Ankle

Deteriorating Osteoarthritis of the ankle joint

Significant History/Physical symptoms

The ankle is the most commonly injured joint in athletic and work activities. In contrast, osteoarthritis of the ankle joint is relatively rare and is typically post-traumatic or inflammatory in nature. Common symptoms that prompt a consultation include pain, disability and altered gait biomechanics. Cartilage destruction due to trauma to the distal tibia, medial and lateral malleoli, and the talus is the most common aetiology of arthritis of the ankle.

Similarly, cumulative trauma from chronic ligamentous instability can lead to mechanical derangement resulting in insidiously progressive arthritis. Inflammatory arthropathies account for many of the remaining cases.

Ankle arthritis is painful and can seriously alter day-to-day function by causing pronounced deterioration of gait and weight bearing ability. Pain, swelling, stiffness, and deformity due to ankle arthritis are common afflictions.

Less Common Differential Diagnoses not included in this pathway

• Os Trigonum
• Anterior ankle Impingement /Bony spur
• Osteochondral Defect
• Syndesmosis damage
• Sinus Tarsi Syndrome
• Spring ligament damage
• Missed Fractures- Osteochondral, Lateral Talar process
• Posterior Tibial pathology
• Reflex Sympathetic Dystrophy
• Fracture of the lateral malleolus or anterior calcaneal process
• Peroneal tubercle hypertrophy or spurring of the retromalleollar groove
• Osteochondritis Dessicans
• Os Peroneum Syndrome
• Avascular Necrosis of the talus

The first line intervention should focus on educating the patient about the condition, and prescribing therapies that can be self-administered by the patient.

• Video on weightbearing lunge test
• Video on Silfverskiold test
• Video on testing Syndesmosis

Leaflets should be given to patients to reinforce verbal advice and links to NHS website resources where available.

Leaflet on Ankle Osteoarthritis

Initial Patient Directed Treatment Options

• Advise weight loss if appropriate
  • Signposting to activities which may promote weight loss link exit/parallel pathways
  • Referral to Weight Management Service if BMI greater than 30.
  • NHS Choices - Lose weight
  • Leisure Pathway
• Activity modification and management advice
• Analgesia & Non-Steroidal Anti Inflammatory Drugs as appropriate.
  • See guidance on good practice for analgesia advice. 
• PEACE and LOVE (Protect, Elevate, Avoid anti-inflammatory modalities, Compress, Educate, Load, Optimisation, Vascularisation and Exercise)
• Footwear Advice
• Give leaflet to reinforce verbal advice - NHSGGC Footwear advice leaflet 
• Alternative Shoe Lacing Options
• Exercise Prescription
  • Mobilisation and strengthening exercises should be prescribed.
• Heel Raise
  • These should be given bilaterally so as to avoid Leg Length Discrepancy

Non evidenced treatments

The following treatments are not supported by high quality evidence therefore they should not be considered as a treatment option for patients unless all other evidenced treatments have been tried unsuccessfully and there is clear clinical justification as to why these treatments are being used.

• Intra articular injection of Hyaluronic Acid
• Acupuncture
• Therapeutic Ultrasound
  • Minimal benefit and no conclusion on effective dosage parameters 

If a patient is not improving as expected they should be referred on to another AHP who can deliver an escalated evidenced intervention or referred to orthopaedics as per the escalation guidance on the pathway.

Biomechanical assessment and prescription of Foot Orthosis

• Address biomechanical deficit if indicated by assessment.
• Off the shelf or custom made insoles should be prescribed dependant on the severity of biomechanical deficit
• The orthotic prescription should be decided by the clinician, who should describe the prescription in detail in the patient records

Ankle Bracing

• To limit excessive range of motion and support increased activity level while controlling pain

Intra Articular Corticosteroid injection

Complete Immobilisation of the ankle joint

• Using a cast or walker or Ankle Foot Orthosis
• Allows mobility and function without pain
• Mimics effect of ankle fusion

One reason for referring to the orthopaedic department is for a surgical opinion. This is not a guarantee that surgery is the correct option for your patient so it’s important that this is not the expectation given to the patient by the referring clinician.

It is important that the patient has the option of a surgical opinion if this may be an appropriate treatment option for them so that they can discuss what is involved in surgery and make an informed decision.

Common conditions which are operated on include:

• hallux valgus
• hallux rigidus
• Morton’s neuroma
• lesser toe issues
• tendon pathology
• degenerative changes of the joints of the foot and ankle.

The indications for surgery include:

• persistent pain
• worsening symptoms
• significant limited mobility
• failure of conservative therapy.

Foot and ankle surgery is generally successful with many of the common foot operations achieving 85% success rate, however complications can occur and will be considered as part of the decision making process for surgery.

Remember to exhaust all conservative means ie: orthotics, footwear advice , physiotherapy, pain relief medication , if appropriate steroid injections, before considering surgical opinion.

Further Investigation

The other reason for referral to Orthopaedics is for “Further Investigations”.

MRI and CT are helpful and can be arranged within orthopaedics as appropriate – if your patient does not have a clear diagnosis or there is a concern about a diagnosis and as above, struggling with symptoms, referral on to orthopaedics is appropriate

Things to consider before referring for further investigation are:

• the severity of the symptoms
• whether there are odd/suspicious symptoms making it difficult to make a clear diagnosis.

Things to consider before referring to Orthopaedics.

Before referring to orthopaedics ensure the following:

• Vascular status – palpable pulses (for surgery)
• Patient is happy to attend for further review, possible further investigation and possible surgery as an outcome.
• Conservative means have been attempted.

This is a referral guide however please do not hesitate to contact your local ESP Orthopaedic clinician if you are unsure whether to refer.

The majority of the papers included here are level 1 or level 2 evidence, however other papers have been included to allow for further reading around the subject. Articles are listed in Harvard format.

Bernstein, R.H., Bartolomei, F.J. and McCarthy, D.J., 1985. Sinus tarsi syndrome. Anatomical, clinical, and surgical considerations. Journal of the American Podiatric Medical Association, 75(9), pp.475-480.
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Cushnaghan, J. and Dieppe, P., 1991. Study of 500 patients with limb joint osteoarthritis. I. Analysis by age, sex, and distribution of symptomatic joint sites. Annals of the rheumatic diseases, 50(1), pp.8-13.
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Friedman, D.M. and Moore, M.E., 1980. The efficacy of intraarticular steroids in osteoarthritis: a double-blind study. The Journal of rheumatology, 7(6), pp.850-856.
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Fucaloro, S.P., Berhane, M., Mulvey, M., Bragg, J., Krivicich, L. and Salzler, M., 2025. Platelet Rich Plasma Injections for Foot and Ankle Pathologies have Significantly Higher Complications Compared to Hyaluronic Acid injections, Saline Injections, and Dry Needling: A Systematic Review. Arthroscopy: The Journal of Arthroscopic & Related Surgery.
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Harrington, K.D., 1979. Degenerative arthritis of the ankle secondary to long-standing lateral ligament instability. The Journal of bone and joint surgery. American volume, 61(3), pp.354-361.
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Huang, Y.C., Harbst, K., Kotajarvi, B., Hansen, D., Koff, M.F., Kitaoka, H.B. and Kaufman, K.R., 2006. Effects of ankle-foot orthoses on ankle and foot kinematics in patient with ankle osteoarthritis. Archives of physical medicine and rehabilitation, 87(5), pp.710-716.
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Jones, K., Bruce, J., Lewis, T.L., Nolan, C.N., Munteanu, S.E., Menz, H.B. and Backhouse, M.R., 2025. Intra-articular corticosteroid injections for the treatment of people with foot and ankle osteoarthritis: a systematic review. Rheumatology Advances in Practice, 9(2), p.rkaf030.
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King, H.A., Watkins Jr, T.B. and Samuelson, K.M., 1980. Analysis of foot position in ankle arthrodesis and its influence on gait. Foot & ankle, 1(1), pp.44-49.
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Muehleman, C., Bareither, D., Huch, K., Cole, A.A. and Kuettner, K.E., 1997. Prevalence of degenerative morphological changes in the joints of the lower extremity. Osteoarthritis and cartilage, 5(1), pp.23-37.
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O'CONNOR, D., 1958. Sinus tarsi syndrome. Clinical entity. J. Bone Joint Surg., 40, p.720.
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Rush, J., 1996. Management of the rheumatoid ankle and hindfoot. Current Orthopaedics, 10(3), pp.174-178.
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Saltzman, C.L., Salamon, M.L., Blanchard, G.M., Huff, T., Hayes, A., Buckwalter, J.A. and Amendola, A., 2005. Epidemiology of ankle arthritis: report of a consecutive series of 639 patients from a tertiary orthopaedic center. The Iowa orthopaedic journal, 25, p.44.
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Smith, M.D., Vuvan, V., Collins, N.J., Smith, M.M.F., Costa, N., Southern, Z., Duffy, T., Downie, A., Hunter, D.J. and Vicenzino, B., 2024. A combined program of education plus exercise versus general advice for ankle osteoarthritis: A feasibility randomised controlled trial. Musculoskeletal Science and Practice, 74, p.103169.
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Taga, I., Shino, K., Inoue, M., Nakata, K. and Maeda, A., 1993. Articular cartilage lesions in ankles with lateral ligament injury: an arthroscopic study. The American journal of sports medicine, 21(1), pp.120-127.
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Taillard, W., Meyer, J.M., Garcia, J. and Blanc, Y., 1981. The sinus tarsi syndrome. International orthopaedics, 5(2), pp.117-130.
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Thomas, R.H. and Daniels, T.R., 2003. Ankle arthritis. JBJS, 85(5), pp.923-936.
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Valderrabano, V., Horisberger, M., Russell, I., Dougall, H. and Hintermann, B., 2009. Etiology of ankle osteoarthritis. Clinical Orthopaedics and Related Research®, 467(7), p.1800.
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Woo, I., Park, J.J. and Park, C.H., 2025. Dual intra-articular injections of corticosteroid and hyaluronic acid versus single corticosteroid injection for ankle osteoarthritis: a randomized comparative trial. BMC Musculoskeletal Disorders, 26(1), p.239.
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