Arthritis is the inflammation of one or more joints. There are over 100 forms of arthritis, and although it can cause pain and stiffness in any joint of the body, a large portion affect the foot and ankle. All kinds of arthritis can make it hard to walk and perform various activities.

Although there is no found cure for arthritis yet, there are numerous treatment options available to relieve the symptoms and slow the progress of the disease. With suitable treatment, many patients are able to effectively manage their pain, remain active and lead fulfilling lives.

The foot and ankle provide support, balance, shock absorption and several other functions that are essential for motion during standing, walking and running. The foot is made up of 28 bones and over 30 joints that allow for a wide range of movements. There are three bones that form the ankle joint, of which their main purpose is to enable upward and downward movement. 

In many of the joints, the ends of the bones are covered with articular cartilage. This articular cartilage is a slippery substance that helps the bones glide smoothly over each other during movement. The joints are surrounded by a thin lining called the synovium, which produces a fluid that lubricates the cartilage and reduces friction.

Ligaments are tough bands of tissue that connect the bones and keep the joints in place. The muscles and tendons also support the joins and give them the strength to move.

The main types of arthritis that affect the foot and ankle are osteoarthritis, rheumatoid arthritis and posttraumatic arthritis.

Osteoarthritis

Also known as “wear-and-tear” or degenerative arthritis, osteoarthritis is a common problem for many in the middle age, as well as some younger people.

In osteoarthritis, the cartilage in the joint gradually wears away. As this happens, the cartilage becomes frayed and rough, reducing the protective space between the bones. As a result, the bones can end up rubbing against each other, producing painful osteophytes, also known as bone spurs.

Osteoarthritis develops slowly, causing pain and stiffness that worsens over time. Apart from age, obesity and family history of the diseases are some of the other risk factors.

Rheumatoid arthritis

Rheumatoid arthritis is a chronic condition that can affect multiple joints in the body. It often starts in the foot and ankle and is symmetrical, meaning that it typically affects the same joints on both sides of the body.

In autoimmune diseases, the immune system attacks its own tissues. Since it is an autoimmune disease, in rheumatoid arthritis, the immune cells attack the synovium covering the joint, causing it to swell. As time passes, the synovium invades and damages the bone and cartilage, as well as ligaments and tendons. Consequentially, serious joint deformity and disability may be caused.

Swollen, inflamed synovium and joint deformity are signs of rheumatoid arthritis. The exact cause of this condition is unknown. Despite it not being an inherited disease, researchers believe that the genes in certain people make them more susceptible. Usually, a “trigger”, such as an infection or environmental factor, activates these genes. When the body is exposed to this trigger, the immune system starts to produce substances that attack the joints.

Posttraumatic arthritis

Posttraumatic arthritis can develop after an injury to the foot or ankle. The most common injuries that lead to posttraumatic arthritis are dislocations and fractures, particularly ones that damage the joint surface. Similar to osteoarthritis, posttraumatic arthritis causes the cartilage between the joints to wear away. It can develop many years after the initial injury.

The chances of an injured joint becoming arthritic are about seven times higher than that of an uninjured joint, even if the injury has been properly treated. In fact, after an injury, the body may even secrete hormones that stimulate the death of one’s cartilage cells.

Depending on which joint is affected, the symptoms of arthritis may vary. In several cases, an arthritic joint will be painful and inflamed. The pain typically develops gradually over time, but a sudden onset is also possible. Other symptoms can include:

• Pain during movement
• Pain that flares up with vigorous activity
• Swelling, warmth, and redness in the joint
• Tenderness when pressure is applied to the joint
• Increased pain and swelling in the morning, after sitting or resting
• Difficulty in walking or applying weight on the area due to any of the above symptoms

Physical examination

The doctor will discuss the patient’s overall health and medical history and ask about any medications they may be taking. The patient’s foot and ankle will be examined for tenderness and swelling and more questions will be asked to understand more about the symptoms. Such questions may include:

• When did the pain begin?
• Where exactly is the pain? Does it occur only in one foot or both?
• When is the pain felt? Is it continuous, or does it come and go?
• Is the pain worse in the morning or at night? Does it get worse when walking or running?

The doctor will also inquire if the patient has had an injury to the foot or ankle in the past. If so, the injury will be discussed, including when it occurred and how it was treated.

The patient’s shoes will also be examined to determine if there is any abnormal or uneven wear and to ensure they provide sufficient support to the foot and ankle.

Gait analysis

During the physical examination, the doctor will observe the way the patient walks, also known as their gait. Paint and stiffness of the joints can change the way one walks. For example, the doctor is able to find out more about the severity and location of arthritis by the way one limps. In the gait analysis, the doctor will assess how the bones in the leg and foot line up when walking. The doctor will also measure the patient’s stride and test the strength of the ankles and feet.

Tests

X-rays
X-rays are imaging tests that provide detailed pictures of dense structures such as bone. An X-ray of an arthritic foot may show a narrowing of the joint space between bones, which is an indication of cartilage loss. It may also show changes in the bone such as fractures or the formation of bone spurs. Weight-bearing X-rays are the most valuable additional test in diagnosing the severity of arthritis and noting any joint deformity associated with it. As much as possible, it is important to take the X-ray while standing. If not, it will be difficult to assess how much arthritis and deformity is present, as well as where it is located in the joint.

Other imaging tests
In certain cases, a magnetic resonance imaging (MRI) scan, computerized tomography (CT) scan or bone scan may be performed to determine the condition of the bone and soft tissues.

Laboratory tests
Blood tests may also be recommended to determine what type of arthritis the patient has. Blood tests are crucial for an accurate diagnosis with certain kinds of arthritis, such as rheumatoid arthritis.

If the doctor suspects rheumatoid arthritis, the patient may be referred to a rheumatologist. Even though the symptoms and results may be consistent with rheumatoid arthritis, only a rheumatologist will be able to determine the specific diagnosis. Other less common forms of inflammatory arthritis will also be considered.

Although there is no found cure for arthritis yet, there are a number of treatments that can help to relieve the pain and disability it causes.

Nonsurgical treatment

Usually, initial treatment of arthritis of the foot and ankle is nonsurgical. A range of treatment options may be recommended by the doctor.

Lifestyle modifications
Making certain adjustments to one’s daily life can help relieve the pain of arthritis and slow the progression of the disease. Some of these changes include:

• Doing less of activities that aggravate the condition.
• Replacing high-impact activities, such as jogging or tennis, with lower impact activities, such as swimming or cycling, to lessen the stress on the foot and ankle.
• Losing weight to reduce stress on the joints, resulting in less pain and increased functionality.

Physical therapy
There are specific exercises that can help to increase range of motion and flexibility, as well as help to strengthen the muscles in the foot and ankle. An individualized exercise program that meets one’s needs and lifestyles can be developed by a doctor or physical therapist. Even though physical therapy usually helps to relieve stress on arthritic joints, there are some cases where it intensifies joint pain. This can occur when movement creates increasing friction between the arthritic joints. If the physical therapy aggravates joint pain, the doctor will stop this form of treatment.

Assistive devices
Wearing a brace, such as an ankle-foot orthosis (AFO), may help improve mobility. For example, a custom-moulded leather brace can effectively help to minimize the pain and discomfort from ankle and hindfoot arthritis. Additionally, wearing shoe inserts (orthotics) or custom-made shoes with stiff soles and rocker bottoms can help minimize pressure on the foot and reduce pain. If a deformity is present, a shoe insert may also be used to tilt the foot or ankle back straight, creating less pain in the joint.

Medications
Nonsteroidal anti-inflammatory drugs (NSAIDs), such as naproxen and ibuprofen, can help in pain relief and reducing swelling. Cortisone, a very effective anti-inflammatory agent, can also be injected into the arthritic joint. However, although it can reduce inflammation and provide pain relief, its effects are only temporary.

Surgical treatment

If the pain causes disability and is not able to be relieved with nonsurgical treatment, surgery may be recommended. The kind of surgery needed is dependent on the type and location of arthritis, as well as the impact of the condition on the joints. In certain cases, more than one kind of surgery may be recommended.

Arthroscopic debridement
Debridement (cleansing) is a procedure to remove loose cartilage, inflamed synovial tissue and bone spurs around the joint. This surgical procedure may be effective in the initial stages of arthritis.

During arthroscopy, the surgeon will insert a small camera, known as an arthroscope, into the foot or ankle joint. The camera will display pictures on a television screen, which the surgeon uses to guide miniature surgical instruments. As the arthroscope and surgical instruments are thin, tiny incisions or cuts are used instead of larger ones used in traditional open surgery. 

Arthroscopic surgery is most effective when the pain is because of contact between bone spurs and there is no significant narrowing of the joint space between the bones yet. However, arthroscopy can make an arthritic joint deteriorate more rapidly. Removing bone spurs may increase motion in the joint, and as a result, cause the cartilage to wear away faster.

Arthrodesis (fusion)
In arthrodesis, the bones of the joint are fused together completely, forming one continuous bone out of two or more bones. The goal of this procedure is to reduce pain by eliminating motion in the arthritic joint.

During the procedure, the damaged cartilage is removed and pins, plates and screws or rods are used to fix the joint in a permanent position. As time passes, the bones fuse or grow together, similar to how two ends of a broken bone grow together as it heals. Removing the joint will cause the pain to disappear.

Although arthrodesis is normally successful, there can be complications. In certain cases, a nonunion may happen, where the joint does not fuse together, and the hardware may break. The broken hardware does not cause pain, but the nonunion of the fusion can result in pain and swelling. If a nonunion occurs, a second operation to place a bone graft or new hardware may be required. Unfortunately, repeated fusions are less likely to be successful, so it is crucial to follow the doctor’s instructions during the recovery period of the original procedure.

A small fraction of patients run into problems with wound healing, but they can normally be addressed by local wound care (dressing changes) or additional surgery. In certain cases, loss of motion in the ankle after a fusion causes the joints adjacent to the one fused to bear more stress than before the surgery. As a result, arthritis can also develop in these adjacent joints years after the surgery.

Total ankle replacement (arthroplasty)
In this procedure, the damaged cartilage and bone are removed, while new metal or plastic joint surfaces are positioned to restore the function of the joint.

Total ankle replacement is not as common as total knee or total hip replacement, but advances in implant design have made it a feasible option for many.

Ankle replacement is usually recommended to patients with advanced arthritis of the ankle, arthritis that has damaged the ankle joint surfaces, or ankle pain that hinders daily activities.

Total ankle replacement is able to relieve the pain of arthritis and offer patients more mobility and movement than fusion. On top of that, the formerly arthritic joint will be able to move, meaning that less stress is transferred to the adjacent joints. Thus, this reduces the risk of adjacent joint arthritis developing.

As in any type of joint replacement, the ankle implant may loosen or fail over the years. Depending on the severity of the implant failure, the replaced joint can be exchanged for a new implant. This procedure is called a revision surgery.

Alternatively, one can remove the implant and fuse the joint. This kind of fusion is more challenging than a fusion done as the initial procedure. After the implant is removed, the space in the bone must be filled with a bone graft to maintain the length of the leg. However, the risk of nonunion is greater as the new bone may not be as strong.

In the majority of cases, surgery is able to relieve the pain of arthritis and make it easier to carry out daily activities. It can take 4 to 9 months for a full recovery to take place, depending on the severity of the condition and the complexity of the procedure.

Foot and ankle surgery can be painful, so it is normal to feel some discomfort. However, with advancements in pain control, managing and relieving pain should be easier now. The patient will be given medication for pain relief immediately after surgery. On top of that, they will be provided with a pain reliever to take for a short while at home if needed.

A cast will probably be worn on the foot and ankle to limit movement and prevent nonunion after surgery. In order to reduce swelling, it is essential that the patient’s foot is kept elevated above the level of the heart for 1 to 2 weeks post-surgery.

In the later stages of recovery, physical therapy may be suggested to help with regaining the strength in the foot or ankle and restoring the range of motion. Most patients are able to resume their daily activities in 3 to 4 months, although a brace or supportive shoes may be needed for a period of time.