Ankle Joint Osteoarthritis

What is ankle joint osteoarthritis?

Ankle joint osteoarthritis is a degenerative, non-inflammatory disease of the cartilage in the ankle joint. 

Osteoarthritis is an umbrella term for degenerative, non-inflammatory diseases of joint cartilage. Excessive mechanical stress causes progressive damage and reduction of the cartilage. As a result, the bones within a joint are no longer protected and get damaged. 

In most cases, osteoarthritis develops physiologically through wear and tear with age. In contrast, ankle joint osteoarthritis commonly develops following sports injuries rather than ageing.

The cartilage is not vascularized and is nourished only by the surrounding joint fluid. Therefore, it has a very limited capacity to regenerate. Osteoarthritis is a condition that cannot be fully cured – only the progression can be slowed.

Anatomy of the ankle joint

The ankle joint is composed of two joint compartments: the upper and lower ankle joint. 

Several bones articulate in this joint. The proximal joint surface is formed by the tibia (shinbone) and fibula. Their surfaces are covered with cartilage and articulate with the talus (ankle bone) in the upper joint compartment. The talus forms a pulley-like structure that functions as a hinge, allowing flexion and extension of the foot.

The lower ankle joint consists of part of the talus, calcaneus (heel bone), and navicular bone, which are held together by strong ligaments. The joint allows inward (supination) and outward (pronation) turning movements of the foot.

This joint is unique in its ability to combine stable weight-bearing with maximal flexibility for upright gait. Therefore, stiffness of the joint through ligaments would significantly impair its function and mobility.

Causes of ankle joint osteoarthritis

Ankle joint osteoarthritis can have various causes. Ankle osteoarthritis rarely results from age-related degeneration compared to hip and knee osteoarthritis, which develop with advancing age or due to long-term obesity.

In about 80% of cases, ankle joint osteoarthritis develops following injuries to the cartilage, bones or ligaments. It is very difficult for a trauma surgeon to restore a completely smooth joint surface after a fracture. Once cartilage is damaged, it cannot be regenerated.

If ligaments are damaged during an injury, the stability of the joint may be compromised, leading to chronic malalignment. This results in an uneven pressure distribution in certain areas of the joint and accelerated wear of the cartilage.

The first symptoms typically appear around 20 years after the injury, as the cartilage initially compensates for the damage. The same applies to congenital foot deformities (e.g., clubfoot, flatfoot, high-arched foot). In such cases, improper arch support due to abnormal ligament structure leads to increased mechanical pressure on certain parts of the cartilage, resulting in accelerated degeneration.

In rare cases, systemic diseases such as hemochromatosis (iron storage disease) can lead to the development of ankle joint osteoarthritis.

Stages of ankle joint osteoarthritis

Osteoarthritic changes in joints can be classified according to the Kellgren grading scale, which is defined by radiological imaging findings.

• Stage I is characterized by subchondral sclerosis, which can be seen on x-ray as a compensatory thickening of the bone due to increased mineralization due to overload.
• Stage II shows a visible loss of cartilage. Since cartilage cannot be visualized on x-ray, the damage can be inferred from narrowing of the joint space. Moreover, bone spurs (osteophytes) start to form as the bone attempts to balance out the pressure load over a larger surface area.
• Stage III presents the same findings as stage II, but more severe.
• Stage IV involves deformation of the joint surface and necrosis of the superficial layer of the bone. This means that the bone is slowly dying due to chronic overload.

Symptoms of ankle joint osteoarthritis

Osteoarthritis can cause various symptoms depending on the disease stage. It can remain asymptomatic during early stages and may only be detected by X-ray or MRI. Initially, patients start experiencing ankle pain primarily at the beginning of movement or after prolonged strain.

As the disease progresses, persistent and nighttime pain may occur. In end-stage osteoarthritis, the function of the ankle is severely limited due to pain, to the extent that it affects daily activities and not just sports.

Pain-relieving protective postures can lead to chronic misloading of other joints, consequently promoting the development of additional joint osteoarthritis. The foot or the knee joint is particularly affected.

Diagnosis of ankle joint osteoarthritis

As ankle joint osteoarthritis usually develops as a consequence of trauma, patients should be informed about the increased possibility of developing post-traumatic ankle osteoarthritis during the initial treatment of the injury. Therefore, it is recommended to consult a specialist in the case of any later complaints in the ankle joint.

The diagnostic evaluation starts with a thorough medical history, particularly regarding previous injuries or strains of the ankle. This is followed by a physical examination, during which the joint’s range of motion and stability are assessed.

If ankle joint osteoarthritis is suspected, the diagnosis can be confirmed using imaging methods. Firstly, an x-ray is performed to assess the bony structures. Although cartilage cannot be visualized directly, the width of the joint space provides important clues about osteoarthritic processes.

To accurately evaluate the condition of the joint surfaces and cartilage, MRI should be performed. This imaging method allows three-dimensional visualization of the soft tissues and therefore is an optimal addition to the x-ray.

How is ankle joint osteoarthritis treated?

The goal of treatment of any osteoarthritic degeneration is pain relief and slowing the progression of the disease. Symptomatic pain management according to the WHO analgesic ladder allows the patient to regain quality of life.

A targeted, causal treatment of the cartilage reduces the damage to the underlying bone and therefore prevents further pain. Surgical correction of foot deformities or a surgical reconstruction of ligaments can improve stability of the ankle, which can also slow the progression of osteoarthritis.

Conservative treatment

Conservative treatment options are particularly useful in mild to moderate osteoarthritis. As with all forms of osteoarthritis in the lower extremities, maintaining a healthy body weight is recommended to reduce excessive pressure-induced cartilage damage.

For degenerative wear of the ankle, custom-made orthopedic insoles are usually prescribed to compensate for incorrect loading of the foot as much as possible.

Alongside physiotherapeutic exercises, targeted application of heat or cold may be considered to further relieve symptoms. These measures can be supported with the use of pain medications. During severe pain episodes, corticosteroid injections can be administered into the joint space for temporary relief.

Surgery for ankle joint osteoarthritis

Generally, there are three different surgical techniques available for treating ankle joint osteoarthritis. These are ankle arthroscopy, total ankle replacement, and joint fusion (arthrodesis) as a last resort.

Ankle arthroscopy is a minimally invasive option, which aims to remove bone overgrowths (osteophytes) or cover minor cartilage defects with grafts to achieve significant pain reduction. This autologous cartilage graft is harvested from less affected areas of the patient’s body or cultured in a laboratory from a tissue sample.

Unlike open surgery, arthroscopy inserts a small camera (endoscope) through a skin incision. Two additional skin incisions allow the necessary instruments to be introduced into the joint space.

In cases of advanced cartilage damage, arthroscopy is usually not sufficient to reduce symptoms adequately. Particularly in young and highly active patients, total joint replacement should be considered.

During this surgery, the bony ends of the joint are usually capped – without cement – using high-grade metal components and a polyethylene spacer is inserted between them to minimize friction.

Following the implantation of an artificial ankle, a structured rehabilitation is required, which can be conducted on an outpatient or inpatient basis.

Another surgical option is arthrodesis. This involves fusion of the joint until both joint segments have healed together. Consequently, the joint loses its functionality but is also no longer causing pain.

As this kind of surgery cannot be reversed and precludes any further surgical options, arthrodesis is considered the last resort.

When is surgery for ankle joint osteoarthritis indicated?

Surgery for existing ankle joint osteoarthritis is generally indicated if all conservative treatments have been exhausted. The decision should be assessed on an individual basis after weighing potential benefits and risks of surgery.

Ankle arthroscopy should be considered first if it is a viable treatment option. One of the advantages is that the ankle can be loaded relatively quickly after the procedure. Another advantage is that further surgical options are still possible. 

Arthrodesis was considered the only surgical option for advanced ankle joint osteoarthritis for many years. However, in recent years, total ankle replacement endoprostheses have been improved to the extent that they are now considered an equally suitable alternative to arthrodesis.

What should be considered after surgical treatment of ankle joint osteoarthritis?

The success of surgery for ankle joint osteoarthritis depends not only on the intraoperative technique but also on the postoperative care. It is the responsibility of the treating physician to develop a structured postoperative rehabilitation plan and to communicate it clearly to the patient, ensuring optimal compliance.

The postoperative rehabilitation plan always depends on the type of surgery performed. The plan specifies at what stage what range of motion is permitted, as well as how long the ankle must be rested or partially loaded. Regular physiotherapy sessions are prescribed to support patients during this process.

On average, the ankle should not be fully loaded for about 6-8 weeks after surgery. An orthosis or a special walking boot may be necessary during this period to offload the joint.

Full weight-bearing should only be allowed once the surgical outcome is deemed satisfactory and sufficient healing and stability of the joint have been achieved.

What shoes & insoles are recommended for ankle joint osteoarthritis?

Custom-made orthopedic insoles can be worn to alleviate osteoarthritic pain. Furthermore, cushioning heel pads are recommended to absorb axial shock forces travelling along the leg axis to the ankle during walking.

Sports & exercise with ankle joint osteoarthritis

“A rolling stone gathers no moss”. Moderate mobilization and physiotherapeutic exercise of all joints remain important even in advanced stages of osteoarthritis. This is because the cartilage is not vascularized and gets all its nutrients from the synovial fluid within the joint space. Therefore, regular loading is important for maintaining cartilage health.

However, patients with osteoarthritis should avoid excessive strain and high-impact sports, as they accelerate cartilage wear. Since jogging places a high stress on the ankle joint, sports like cycling or Nordic walking should be considered as an alternative.

Particularly watersports such as swimming and aqua jogging are well suited, as the buoyancy of water reduces the load on the joint.

For some specific activities, a brace can also be prescribed. Nevertheless, patients with ankle joint osteoarthritis should generally avoid all sports that cause ankle pain. It is therefore very important to raise awareness of their condition.

Nutrition: What should be considered in cases of osteoarthrosis?

For individuals suffering from osteoarthrosis of the lower extremities, it is generally recommended to maintain their body weight within the normal range, since every kilogram lost reduces the load on the affected joint. In principle, a balanced and varied diet is recommended.

In cases of arthrosis, a diet low in omega-6 fatty acids (linoleic acid) is particularly important. These fatty acids are found in large quantities in sunflower and safflower oil, as well as nuts. Since linoleic acid is converted into arachidonic acid, which is pro-inflammatory, it is advisable to consume these foods in moderation.

In contrast, omega-3 fatty acids have anti-inflammatory properties and are found in fish, leafy green vegetables, and products containing algae. These foods have a positive effect on the course of the disease.

Degree of disability in ankle joint osteoarthritis 

The degree of disability in ankle joint osteoarthritis depends on the severity of the disease and whether there is a misalignment (axis deviation) of up to 20% present.

Other forms of foot osteoarthritis

The foot contains additional joints that can also be affected by osteoarthritis. The two most common forms are:

• Midfoot osteoarthritis located in the Lisfranc joint between the midfoot and tarsal bones.
• Hallux rigidus located in the metatarsophalangeal joint of the big toe.

Similar to ankle joint osteoarthritis, these forms also result from injuries or congenital foot deformities rather than age-related degeneration. The symptoms are similar to all types of osteoarthritis. In the early stages, individuals mainly suffer from morning stiffness and pain after prolonged physical activity. In more advanced stages, pain may occur at rest or during the night.

What physicians and clinics are specialists for ankle joint osteoarthritis in Germany, Switzerland and Austria?

Ankle joint osteoarthritis falls under the medical specialty of orthopedics. Board-certified orthopedic surgeons focus on the diseases of the muskuloskeletal system. They are responsible for the diagnosis, treatment, and follow-up care of ankle osteoarthritis. If a joint replacement (endoprosthesis) is indicated, patients can consult specialized clinics for orthopedic surgery and endoprosthetic surgery.

We have carefully reviewed and selected all the physicians listed. They are all experts in their respective fields and specialize in the treatment of ankle joint osteoarthritis. Benefit from the experience of our specialists and schedule a consultation quickly and easily.