Ankle Osteoarthritis Overview

Ankle-Foot Clinical Processes

• Common ankle conditions include osteoarthritis, chronic ankle instability, Achilles tendinopathy, fasciitis, Morton's neuroma, and tarsal tunnel syndrome.

Ankle Osteoarthritis

• A degenerative joint condition marked by progressive articular cartilage loss, leading to marginal bone hypertrophy (osteophytes) and synovial membrane changes.
• It's considered an irreversible condition.
• Prevalence is lower than in the knee or hip joint, but higher if post-traumatic (65-80%).
• Contributing factors include age, overweight, anatomical malformations, mortise fractures, recurrent sprains, and high-performance physical activity.
• Symptoms include pain, swelling, stiffness localized initially at the rearfoot, then progressing towards the forefoot.
• 24-hour behaviors include stiffness, crepitation, inflammation, pain, decreased physical activity, limitations in daily activities, and relief with NSAIDs and rest.

Ankle Osteoarthritis: Current and Past History

• Post-traumatic causes include tibial, malleolus, and talus fractures.
• Anatomical causes include joint alignment issues and joint damage.
• Chronic ankle instability is also a factor.

Ankle Osteoarthritis: Special Questions

• Possible diagnoses include osteonecrosis, Freiberg disease, Müller-Weiss disease, and the need for orthopedic soles.

Chronic Ankle Instability

• Differentiating mechanical instability involves ligament injury, assessed through examination.
• Functional instability involves proprioception and neuromuscular deficits stemming from ankle sprains.
• Congruency of the astragalar dome and talocrural mortise is vital for stability.
• The major cause is ankle sprains, where posterior-anterior-lateral ankle ligament (PAAL) sprains are particularly prevalent with rupture in approximately 60% of cases.
• Symptoms, 24-hour behaviors include persistent and dull pain along the lateral surface, instability during inversion, insecurity, mechanical disturbances, acute episodes, and hypersensitivity with swelling.
• Relevant history factors include repetitive acute sprains leading to instability, recurrent sprains linked to dependence on footwear, deformities (e.g., varus-valgus), and ankle mobility (tibiotalar, subtalar, midfoot).
• Specific questions might pertain to past ankle osteoarthritis, sports participation history, injury mechanisms, duration of symptoms, biomechanical assessments, and pathologies affecting laxity.

Sprain

• Lateral sprains are the most common type, involving forced plantar flexion and inversion with slight rotation.
• They affect the anterior talofibular ankle ligament (ATAL) approximately 85% of the time.
• These constitute approximately 15-25% of all musculoskeletal injuries, with an average of one sprain per day per 10,000 inhabitants, and 20-30% of cases in sports-related injuries.
• Approximately 80% of sprains resolve without sequelae.

Chronic Ankle Instability: Factors Involved

• Intrinsic factors include alignment, muscle strength, neuromuscular control, and proprioception.
• Extrinsic factors include footwear, terrain, and physical activity.
• Mechanical and functional insufficiencies also contribute.

Achilles Tendinopathy

• Achilles tendon overload injuries are linked to poor vascularization leading to increased susceptibility, inflammation, and potential degeneration.
• Mechanical and metabolic factors contribute.
• Differentiation distinguishes non-insertional from insertional tendinopathy, the latter potentially characterized by enthesopathy or enthesitis.
• Incidence is 24% in athletes (7.4% in marathon runners). Running-related injuries range between 11% and 85%, with about 2.5 to 59 injuries per 1000 hours of running, resulting in approximately 2.1 ruptures per 100,000 individuals annually with a ratio of 3.5 to 1 of male to female.
• Factors include age, gender (men), flat feet (varus or valgus), overpronation, obesity, muscle stiffness/weakness, impact sports, improper footwear, surfaces during training, existing medical conditions, medication (e.g., fluoroquinolones), and "weekend warrior" activity patterns.
• 24-hour behaviors include heel and walking pain, affected by footwear and localized deformity, often improving with ice, NSAIDs, and rest.
• Special questions to ask might include identifying knee valgus, discussing the use of orthopedic insoles, and evaluating sports activity history.

Fasciopathologies

• Fasciopathologies are characterized by plantar fasciitis/calcaneal entesopathy, also known as "calcaneal spur syndrome," featuring plantar aponeurosis retraction, thickening (greater than 5 mm), acute inflammation (fasciitis), and chronic, degenerative conditions (fasciosis).
• The most frequent type of heel pain accounts for 13% of consultations in podiatric settings, a significant 89% of these cases resulting in calcaneal spurs.
• This condition is often observed among military personnel and athletes (runners).
• Factors linked to fasciitis include older age, female sex (16.3% compared to 6.5% for men), plantar fat ratio variations, and asymptomatic cases.
• Contributing factors to fasciitis include age, gender, mechanical factors, overweight conditions, overload issues, intoxications, occupational-related problems, and also conditions associated with Achilles tendon shortening.
• Symptoms include localized calcaneal pain, referred arch pain, and pain in the Achilles tendon. 24-hour behaviors involve pain, potentially accompanied by flushing, heat, and tumor, worse in the morning or after inactivity, improved by NSAIDs, stretching, and ice, and exacerbated by footwear and prolonged walking.
• Special questions include examining for calcaneal bursitis, arthritis, false fasciitis, fascia tear, plantar fat atrophy, soleus or anterior tibial tendon issues, L5-S1 radiculopathy, or insertional Achilles tendinopathy.
• History should include acute onset or past history of injuries, including immobilization or orthosis use, calcaneal stress fractures, and associated posterior chain muscle issues.

Morton's Neuroma

• A condition involving plantar interdigital nerve neuralgia at the third metatarsal space, characterized by thickening of the endoneurium and epineurium, hyalinization of endoneural vessels, and demyelination/degeneration of nerve fibers.
• Possible causes are inflammatory factors (e.g., bursae compression) and anatomical issues (nerve confluences). Mechanical aetiology also relates to radius mobility.
• Incidence is primarily unilateral (less than 20% bilateral) and diagnosed more accurately through ultrasound (88% and 68% compared to MRI). The majority of neuromas are situated in the foot (75%). They can sometimes be found between the second and third metatarsal spaces.
• Key factors associated with development include female gender (60-75% compared to 4:1 of men), age range (25-50), footwear types, deformities, sports participation, and potential trauma or adjacent anatomical concerns.
• Pain presentation includes electrical or hot sensations radiating to the interdigital space, often worse in conjunction with activity and alleviated by rest or unloading of the area, particularly improved by wide-toe box footwear options with low heels.
• Critical questions should cover potential issues of narrow or stiff-toe footwear use, low-heeled shoes, insoles used for subcapital off-loading, possible synovitis of metatarsal heads, metatarsalgia (possibly related to psoriatic arthritis), second space syndrome, and the necessity for surgical intervention if other considerations are not sufficient.

Tarsal Tunnel Syndrome

• Peripheral neuropathy involves the tarsal tunnel, predominantly impacted by the posterior tibial nerve, influenced by external (17-43%) or internal compressions.
• Associated risk factors include women aged 40-45, obesity, and foot characteristics.
• Risk factors encompass previous injuries, space occupation, and involvement in impact sports.
• Key symptoms for 24-hour behavior include intense burning pain, paraesthesia, hypoaesthesia, and dysaesthesia, potential for cramp-like spasms, and the potential extension of pain to the tibia.
• Common 24-hour behaviors include pain worsening with activities, tight shoes, improved condition with rest, ice, and NSAIDs, and possible night pain intensification.
• History should explore potential acute onset cases (such as marathon runners) and potentially latrogenic injuries or underlying systemic diseases for additional insights.
• Diagnosis differentiation should exclude anterior tarsal tunnel syndrome (where the Peroneus profundus is located in the extensor retinaculum) and plantar fasciitis. Foot examination (footprint study) is key.