Ortho Dx: Ankle Pain for 6 Months - Clinical Advisor

Ortho Dx: Ankle Pain for 6 Months

Slideshow

  • Figure 1. Anteroposterior radiograph of the right ankle.

  • Figure 2. Mortise radiograph of the right ankle.

A 64-year-old woman presents with pain in her right ankle that has persisted for approximately 6 months. She had injured the ankle 2 years ago and underwent an open reduction and internal fixation for a displaced bimalleolar ankle fracture. The patient stated that her ankle never felt completely normal following surgery, but the pain only started to intensify within the past 6 months.  Examination finds pain with passive range of motion of the ankle and pain to palpation over the anterior ankle joint. Anteroposterior and mortise radiographs of the ankle (Figures 1 and 2) are obtained.  

Post-traumatic arthritis can result from an injury that disrupts the normal mechanics of a joint. The injury can directly disrupt the articular cartilage and the damage can worsen over time. An indirect injury disrupts the supporting structures of the joint...

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Post-traumatic arthritis can result from an injury that disrupts the normal mechanics of a joint. The injury can directly disrupt the articular cartilage and the damage can worsen over time. An indirect injury disrupts the supporting structures of the joint causing incongruent loading across the joint. Over time, an uneven distribution of weight-bearing stress can wear down articular cartilage prematurely.

The ankle is uniquely prone to post-traumatic arthritis compared with other joints, representing 70% of all patients with ankle arthritis.1 The likelihood of developing post-traumatic ankle arthritis is often determined by the severity of the original injury. The 3 most common causes of post-traumatic arthritis are rotational ankle fracture (37%), recurrent ankle instability (14.6%), and history of a single sprain with continued pain (13.7%).2

The most common physical examination finding in patients with ankle arthritis is painful ankle dorsiflexion and plantarflexion.2,3 Radiographs taken with weight-bearing will show loss of the tibiotalar joint space and possibly asymmetrical wear with varus/valgus tilt of the talus.

Conservative treatment for ankle arthritis includes nonsteroidal anti-inflammatory drugs, corticosteroid injections, and immobilization to limit painful movement.1,2 Surgical options generally involve either an arthroplasty or arthrodesis with the exception of younger patients who may try an arthroscopic “clean out” debridement to remove loose bodies, osteophytes, etc.1-3

Of all surgical options, ankle arthrodesis (fusion) is the gold standard treatment for end-stage ankle arthritis.1 Ankle fusion generally requires 3 months of immobilization postoperatively and permanently changes gait pattern with the ankle fixed in a neutral position. Arthroscopic debridement and osteophyte resection is used for younger patients with mild arthritis. Join distraction arthroplasty is a joint preserving technique used for younger patients with significant arthritis. Total ankle replacement has an increased risk of complications such as infection and prosthetic loosening and is not indicated in active patients due to an increased demand placed on the implant.1-3

Dagan Cloutier, MPAS, PA-C, practices in a multispecialty orthopedic group in the southern New Hampshire region and is editor in chief of the Journal of Orthopedics for Physician Assistants.

References

1. Saltzman CL, Salamon ML, Blanchard GM, et al. Epidemiology of ankle arthritis: report of a consecutive series of 639 patients from a tertiary orthopaedic centerIowa Orthop J.  2005;25:44-46.

2. Weatherall JM, Mroczek K, McLaurin T, Ding B, Tejwani N. Post-traumatic ankle arthritis. Bull Hosp Jt Dis. 2013;71(1):104-112.

3. Martin RL, Stewart GW, Conti SF. Posttraumatic ankle arthritis: an update on conservative and surgical management.  J Orthop Sports Phys Ther. 2007;37(5):253-259.  

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