space, bone spurs (osteophytes) and, in advanced cases, bone-on-bone contact. MRI or CT scans may be used for a detailed assessment of the cartilage, bone quality and alignment.

What are the non-surgical options?

• Activity modification
• Anti-inflammatory medication (NSAIDs)
• Ankle bracing or lace-up supports
• Custom orthotics or rocker-soled shoes
• Physiotherapy to maintain movement, strength and balance
• Corticosteroid injections to reduce inflammation during flares

Lace-up boots and a walking stick can also help, and injections are sometimes done under X-ray or ultrasound guidance. Maintaining a healthy weight is part of care, as the NHS advises for osteoarthritis generally.

When is surgery recommended?

Surgery may be an option if these measures fail to control symptoms and the pain is interfering with quality of life and daily function. The surgical options are:

• Arthroscopic debridement: removal of loose cartilage, inflamed tissue and bony spurs; most effective in early stages
• Osteotomy: bone realignment to shift pressure away from the damaged part of the joint
• Ankle fusion (arthrodesis): damaged joint surfaces are removed and bones fixed together; eliminates movement but reliably relieves pain
• Total ankle replacement (arthroplasty): The ankle joint is replaced with an artificial implant to preserve motion — suitable for selected patients with good bone quality and alignment.

Mr Hester will discuss the most appropriate approach based on the severity of your arthritis, activity level, foot alignment, and overall health.

What do the sources say about each option?

Keyhole debridement. It may suit selected cases of early arthritis. Results are often good in the short term in milder disease, but there is a relatively high chance that symptoms return and a small chance of worsening pain.

Osteotomy. Cutting and repositioning the bones where wear is limited to one side of the joint may reduce pain and slow the progression of arthritis. It can help younger patients with relatively early-stage arthritis, but is not suitable for all, and the chance of later failure rises as the arthritis becomes more advanced.

Fusion. The joints beneath the ankle keep their movement and partly make up for the loss of movement at the ankle. After a successful fusion, with healthy foot joints, many people can walk without a limp, cycle, play sports such as golf and wear normal shoes. Fusion is a reliable operation for pain relief and can also correct deformity. A systematic review comparing arthroscopic and open ankle fusion (Park and colleagues) found similar union rates between the two approaches; keyhole fusion is usually reserved for ankles with little or no deformity, and open fusion for moderate to severe deformity.

What are the risks?

Risks include stiffness or persistent pain, nerve damage, blood clots in the leg or lung, and infection. Further surgery may be required if a fusion does not join or joins in a poor position. Most complications are minor and can usually be treated successfully.

What is recovery like?

• 0–8 weeks: up to eight weeks in a cast after fusion, with the foot elevated early on; wound review at around two weeks
• 8–14 weeks: then about six weeks in a walking boot, with weight-bearing as advised
• Around 3–4 months: bone healing from fusion checked; physiotherapy ongoing
• 6–12 months: progressive return to full activity, depending on the procedure

After an ankle fusion, recovery is typically up to eight weeks in a cast, then about six weeks in a boot.

How Mr Hester can help

Mr Hester is a dual fellowship-trained foot and ankle surgeon (FRCS Tr&Orth), trained at Guy's and St Thomas' and in Toronto and Calgary, and a member of BOFAS and EFAS. He sees patients privately at The London Clinic, Cromwell Hospital, King Edward VII's Hospital and HCA The Shard. His NHS practice is at King's College Hospital.

Insured patients need a GP referral and an authorisation code from their insurer. Self-pay patients are welcome. To book, call 020 7046 8004.

Frequently Asked Questions

Sources

1. Osteoarthritis. NHS. https://www.nhs.uk/conditions/osteoarthritis/
2. Valderrabano V, Horisberger M, Russell I, Dougall H, Hintermann B. Etiology of ankle osteoarthritis. Clin Orthop Relat Res. 2009;467(7):1800–1806. PMID: 18830791. https://pubmed.ncbi.nlm.nih.gov/18830791/
3. Saltzman CL, Salamon ML, Blanchard GM, et al. Epidemiology of ankle arthritis: report of a consecutive series of 639 patients from a tertiary orthopaedic center. Iowa Orthop J. 2005;25:44–46. PMID: 16089071. https://pubmed.ncbi.nlm.nih.gov/16089071/
4. Park JH, Kim HJ, Suh DH, et al. Arthroscopic Versus Open Ankle Arthrodesis: A Systematic Review. Arthroscopy. 2018;34(3):988–997. PMID: 29122435. https://pubmed.ncbi.nlm.nih.gov/29122435/