Arthritis is defined as inflammation of one or more of the joints in the body. The foot and ankle joints are comprised of 28 bones with more than 30 or more articulations.
Approximately 1-2 million ankle injuries occur each year in the United States with 85% of them sprains. According to the National Trauma Data Bank 280,000 ankle sprains reported from 2007-2011. Seven in 1000 Americans will have an ankle sprain. The common age group for ankle sprains is the younger population less than 25 with female preponderance. Estimated 2-3 billion dollars annually spent on ankle sprains alone. 30% of all sports injuries are ankle sprains.
Ankle fractures comprise about 15% of all ankle injuries. The incidence of ankle fractures has been increasing over the past 20 years. Rate of ankle fractures is approximately 187 in 100,000 person- years. Fracture ratio is male to female 2 to 1. Most fractures under 50 years of age are male and over 50 being female.
As the population ages, ankle sprains and fractures are the leading cause of osteoarthritis of the ankle. An injured joint is 7 times more likely than an uninjured joint to become arthritic. The incidence of osteoarthritis of the ankle is difficult to estimate therefore no true general population estimates were found. One study quoted 1% of the population over 50 while another stated 3.4%
In one study, adults greater than 50, 5109 participants were given a health questionnaire and the response was 11.7% answered they had ankle pain yet only 3.4% had x-ray proven osteoarthritic changes. An explanation for the lack of x-ray findings to correlate with the patients symptoms is previous trauma may cause microscopic breaks in the bone and cartilage. This was proven in a study where x-rays were basically negative yet MRI showed bony and cartilage changes.
Osteoarthritis is primarily considered to be caused by the destruction of articular cartilage resulting in pathological bony changes. In the ankle, Articular cartilage covers the distal end of the tibia, the fibula and the top surface of the talus.
Since cartilage does not contain nerve supply, changes to the surface of the bones and other tissues cause the pain associated with arthritis
As the cartilage is damaged and worn away:
- Osteophytes develop or Spurs- These can cause pain
- Subchondral Sclerosis- The bony surfaces harden. These areas are beneath the damaged or lost cartilage
- Cysts or abnormal lesions may develop in the bony area not protected by the damaged cartilage
Common Symptoms of Ankle Osteoarthritis
Pain is the most common symptom. The pain may be sharp or dull. Initially, in early osteoarthritis, the pain can be relieved with resting the joint. Stiffness is also very common. As an articulating joint, the ankle becomes more and more stiff as the cartilage is eroded. The greatest range of motion is flexion of the foot (downward motion) and dorsiflexion (upward toward head). There is a secondary side to side motion also in this joint.
The ankle can “pop or grind” when flexed and extended called crepitation, this is also due to loss of cartilage. Gait is affected due to pain and stiffness. The knee and hip can also become painful as the normal gait pattern is affected. The ankle can lock or become unstable due to cartilage fragmentation, bony changes and soft tissue changes.
As explained above, trauma to the ankle joint is extremely common and it is reported that post-traumatic arthritis was one of the most frequent causes of osteoarthritis of the ankle in the US.
Causes of Arthritis in the Ankle
- Post- traumatic arthritis- an injured joint is about 7 times more likely to develop arthritis even if properly treated
- Osteoarthritis- cartilage is worn away with age
- Obesity- Weight putting more stress on the joint. Pressure is normally 5 times body weight while walking
- Family History- More common in families with osteoarthritis
- Age- Chances of the development of OA ankle increase with age
- Metabolic Diseases- About 12% of OA is linked to metabolic diseases
Autoimmune diseases such as Rheumatoid Arthritis
Birth defects such as club foot
Disruption of the blood supply causing necrosis of bone
Blood Dyscrasias such as hemochromatosis
Any disease process linked to joint disruption
Ankle Arthritis Diagnosis
- Primary diagnosis is History and Physical exam
- Blood Testing to rule out other causes
- Lifestyle changes and modifications such as weight loss or activity modifications such as exercising in a pool instead of jumping on hard surfaces.
- Ankle braces or shoe inserts. Shoes with more support and cushion. Assist devices such as a cane or walker.
- Physical Therapy- directed toward better range of motion and strengthening the tissue supporting structures, gait training, aqua-therapy
- NSAIDS- Reduce inflammation and pain
- Tylenol- Pain control
- Topicals- Capsaicin for pain control
- Narcotics should not be used for chronic pain as can cause addiction
- Oral Corticosteroids- Not indicated for long term use
- Injectable corticosteroids- may provide short term anti-inflammatory relief but chronic repeated use will degrade the joint
- Hyaluronic acid- Use is approved for knee use only however as the ankle is a synovial joint it has been used with mixed results
- Platelet- Rich-Plasma- used to encourage cell growth and repair
- Arthroscopy- to remove osteophytes and degenerated tissue. Arthroscopic surgery may cause further degeneration of the joint space. By removing bone spurs, the motion of the joint may increase causing the cartilage to deteriorate quicker
- Arthrodesis (Fusion)- the bony areas are fused with plates and screws making a single joint. Arthrodesis has the potential of non- union of the bones or the screws and plates may become loose. This results in pain and swelling and a second operation and commonly used bone graft. This surgery can also cause arthritis in adjacent joints because of the altered mechanics of the ankle and foot.
- Total Ankle Replacement- Not as common as knee or hip replacement but is an alternative to fusion. Can fail over time and then revision surgery must be initiated. Surgical complications are infection, poor healing, loosening of the appliance. Also, blood clots, hemorrhage, nerve damage are potential complications in all lower extremity replacement surgeries. Recovery can be 6-12 months
Platelet-Rich-Plasma (PRP) is an autologous blood derived product with super physiologic concentrations of platelets containing growth factors and cytokines used in the regenerative process of the body. When placed in an area of damaged tissue it can have downstream effects on local inflammatory reactions, recruitment and proliferation of stem cells, cell adhesion and angiogenesis. By concentrating the molecules in PRP and delivering them to injured tissue, it enhances the natural healing response.
- Platelet-Rich-Plasma in the Foot and Ankle (Musculoskelet Med 2018.Dec;11(4) 616-623 PMID 30259330)
Multiple studies were reviewed in PRP for foot and ankle applications. In osteochondral lesions of the talus the author found PRP treatment led to significant better outcomes in pain and function and the evidence of PRP in these cases was promising. In osteoarthritis of the ankle, the authors found significant improvement in pain and function up to 24 weeks after treatment
- Conservative Treatment of Ankle Osteoarthritis; Can Platelet-Rich-Plasma Effectively Postpone Surgery? (J Foot Ankle Surg Mar-Apr 2017;56(2):362-365)
The authors evaluated the mid-to long-term clinical results for PRP in ankle arthritis. They found strong positive effects ,with a 80% satisfaction rate among the patients evaluated. They concluded Platelet-Rich-Plasma is a valid and safe alternative to postpone the need for surgery
- Safety and Efficacy of Intra-articular Injection of Platelet-Rich-Plasma in Patients with Ankle Osteoarthritis Foot Ankle Int 2017 Jun;38(6) 596-604 PMID 28399635
The purpose of this study was to evaluate the safety and efficacy of intra-articular injection of PRP in patients with ankle OA during a 24 week period
Conclusion- Injections of PRP resulted in no serious side effects and significantly reduced pain in the patients with OA of the ankle. PRP treatment can be safe and effective and may be an option in the treatment of ankle OA
- Biologic Therapies for Foot and Ankle Injuries (Expert Opin Biol Ther 2021Jun;21(6) 717-736 PMID 33382002)
The utilization of biologic adjuncts for improved repair and regeneration of ankle injuries represents a promising future in our efforts to address difficult clinical problems. The use of bone marrow and PRP each represents the most widely studied and commonly used injection therapies with early clinical studies demonstrating promising results
- The Role Of Biologic in Foot and Ankle Trauma- mA review of the Literature (Curr Rev Musculoskelet Med 2018 Sep;11(3): 495-502 PMID 30054808)
Purpose of this article is a review of the literature in regard to foot and ankle trauma.
Conclusion- The use of biologics in foot and ankle trauma is a relatively new and developing field. The main purpose of biologics is to provide an adjunct to stimulate bone and soft tissue healing. The current literature regarding biologic use in traumatic injuries as well as long term complication (ie post traumatic arthritis) shows promising results.
Juventix Regenerative Medical manufactures a FDA approved Platelet-Rich-Plasma Kit that is cost effective, easy to use and scientifically provides reproducible amounts of product from the same source. The kits are designed for safety and effectiveness.
Juventix Regenerative Medical has a patent pending LED activator for activation of the platelet concentrate without the use of additives such as Calcium Chloride or Thrombin.
Juventix Regenerative Medical has an innovative Bio- Incubator that converts platelet rich plasma into a flowable platelet rich fibrin for prolonged release of growth factors and other molecules needed in the tissue repair process.
RESTORE, REVIVE, REGENERATE JUVENTIX REGENERATIVE MEDICAL
Dr. Robert McGrath