Arthritis of the Foot and Ankle
Arthritis is the leading cause of disability. It can occur at any age, and literally means “pain within a joint.” As a result, arthritis is a term used broadly to refer to a number of different conditions.
Although there is no cure for arthritis, there are many treatment options available. It is important to seek help early so that treatment can begin as soon as possible. With treatment, people with arthritis are able to manage pain, stay active, and live fulfilling lives, often without surgery.
There are three types of arthritis that may affect your foot and ankle.
Osteoarthritis, also known as degenerative or “wear and tear” arthritis, is a common problem for many people after they reach middle age. Over the years, the smooth, gliding surface covering the ends of bones (cartilage) becomes worn and frayed. This results in inflammation, swelling, and pain in the joint.
Osteoarthritis progresses slowly and the pain and stiffness it causes worsens over time.
Unlike osteoarthritis which follows a predictable pattern in certain joints, rheumatoid arthritis is a system-wide disease. It is an inflammatory disease where the patient’s own immune system attacks and destroys cartilage.
Post-traumatic arthritis can develop after an injury to the foot or ankle. This type of arthritis is similar to osteoarthritis and may develop years after a fracture, severe sprain, or ligament injury.
Many factors increase your risk for developing osteoarthritis. Because the ability of cartilage to heal itself decreases as we age, older people are more likely to develop the disease. Other risk factors include obesity and family history of the disease.
The exact cause of rheumatoid arthritis is not known. Although it is not an inherited disease, researchers believe that some people have genes that make them more susceptible. There is usually a “trigger,” such as an infection or environmental factor, which activates the genes. When the body is exposed to this trigger, the immune system begins to produce substances that attack the joint. This is what may lead to the development of rheumatoid arthritis.
Fractures – particularly those that damage the joint surface – and dislocations are the most common injuries that lead to this type of arthritis. An injured joint is about seven times more likely to become arthritic, even if the injury is properly treated. In fact, following injury, your body can secrete hormones that stimulate the death of your cartilage cells.
There are 28 bones and more than 30 joints in the foot. Tough bands of tissue, called ligaments, keep the bones and joints in place. If arthritis develops in one or more of these joints, balance and walking may be affected.
The joints most commonly affected by arthritis in the lower extremity include: The ankle (tibiotalar joint). The ankle is where the shinbone (tibia) rests on the uppermost bone of the foot (the talus). The three joints of the hindfoot.
These three joints include:
The subtalar or talocalcaneal joint, where the bottoms of the talusconnects to the heel bone (calcaneus);
The talonavicular joint, where the talus connects to the inner midfoot bone (navicular); and the calcaneocuboid joint, where the heel bone connects to the outer midfoot bone (cuboids).
The midfoot (metatarsocuneiform joint). This is where one of the forefoot bones (metatarsals) connects to the smaller midfoot bones (cuneiforms). The great toe (first metatarsophalangeal joint). This is where the first metatarsal connects to the great toe bone (phalange).This is also the area where bunions usually develop.
Signs and symptoms of arthritis of the foot vary, depending on which joint is affected. Common symptoms include:
Pain or tenderness
Stiffness or reduced motion
Difficulty walking due to any of the above
Your doctor will base a diagnosis using your medical history, symptoms, a physical examination, and additional tests.
Medical History and Examination
A medical history is important to understand more about the problem. Your doctor will want to know when the pain started and when it occurs. Is it worse at night? Does it get worse when walking or running? Is it continuous, or does it come and go?
He or she will want to know if there was a past injury to the foot or ankle. If so, your doctor will discuss your injury, when it occurred, and how it was treated.
Your doctor will want to know if the pain is in both feet or only in one foot, and where it is located exactly. Footwear will be examined, and any medications will be noted.
One of the tests performed during the physical examination is the gait analysis. This shows how the bones in the leg and foot line up with walking, measures stride, and tests the strength of the ankles and feet.
X-rays can show changes in the spacing between bones or in the shape of the bones themselves. Weight-bearing X-rays are the most valuable additional test in diagnosing the severity of arthritis.
A bone scan, computed tomographic (CT) scan, or magnetic resonance image (MRI) may also be used in the evaluation.
Depending on the type, location, and severity of the arthritis, there are many types of treatment available.
Nonsurgical treatment options include:
Pain relievers and anti-inflammatory medications to reduce swelling
Shoe inserts (orthotics), such as pads or arch supports
Custom-made shoe, such as a stiff-soled shoe with a rocker bottom
An ankle-foot orthosis (AFO)
A brace or a cane
Physical therapy and exercises
Weight control or nutritional supplements
Medications, such as a steroid medication injected into the joint
If arthritis doesn’t respond to nonsurgical treatment, surgical treatment might be considered. The choice of surgery will depend on the type of arthritis, the impact of the disease on the joints, and the location of the arthritis. Sometimes more than one type of surgery will be needed.
Surgery performed for arthritis of the foot and ankle include arthroscopic debridement, arthrodesis (or fusion of the joints), and arthroplasty (replacement of the affected joint).
Arthroscopic surgery may be helpful in the early stages of arthritis.
A flexible, fiberoptic pencil-sized instrument (arthroscope) is inserted into the joint through a series of small incisions through the skin.
The arthroscope is fitted with a small camera and lighting system, as well as various instruments. The camera projects images of the joint on a television monitor. This enables the surgeon to look directly inside the joint and identify the problem areas.
Small instruments at the end of the arthroscope, such as probes, forceps, knives, and shavers, are used to clean the joint area of foreign tissue, inflamed tissue that lines the joint, and bony outgrowths (spurs).
Arthrodesis or Fusion
Arthrodesis fuses the bones of the joint completely, making one continuous bone.
The surgeon uses pins, plates and screws, or rods to hold the bones in the proper position while the joint(s) fuse. If the joints do not fuse (nonunion), this hardware may break.
A bone graft is sometimes needed if there is bone loss. The surgeon may use a graft (a piece of bone, taken from one of the lower leg bones or the wing of the pelvis) to replace the missing bone.
This surgery is typically quite successful. A very small percentage of patients have problems with wound healing. These problems can be addressed by bracing or additional surgery.
The biggest long-term problem with fusion is the development of arthritis at the joints adjacent to those fused. This occurs from increased stresses applied to the adjacent joints.
Arthroplasty or Joint Replacement
In arthroplasty, the damaged ankle joint is replaced with an artificial implant (prosthesis).
Although not as common as as total hip or knee joint replacement, advances in implant design have made ankle replacement a feasible option for many people.
In addition to providing pain relief from arthritis, ankle replacements offer patients better mobility and movement compared to fusion. By allowing motion at the formerly arthritic joint, less stress is transferred to the adjacent joints. Less stress results in reduced occurrence of adjacent joint arthritis.
Ankle replacement is most often recommended for patients with:
Advanced arthritis of the ankle
Destroyed ankle joint surfaces
An ankle condition that interferes with daily activities
As in any joint replacement surgery, the ankle implant may loosen over the years or fail. If the implant failure is severe, revision surgery may be necessary.
Foot and ankle surgery can be painful. Pain relievers in the hospital and for a time period after being released from the hospital may help.
It is important to keep your foot elevated above the level of your heart for one to two weeks following surgery.
Your doctor may recommend physical therapy for several months to help you regain strength in your foot or ankle and to restore range of motion. Ordinary daily activities usually can be resumed in three to four months. You may need special shoes or braces.
In most cases, surgery relieves pain and makes it easier to perform daily activities. Full recovery takes four to nine months, depending on the severity of your condition before surgery, and the complexity of your procedure.
How Does Osteoarthritis Affect the Foot and Ankle?
Each foot has 28 bones and more than 30 joints. The following are the most common foot joints affected by osteoarthritis:
The three joints of the foot that involve the heel bone, the inner mid-foot bone, and the outer mid-foot bone
The joint of the big toe and foot bone
The joint where the ankle and shinbone meet
What Are the Symptoms of Foot and Ankle Osteoarthritis?
Symptoms of foot and ankle osteoarthritis often include:
Tenderness or pain
Reduced ability to move, walk, or bear weight
Stiffness in the joint
Swelling in the joint
How Is Foot and Ankle Osteoarthritis Diagnosed?
The diagnosis of foot and ankle osteoarthritis most likely will involve:
A medical history
Magnetic resonance imaging (MRI) or CT scans
How Is Foot and Ankle Osteoarthritis Treated?
Foot and ankle osteoarthritis can be treated in many ways.
Nonsurgical methods to treat foot and ankle arthritis include:
Steroid medications injected into the joints
Anti-inflammatory drugs to reduce swelling in the joints
Pads or arch supports
Canes or braces to support the joints
Inserts that support the ankle and foot (orthotics)
Tips on Foot Care With Osteoarthritis
The most essential element of foot care for people with foot and ankle osteoarthritis is to wear shoes that fit properly and feel comfortable. The following are things to look for in finding a comfortable shoe:
Shoes shaped like your foot
Shoes that have support — for example, no slip-on shoes
Rubber soles to provide more cushioning
Proper fit — ask the salesperson to help you with this
Exercise can help keep your feet pain-free, strong, and flexible. Exercises that can be good for your feet include:
Achilles stretch. With your palms flat on a wall, lean against the wall and place one foot forward and one foot back. Lean forward, leaving your heels on the floor. You can feel the pull in your tendon and your calf. Repeat this exercise three times, holding for 10 seconds on each repeat.
Big-toe stretch. Place a thick rubber band around your big toes. Pull the big toes away from each other and toward the other toes. Hold this position for five seconds and repeat the exercise 10 times.
Toe pull. Place a rubber band around the toes of each foot, and then spread your toes. Hold this position for five seconds and repeat the exercise 10 times.
Toe curl. Pick up marbles with your toes.
Arthritis of the Foot and Ankle
The pain and stiffness you feel in your feet and ankles as you grow older could be arthritis. If left untreated, this nagging pain can grow worse, eventually becoming so excruciating that you can no longer walk even short distances. Severe arthritis can restrict your mobility and limit your quality of life, but with proper treatment, you can slow the development of arthritis and lead a more productive life.
What is Arthritis?
Arthritis is a broad term for a number of conditions that destroy the workings of a normal joint.
Arthritis may occur in your back, neck, hips, knees, shoulders or hands, but it also occurs in your feet and ankles. Almost half of people in their 60s and 70s have arthritis of the foot and/or ankle that may not cause symptoms.
There are many different types of arthritis. The most common type, osteoarthritis (OSS-tee-oh-ar-THRI-tiss), results from the “wear and tear” damage to joint cartilage (the soft tissue between joint bones) that comes with age. The result is inflammation, redness, swelling and pain in the joint.
Also, a sudden and traumatic injury such as a broken bone, torn ligament or moderate ankle sprain can cause the injured joint to become arthritic in the future. Sometimes a traumatic injury will result in arthritis in the injured joint even though the joint received proper medical care at the time of injury.
Another common type, rheumatoid arthritis, is an inflammatory condition caused by an irritation of the joint lining (the synovium). People with rheumatoid arthritis for at least 10 years almost always develop arthritis in some part of the foot or ankle.
Other types of inflammatory arthritis include gout, lupus, ankylosing spondylitis and psoriatic arthritis.
The foot has 26 bones and more than 30 joints. Tough bands of tissue called ligaments hold these together. The muscles, tendons and ligaments work together with the many joints of the foot to control motion. This smooth motion makes it possible for a person to walk well. When you get arthritis in the foot, you develop pain and limited motion so that you cannot walk as well.
Treatment of Arthritis of the Foot and Ankle
Proper treatment of foot and ankle arthritis addresses both pain and joint deformity. Pain develops when the joint is injured. Injury to the joint may result from swelling caused by inflammatory arthritis or from the loss of joint surface (cartilage), often caused by trauma. If left untreated, the foot and ankle may eventually become deformed.
If your doctor suspects you have arthritis of the foot and ankle, he/she will ask you to have a complete medical history and physical examination. X-rays and laboratory tests often can confirm the type and extent of the arthritis. Other tests such as a bone scan, computed tomography (CT) scan or magnetic resonance imaging (MRI) may be used to evaluate your condition.
Once your doctor confirms you have arthritis, he/she will recommend a treatment regimen which may include medications by mouth (anti-inflammatories), injections (steroids), physical therapy, weight loss, or orthotics such as pads in your shoes or custom-made braces. Surgery may be necessary. This may mean cleaning the arthritic joint, eliminating the painful motion of the joint, replacing the joint with an artificial joint or a combination of all these.
After surgery, you will require a period of rehabilitation when your foot might have to be in a cast and you might have to wear special shoes or braces for a while.
Who Will Care for You?
Orthopaedic surgeons, medical doctors who specialize in the nonsurgical and surgical care of foot and ankle problems, can diagnose and treat your arthritis. In addition to your orthopaedic surgeon, other health care professionals may care for you, including a rheumatologist (medical arthritis specialist), physiatrist (rehabilitation specialist), pedorthist (footwear specialist), physical therapist, orthotist (brace specialist), occupational therapist, nurse and/or clinical social worker.
You Are an Important Part of the Treatment
You are often told you must live with arthritis, but that does not mean that you have to stop living. You should take an active part in your treatment. Seek treatment for arthritis as early as possible to help control pain and reduce damage to joints. Take medications as directed, exercise, control your weight and participate in all aspects of your care.
Remember, if you have questions about the need for a test, or the risks or benefits of your treatment, ask your doctor. Even with the best of treatment, arthritis of the foot and ankle may continue to cause you pain or changes in your activities. However, proper diagnosis and treatment will help to minimize these limitations and allow you to lead a productive, active lifestyle.
Osteoarthritis of the Foot and Ankle
What Is Osteoarthritis?
Osteoarthritis is a condition characterized by the breakdown and eventual loss of cartilage in one or more joints. Cartilage (the connective tissue found at the end of the bones in the joints) protects and cushions the bones during movement. When cartilage deteriorates or is lost, symptoms develop that can restrict one’s ability to easily perform daily activities.
Osteoarthritis is also known as degenerative arthritis, reflecting its nature to develop as part of the aging process. As the most common form of arthritis, osteoarthritis affects millions of Americans. Some people refer to osteoarthritis simply as arthritis, even though there are many different types of arthritis.
Osteoarthritis appears at various joints throughout the body, including the hands, feet, spine, hips, and knees. In the foot, the disease most frequently occurs in the big toe, although it is also often found in the midfoot and ankle.
Osteoarthritis is considered a “wear and tear” disease because the cartilage in the joint wears down with repeated stress and use over time. As the cartilage deteriorates and gets thinner, the bones lose their protective covering and eventually may rub together, causing pain and inflammation of the joint.
An injury may also lead to osteoarthritis, although it may take months or years after the injury for the condition to develop. For example, osteoarthritis in the big toe is often caused by kicking or jamming the toe, or by dropping something on the toe. Osteoarthritis in the midfoot is often caused by dropping something on it, or by a sprain or fracture. In the ankle, osteoarthritis is usually caused by a fracture and occasionally by a severe sprain.
Sometimes osteoarthritis develops as a result of abnormal foot mechanics such as flat feet or high arches. A flat foot causes less stability in the ligaments (bands of tissue that connect bones), resulting in excessive strain on the joints, which can cause arthritis. A high arch is rigid and lacks mobility, causing a jamming of joints that creates an increased risk of arthritis.
People with osteoarthritis in the foot or ankle experience, in varying degrees, one or more of the following:
Pain and stiffness in the joint
Swelling in or near the joint
Difficulty walking or bending the joint
Some patients with osteoarthritis also develop a bone spur (a bony protrusion) at the affected joint. Shoe pressure may cause pain at the site of a bone spur, and in some cases blisters or calluses may form over its surface. Bone spurs can also limit the movement of the joint.
In diagnosing osteoarthritis, the foot and ankle surgeon will examine the foot thoroughly, looking for swelling in the joint, limited mobility, and pain with movement. In some cases, deformity and/or enlargement (spur) of the joint may be noted. X-rays may be ordered to evaluate the extent of the disease.
To help relieve symptoms, the surgeon may begin treating osteoarthritis with one or more of the following non-surgical approaches:
Oral medications. Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, are often helpful in reducing the inflammation and pain. Occasionally a prescription for a steroid medication is needed to adequately reduce symptoms.
Orthotic devices. Custom orthotic devices (shoe inserts) are often prescribed to provide support to improve the foot’s mechanics or cushioning to help minimize pain.
Bracing. Bracing, which restricts motion and supports the joint, can reduce pain during walking and help prevent further deformity.
Immobilization. Protecting the foot from movement by wearing a cast or removable cast-boot may be necessary to allow the inflammation to resolve.
Steroid injections. In some cases, steroid injections are applied to the affected joint to deliver anti-inflammatory medication.
Physical therapy. Exercises to strengthen the muscles, especially when the osteoarthritis occurs in the ankle, may give the patient greater stability and help avoid injury that might worsen the condition.
When Is Surgery Needed?
When osteoarthritis has progressed substantially or failed to improve with non-surgical treatment, surgery may be recommended. In advanced cases, surgery may be the only option. The goal of surgery is to decrease pain and improve function. The foot and ankle surgeon will consider a number of factors when selecting the procedure best suited to the patient’s condition and lifestyle.