INJECTION THERAPY FOR ANKLE OSTEOARTHRITIS

What is osteoarthritis of the ankle?
Osteoarthritis of the ankle is a painful degenerative joint ailment caused by the loss of the joint’s protecting articular cartilage layer. This articular cartilage acts as a friction-free surface for the joint to glide over while moving. Ankle osteoarthritis pain begins when the protective layer of the joint capsule is compromised and the innermost layer of the joint capsule becomes inflammatory (this as known as synovitis). The weight bearing stresses exerted on the ankle joint during daily life, leisure activities, and sport make it particularly prone to osteoarthritis. Ankle osteoarthritis becomes more common as people get older, with the majority of cases occurring in those over the age of 60.

What are the symptoms of osteoarthritis of the ankle?
Following are the signs and symptoms of ankle osteoarthritis.

  • Stiffness, particularly after periods of rest like sleeping.Swelling of the ankles
  • Ankle joint soreness that is deep and dull. This can be accompanied by busrsts of excruciating agony.
  • In comparison to the other ankle, your sore ankle may appear thicker/enlarged.

What other conditions can present as osteoarthritis of the ankle?

  • Ankle sprain that has been present for a long time
  • Plantar fasciitis is a type of plantar fasciitis
  • Osteoarthritis in the middle of the foot
  • Sinus tarsi syndrome is a condition that affects the feet.
  • Bursitis of the heel
  • Tendinopathy of the Achilles tendon

Osteoarthritis of the ankle vs sinus tarsi syndrome
A bony tunnel that runs through the heel, right below the ankle joint, is known as the sinus tarsi. Sinus tarsi syndrome causes pain on the outside of the heel, right below the ankle, which can be very uncomfortable and cause ankle instability. Sinus tarsi syndrome affects both men and women equally, and it is not age-related.
Ankle osteoarthritis, on the other hand, is far more common in the elderly population, is not always related with trauma, and often develops slowly over time. Ankle osteoarthritis discomfort is frequently accompanied by growing stiffness and ankle joint deformity.
Osteoarthritis of the ankle?
Osteoarthritis is the most common musculoskeletal disease, affecting 15% of the world’s population (Hubbert et al, 2018). When it affects a weight-bearing joint like the hip, knee, or ankle, it can be extremely debilitating. Although osteoarthritis of the hip and knee is quite frequent, osteoarthritis of the ankle is far less common, affecting approximately 1% of the population (Nakamura et al, 2016).

Damage to the articular cartilage can occur when the joint surfaces are subjected to increasing stress (which lines the ends of the bones). When this protective layer is damaged, it thins out over time. Synovitis is the term for when a joint becomes inflamed at a later stage. This causes discomfort and stiffness in the toe as a result of the process.

Physiotherapy, orthotics, activity and footwear adjustment, and, if the pain persists, an ultrasound guided injection are all used to treat osteoarthritis of the big toe. A steroid injection or a hyaluronic acid (HA) injection may be used in injection therapy. Big toe arthritis can be relieved quickly with injections.

The ankle is a complicated region made up of three different joints that work together to provide mobility (see diagram below):
1. The articulation of the tibia, fibula, and talus bones forms the talocrural joint (the ankle joint proper – blue arrow below), which is responsible for dorsiflexion (lifting your foot up) and plantarflexion (planting your foot down) (pointing your foot down).
2. The articulation of the tibia and fibula bones forms the inferior tibiofibular joint (red circle below), which is crucial for stabilising the lower shin and ankle.
3. The subtalar joint (green circle below) is produced by the talus and calcaneus bones articulating and is responsible for inversion (turning your ankle in) and eversion (turning your ankle out) (turning your ankle out).

Osteoarthritis is caused by a variety of factors that are unclear. Some genetic and environmental risk factors are well-known.
These are some of the risk factors:

  • Osteoarthritis is more common as people get older.
  • Obesity can cause arthritic changes due to the increased pressure on the joints.
  • Ankle joint osteoarthritis is found in 78 percent of ankles following a catastrophic event such as an ankle sprain or a shattered bone, according to studies.
  • Changed biomechanics and muscle weakness – If your body weight and accompanying forces are not evenly distributed throughout the joint, you may be more prone to osteoarthritis.
  • Excessive stresses can be applied to a joint over time by sports or vigorous vocations, resulting in arthritic changes.

If one or more of the aforementioned risk factors apply to your ankle joint, it is more likely to develop osteoarthritis. A layer of articular cartilage covers the surfaces of the ankle joints (see image below). The bony surfaces of the ankle joint are covered in articular cartilage, which acts as a shock absorber for the bone surfaces beneath. It gives the joint a smooth, friction-free surface to glide across during movement. When the articular cartilage thins and the joint space shrinks, osteoarthritis develops. Morning stiffness, a loss in range of motion, discomfort, and swelling are all symptoms of this condition.

The sub-chondral bone (the bone beneath the articular cartilage) and the synovium, the joint lining, are thought to be the sources of joint discomfort. Synovitis is the inflammation of the synovium. Synovitis has been linked to the course of illness and is responsible for the painful flare-ups that accompany osteoarthritis.

How do you know if you have osteoarthritis of the ankle?
Osteoarthritis of the ankle joint can be very painful, yet it might take years for symptoms to appear.
The following are some of the symptoms of ankle osteoarthritis:

  • Deep nagging soreness in the ankle joint — this may begin as an intermittent ache that gradually becomes more continuous.
  • Sharp pain that comes and goes – this can disrupt your sleep or cause you to limp.
    When you get out
  • of bed, when you start walking after a time of sitting, or after exercise, your ankle may feel tight. As you begin to move, the stiffness generally diminishes. The stiffness associated with osteoarthritis worsens over time, resulting in a loss in joint range of motion.
  • Swelling and/or distortion of the joint’s bony structure. Joint deformation occurs as osteoarthritis advances and causes the joint to enlarge or change shape.

How is osteoarthritis of the ankle diagnosed? 
It’s crucial to have an accurate diagnosis of ankle osteoarthritis. Your doctor will be able to suggest the most appropriate treatment option for you if you have a correct diagnosis.

An x-ray is used to make a definitive diagnosis. In the NHS, X-ray waiting lists are usually extremely short, and your GP can schedule one for you swiftly and efficiently. We can help you with this if it’s proving problematic.

Your doctor may also request that you undergo some blood testing. Systemic arthritic diseases such as rheumatoid arthritis and gout are diagnosed via blood testing. The gold standard imaging approach for diagnosing osteoarthritis and determining the severity of joint destruction is an X-ray.

Patients frequently report pain levels that do not correspond to the degree of osteoarthritis visible on x-ray. As a result, a comprehensive clinical assessment of your ankle by an expert clinician is required before any further treatment decisions are made. An x-ray of an ankle with osteoarthritis is shown below.

At your Joint Injection consultation, we will perform a thorough examination of your foot as well as a diagnostic ultrasound scan. Diagnostic ultrasound is a fast and effective imaging method for evaluating arthritic changes in the ankle joint. It has a high sensitivity for detecting not just bony joint abnormalities but also the presence of synovitis in osteoarthritis patients (Wakefield et al, 2000, Kaeley et al, 2020). The synovitis is thought to be responsible for a large percentage of the pain associated with osteoarthritis.
How do we treat osteoarthritis of the ankle?
Osteoarthritis is a degenerative joint condition that worsens with time. The goal of treatment is to increase or preserve the joint’s strength and range of motion. In the presence of osteoarthritis, research has shown that having a good range of motion and strong muscle surrounding the joint is vital in maintaining function and lowering discomfort. Your clinician will provide you a gradual stretching and strengthening exercise regimen to help you retain strength, flexibility, and balance, so you can keep doing the things you love. Manual release techniques, which involve manipulating and/or moving your ankle to enhance range of motion, may also be used by your physiotherapist. We’ll provide you tips on how to take care of your joint and how much exercise you should get each day.

We may also utilise taping techniques and/or recommend a brace for you to use during weight-bearing activities like hiking or lengthy walks.

Here are a few pointers that you might want to try:

  • Take a break from difficult tasks. If this isn’t possible, make the best modifications you can. Taking regular breaks is one example.
  • If you’re overweight, lowering weight will help relieve pain and improve function by reducing strain on your ankle joint.
  • Try some simple calf stretches or moderate ankle stretches (see image above)
  • Exercises that strengthen the calf muscles, such as utilising an exercise band, can be beneficial (see image above)
  • Pain relief from osteoarthritis can be achieved with over-the-counter oral medications like paracetamol or ibuprofen, or a topical anti-inflammatory gel like Voltarol. Before taking any drug, consult your pharmacist.

What if conservative management isn’t succesful?
Corticosteroid injection guided by ultrasound

A corticosteroid injection may be appropriate for you if your ankle symptoms do not respond to conservative treatment and your discomfort persists. A corticosteroid is a powerful injectable anti-inflammatory medicine that has been used in the treatment of osteoarthritis for decades and can be especially helpful in the following situations:

  • You’re awakened in the middle of the night by pain.
  • Pain that prevents you from performing your routine daily activities and/or is worsening
  • You are unable to participate in your physiotherapy rehabilitation programme due to pain.
  • All injections are administered under ultrasound supervision at Joint Injections. According to recent studies, ultrasound-guided injections are more accurate and successful than landmark-guided injections at reducing pain and improving function (Finnoff et al, 2015).

The corticosteroid is injected directly into the ankle joint using real-time ultrasound imaging, where its anti-inflammatory properties can quickly alleviate ankle joint pain. While ultrasound-guided steroid injections are highly efficient in lowering pain, physiotherapy should be started within 1-2 weeks of the injection for the best outcomes.

Hyaluronic acid injection with ultrasound guidance

Hyaluronic acid is a man-made substance that replicates the natural lubrication of the ankle joint. Evidence suggests that it is beneficial in lowering arthritic joint pain and inflammation, particularly in active people who are not overweight. Hyaluronic acid injections are widely used as an alternative to corticosteroid injections and are performed under ultrasound guidance using the same process as a corticosteroid injection. Following injection, physiotherapy is highly suggested for optimum results.

Joint Injection’s clinicians are all fully qualified physiotherapists, musculoskeletal sonographers, and independent prescribers who have treated osteoarthritic ankles before. Your clinician will perform a full assessment, including a diagnostic ultrasound scan, during your initial consultation. You will be offered an injection on the same day if it is appropriate. There is no need for a GP referral because your clinician can prescribe the appropriate medication.

What if an injection doesn’t work?
An injection may not be effective in some cases of severe osteoarthritis in the ankle. You might be sent to an orthopaedic specialist for surgical intervention if this is the case. Your physician can talk to you about it and send you to the best consultant for you.

Joint Injection’s experts are dual-trained, highly specialised physiotherapists and musculoskeletal sonographers with extensive experience diagnosing all foot and ankle disorders. We provide a ‘one-stop’ clinic, which means you’ll get an examination, a diagnostic ultrasound, and, if necessary, an ultrasound-guided injection.