Arthritis Treatment: Approach to Ankle Pain

Ankle pain, while not as frequent as pain in the knee, is a common problem. The difficulty lies in making a diagnosis because chronic “ankle pain” covers a wide variety of disorders, each of which requires a customized approach.

A chronic ankle problem should be differentiated from an acute injury. An acute ankle injury is not hard to diagnose. For example, ankle sprains are usually an inversion injury (the foot turns in) and there is damage to the outside (lateral ligaments) of the ankle. While usually mild, some injuries can be more severe with significant injury occurring in the anterior talofibular ligament. A significant percentage of those patients who have this injury go on to develop osteoarthritis of the ankle. It is important that if there is evidence of significant damage to the anterior talofibular ligament, that an MRI scan be obtained.

Patients with chronic ankle pain where there is crunching when the ankle is moved almost always have osteoarthritis of the ankle and this is usually a result of recurrent injury of the inversion type. While the standard programs of non-steroidal anti-inflammatory drugs, physical therapy, and glucocorticoid injections can provide temporary relief, patients may need more aggressive treatment using platelet-rich plasma and/or mesenchymal stem cells.

Pain developing on the outside of the ankle beneath the lateral malleolus (the bump on the outside of the ankle) usually is due to tendonitis involving the peroneal tendon. An MRI will confirm the diagnosis. Treatment consists of ultrasound guided needle tenotomy with platelet-rich plasma. Another condition that causes pain on the outside of the ankle joint is sinus tarsi syndrome. This is an inflammatory condition affecting the joint between the talus (upper ankle bone) and the calcaneus (heel bone). Treatment here involves ultrasound guided glucocorticoid injection and splinting.

Pain in the back of the ankle, particularly if it can be localized to the Achilles tendon is due to Achilles tendinopathy. This is a degenerative condition involving the Achilles tendon and is frequently seen in aging athletes. The danger here is this condition can lead to Achilles rupture. MRI can confirm the diagnostic impression. If there is no tear, ultrasound guided needle tenotomy with platelet-rich plasma can be curative.

Pain the back of the ankle joint usually signifies an arthritic component involving a bone called the os trigonum.

Pain along the inside of the ankle joint can be due to a few things. The first is a problem with the deltoid ligament. Another potential situation is caused by an extra bone- called an accessory navicular. Pain with toeing off at the front/middle part of the ankle joint is caused by pinching between the talus and the tibia (lower leg bone). All of these situations are complicated in regards to treatment.

Pain occurring below and in back of the medial malleolus (bump along the inside of the ankle) is usually due to tendonitis involving the posterior tibial tendon. This can be treated with ultrasound guided needle tenotomy with platelet-rich plasma along with short term splinting.

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