Arthritis of the foot and ankle

Arthritis is caused by the degeneration of cartilage in a joint causing pain, swelling, and stiffness.

Arthritis of the foot and ankle joints can be caused by fractures, dislocations, inflammatory diseases, or congenital deformities.

The joints most commonly affected by arthritis are:

Pain, swelling, and stiffness may be a sign of arthritis.

the ankle joint (between the tibia and talus)
the subtalar joint (the joint below the ankle joint, formed by the calcaneus and talus)
the big toe joint
the midfoot (Lisfranc) joints, usually at the 1st, 2nd or 3rd tarso-metatarsal joints.

The ankle joint.

Types of arthritis

There are three major types of arthritis affecting the foot and ankle.

Post-traumatic arthritis

Post-traumatic arthritis is arthritis that develops following an injury. This condition may develop years after a trauma such as a fracture, dislocation, or even severe sprains (ligament tears). Unlike the arthritis that mainly affects hips and knees, post-traumatic arthritis is the most common type of arthritis in the ankle.

Osteoarthritis

Osteoarthritis, or degenerative joint disease, most often occurs in older people. This disease affects cartilage, the tissue that cushions and protects the ends of the bones in a joint.

With osteoarthritis, the cartilage starts to wear away over time. In end-stage arthritis, the cartilage can completely wear away, leaving nothing to protect the joint and resulting in bone-on-bone contact. Osteoarthritis also results in the formation of bone spurs (osteophytes) at the margins of the joint, as well as bone loss (cysts).

A bone spur.

Rheumatoid Arthritis

This is an auto-immune disease in which the body's immune system (the body's mechanism for fighting infection) attacks healthy joints and soft tissues, causing an inflammation (arthropathy). It can cause pain, stiffness, swelling, and loss of function in joints.

Rheumatoid arthritis mostly affects the joints of the hands and feet and tends to be symmetrical. This means the disease usually affects the same joints on both sides of the body (both feet) at the same time and with the same symptoms.

Other types of inflammatory arthritis include gout (commonly affecting the big toe), psoriatic arthritis, juvenile idiopathic arthritis, lupus and ankylosing spondylitis.

The major symptoms of foot and ankle arthritis include pain or tenderness, swelling, and stiffness in the joint with a limited range of motion.

Gout.

Diagnosis of arthritis

The diagnosis of foot and ankle arthritis is made using a medical history, a physical examination and weight-bearing X-rays of the foot or ankle.

Different types of arthritis appear differently on x-rays. For example, osteoarthritis commonly causes joint space narrowing, subchondral sclerosis, subchondral cysts and osteophytes. Conversely, rheumatoid arthritis causes the loss of bone (periarticular erosions) and displacement of a bone from its natural position in the joint (joint subluxations/dislocations).

In some cases, advanced imaging is required, such as a bone/SPECT scan, computed tomography (CT) scan or magnetic resonance imaging (MRI) scan. Ultrasound does not play a significant role in the diagnosis of foot arthritis, but it can be a very useful tool for image-guided injections into joints.

X-ray of arthritis at first metatarsophalangeal joint 2 position.

Treatment of foot and ankle arthritis

The first line of treatment should always be non-operative.
Treatments include:

medications – painkillers (analgesics) and anti-inflammatories (NSAIDs)
physiotherapy
orthotics, such as insoles with certain supports, pads or posts
shoe-wear modifications
braces
weight loss.

Surgery may be necessary if your symptoms don't improve with more conservative treatments. Surgery performed for arthritis of the foot and ankle broadly falls into three categories: joint preserving surgery, joint replacement, and joint fusion.

Foot brace.

Orthotic insole.

Joint preserving surgery

Joint preserving operations aim to clean up, re-align, offload or promote repair of a partially arthritic joint. Examples include removing bony spurs around joints causing impingement and loss of movement; debridement and microfracture of areas of cartilage damage; or re-alignment of abnormal biomechanics with bone cuts.

Joint replacement

Joint replacement, also known as arthroplasty, involves the replacement of the damaged joint with an artificial implant.

Joint fusion

Joint fusion involves removing the damaged joint surfaces and positioning them together in order to get them to knit together. Screws and plates are often used in order to hold the joint in the ideal position until the bones unite (fuse). Fusing an arthritic joint eliminates pain by stopping movement of the damaged joint surfaces.

Arthroscopic surgery

Arthroscopic surgery is a procedure during which the internal structure of a joint is examined for diagnosis and treatment of problems inside the joint.

In arthroscopic examination, a small incision is made in the skin through which very small instruments that have a small lens and lighting system (arthroscope) are passed. Arthroscopy magnifies and illuminates the structures of the joint with the light that is transmitted through fibre optics. It is attached to a television camera and the interior of the joint is viewed on the television monitor. A variety of probes, forceps, knives, shavers, and other instruments can then be used to clean the joint area of foreign bodies, inflamed tissue, or bony outgrowths (spurs).

Some joint preserving procedures and joint fusions can be performed using arthroscopic techniques. Arthroscopy minimises the size of the cuts made in the skin and limits the amount of soft tissue dissection required.