Ankle Arthritis

Ankle arthritis is a pain when walking and one of the most common complaints patients bring to the attention of Dr. Jose Loor at DeLoor Podiatry in Gramercy, New York. Injury and osteoarthritis can also cause ankle pain, but ankle arthritis is prevalent. It’s among the most commonly affected joints of those with arthritis, which affects 1% of the population. It occurs in more women than men at the ratio of 3 to 1. Symptoms appear in the ages between 40 and 60.

What is ankle arthritis?

Arthritis is an autoimmune disease. At the onset of arthritis, your immune system starts attacking healthy tissues in your body. This causes chronic (long-term) inflammation of the joints and the tissues around the joints. The symptoms usually affect the hands, knees and feet.

Your ankles’ function

The ankles are weight-bearing joints when you are standing or walking. The ankles are also hinged joints that move the foot away from the body (plantar flexion) and toward the body (dorsiflexion). These movements happen when you flex your foot up and down, which happens when you climb or walk.

Because of the ankles’ function, your symptoms would include any of the following when you have ankle arthritis:

Diagnosing Ankle Arthritis

In the early stages of ankle arthritis, the discomfort or pain only happens when you’ve climbed a lot of stairs, or walked a lot. At first, you’d dismiss it as normal.

If you have arthritis in the other parts of the foot, abnormal pressure in those areas would cause calluses. The most common areas are in the ball of the foot (the fleshy part of the feet under your toes, the underside of the forefoot) and midfoot. You might also develop bunions.

The joints remain flexible in the early stages of arthritis. However, as the disease progresses and the inflammation results in loss of cartilage, the pain, ankle swelling and stiffness worsens.

You know you have arthritis when both ankles are affected. Osteoarthritis can also affect the ankles, but it typically appears on just one ankle: the loss of bone happens on one specific joint. Arthritis typically affects both feet, and the same joints on each foot.

To diagnose arthritis, Dr. Loor recommends a full physical and medical history. He would also find the specific areas of tenderness on your feet. Applying pressure to an already-painful foot can be difficult to bear, but it’s how your doctor finds out exactly which joints are affected aside from your ankle, and the severity of your arthritis.

For a more precise diagnosis, Dr. Loor says, “Imaging tests help us see the condition of the bones and joints, and what treatment would be best.

“X-ray is usually enough, but an MRI and an CT scan are recommended for severe cases. CT and MRI shows us the extent of damage on the affected joints, ligaments, and bones, and whether the tendons are inflamed or torn.”


Patients with chronic ankle pain usually have bone marrow lesions (BML). BMLs are part of arthritis and osteoarthritis, and have been found to be the source of pain and joint cartilage destruction in patients.


Solutions and Management for Ankle Arthritis

Technically, arthritis has no cure. There are disease-modifying anti-rheumatic drugs (DMARDS) proven to produce good results in the early stages of the disease. Steroid injections help reduce the inflammation early in the disease, but is only a temporary solution, and doesn’t stop the disease’s continued development.

Other ankle arthritis management options are:

Non-steroidal anti-inflammatories
Your doctor would prescribe naproxen or ibuprofen to reduce inflammation and pain.

Therapy for the joints
You would usually be referred to an occupational or physical therapist for strengthening your muscles, restoring your range of motion and increasing your joint position awareness.

Resting the ankles/Alternate mobility
To minimize pain, you should avoid activities that cause it. Use the elevator. Instead of walking, choose biking. Opt for low-impact exercises like elliptical machines, spinning, and swimming.

Braces
Braces are custom-molded plastic or leather lace ups that support the joints at back of the foot and your ankle, effectively decreasing the pain there.

Ice
You can put an ice compress on your ankle 3-4 times a day, for 20 minutes’ duration. Do this immediately after physical activity.

Foot and ankle surgery
Ultimately, when therapy and medications aren’t enough to help your mobility, or when you have sustained joint damage, you can turn to foot surgery.

Subchondroplasty for Ankle Arthritis

Subchondroplasty or subchondral plasty is a minimally invasive ankle surgery for the treatment of defects caused by bone marrow lesions. Patients with chronic ankle pain usually have bone marrow lesions (BML). BMLs are part of arthritis and osteoarthritis, and have been found to be the source of pain and joint cartilage destruction in patients.

Only MRI can confirm the presence of BML in your ankle, and Dr. Jose Loor would then assess your candidacy for subchondroplasty. First, let’s talk about the subchondral bone.


BMLs, also called “bone void,” are the areas in the subchondral bone with significantly decreased mineralization, and increased microfractures, necrosis (death of bone) and fibrosis (thickening and scarring).


Subchondral Bone

The subchondral bone is the layer of bone right beneath every joint cartilage. It supports the articular (relating to the joints) cartilage and absorbs the impact and force of weight bearing. The ankle has a much smaller contact area than the hip or knee, so your ankle receives and counteracts more force per square centimeter than the knee or hip every time you stand, walk, climb or run.

To do its job, the subchondral bone retains and increases its bone density and mineralization. In the case of arthritis and osteoarthritis, the subchondral bone loses its essential density, which results in pain in your ankle when walking or even standing.

BMLs, also called “bone void,” are the areas in the subchondral bone with significantly decreased mineralization, and increased microfractures, necrosis (death of bone) and fibrosis (thickening and scarring).

Subchondroplasty, the treatment for BML, is also called “bone void filler.”

What is subchondroplasty?

Dr. Loor also calls it subchondral plasty, because this minimally invasive surgery injects synthetic bone graft into the damaged areas of the subchondral bone. The synthetic bone graft is made of flowable nanocrystalline calcium phosphate (CaP) bone substitute.

After injection, heat absorption (endothermic reaction) hardens the CaP into something similar to healthy bone. Over a period of weeks, your body absorbs the the CaP and replaces it with native mature bone.

Subchondroplasty stimulates healing in the subchondral bone, which results in less pain and increased movement and function for your ankles.

Am I a candidate for subchondroplasty?

If you answered yes to the above questions, Dr. Loor would recommend MRI, a full physical, and medical history, so you can proceed with subchondroplasty and reduce and remove your ankle pain, and help you regain full use of your ankles.

What to expect from the subchondroplasty procedure:

Subchondroplasty is an outpatient procedure. You can return home after the surgery on the same day.

BEFORE the procedure:

Subchondroplasty would not be effective if there is already severe loss of cartilage, or if the subchondral plate has already collapsed. Thus, you need a comprehensive examination and MRI to confirm your candidacy.

DURING the procedure:

You would be lying on your back. You would be given general or spinal anesthesia.

With the MRI as a guide, the doctors triangulate a drill bit and a cannula into the BML. When the injection cannula is in position, a syringe filled with the CaP bone substitute is then inserted into the cannula and the CaP is injected into the BML under fluoroscopic imaging. The doctor continues injecting the CaP until he can see a darkening blush the same size as the BML in the MRI. It may take several syringes to fill the BML, depending on its size.

Another arthroscopy, or fluoroscopy, would be done to check and make sure there was no leak (bone graft extravasation) of CaP.

AFTER the procedure:

Patient recovery after subchondroplasty varies for every individual. The most important thing is to follow your doctor’s advice TO THE LETTER.

Several ankle arthritis patients have benefited from subchondroplasty from DeLoor Podiatry in New York and Brooklyn. In as little as 12 weeks post surgery, you too might also go back to full activities with zero or minimal discomfort in your ankle, now manageable with non-steroidal anti-inflammatories.

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