What is osteoarthritis?
Osteoarthritis is the most common form of arthritis, affecting millions of people around the world. It occurs when the cartilage surfaces within your joints become damaged so the joint doesn’t move as smoothly as it should. This can lead to painful, swollen and stiff joints. Osteoarthritis can damage any of the joints in your foot and ankle but most commonly affects the great toe joint and the joints through the middle of the foot. It can also affect the ankle and hindfoot where it is commonly related to a previous injury. Although osteoarthritis gradually worsens with time, and no cure exists some treatments can slow the progression of the disease, relieve pain and improve joint function.
Osteoarthritis diagnosis
Osteoarthritis clinical assessment
This involves a full examination of the joint involved. I will be looking for abnormal swelling or abnormality in the shape of the joint. I will feel the surfaces of the bones and joints to detect any tenderness, warmth and fluid in the joint. I will also test your range of motion. The active range of motion is the maximum range through which people can move a joint by themselves. Limited active range of movement may indicate weakness, pain, or stiffness as well as mechanical abnormalities.
Osteoarthritis investigations
X-rays
This is a painless safe procedure that uses X-rays to image the tissues inside the body, particularly the bones. An X-ray machine is essentially a camera. Instead of visible light, however, it uses X-rays to expose the film. It is good for showing the later stages of arthritis but sometimes an MRI scan of the joint is required in the early stages. If you have arthritis the X-ray will show bony spurs around the joint line as well as loss of the normal joint space and occasionally small cysts around the joint.
MRI
MRI stands for magnetic resonance imaging. This is a painless procedure that uses a strong electromagnet and radio waves to take detailed pictures of your insides. It can show injuries to, or abnormalities of, tendons, ligaments, muscles, cartilage and bone marrow. The process involves lying flat and then passing into the scanner. This is quite an enclosed space and can be difficult for people with claustrophobia. It can also become quite noisy so you will be supplied with headphones to block some of this out. In arthritis joints, the MRI pictures will show loss of the normal cartilage over the joint surface. It may also show abnormalities in the ligaments and other soft tissues around the joint.
CT
CT stands for Computerized Tomography and is sometimes also called a CAT (Computerised Axial Tomography) scan. This uses X-rays to build up detailed images of the inside of the body. It is best at looking at the bony structures within the body. You will be asked to lie flat and the table will then advance you into a large open ring. Unlike the MRI scan, this is not a claustrophobic space and is not noisy so is well tolerated.
Osteoarthritis treatment
There is no cure for osteoarthritis but there are lots of ways to improve the symptoms you are getting. Many patients can manage their symptoms with self-help measures but when they are unable to it is important to contact the healthcare team to seek alternative methods. In the first instance non-surgical management should be tried and when these methods are not working it may be necessary to discuss the surgical treatment options with a specialist orthopaedic surgeon.
Non-surgical management
There are many ways to manage the symptoms of osteoarthritis and it is important to start by managing your symptoms through non-surgical management before considering any surgical intervention.
Physiotherapy and exercise
It is important to maintain activity as much as possible working on maintaining the range of movement of the joint and the strength of the muscles around. Physiotherapists can advise on the most appropriate exercises depending on the joints involved.
Lifestyle advice
Lifestyle advice involves making changes to your everyday activities in order to manage your pain and reduced function on a daily basis. It may be that you change the way you carry out certain activities or reduce the activities that are making your joint problems worse. If you are overweight, losing some of this excess weight will help relieve some of the strain on your joints.
Occupational therapist
An occupational therapist or physiotherapist can offer various devices that can help offload the stresses across painful joints. A walking stick can be used to reduce the weight and stress on a painful foot or ankle.
Orthotics
An orthotic is a brace or support used to improve the function of your joints. Shoe inserts are some of the more commonly used orthotics. Simple foot orthotics can be purchased over the counter but more specialised equipment requires review by a podiatrist, orthotist, physiotherapist or occupational therapist.
Podiatry
A podiatrist specialises in foot complaints and can help diagnose and non-operatively treat osteoarthritis affecting the joints of the foot and ankle. They may provide specialist orthotics to support the joints of our foot and ankle.
Complementary and alternative medicine (CAM)
Complementary and Alternative Medicine uses practices that work alongside current western medicine. It includes treatments not currently considered part of evidence-based Western practice. Examples of CAM include acupuncture, chiropractic, osteopathy, hypnosis, yoga, massage therapy and various herbal remedies.
Osteoarthritis tablets and painkillers
If your symptoms are more severe, you may need additional treatments such as painkilling medication. You can initially try simple over the counter medication such as paracetamol and certain anti-inflammatory medications. If these are not controlling your symptoms then you can speak to your GP about alternative medications.
Steroid injections
Steroids act as an anti-inflammatory and when delivered as an injection directly into the joint can be used to reduce joint inflammation and pain. Injections may be given by several health professionals including GPs, physiotherapists, radiologists, rheumatologists and orthopaedic surgeons. Occasionally we require ultrasound or X-rays to accurately find the joint to be injected and then a radiologist will carry out the procedure.
Self-management
Self-care is an integral part of daily life. It means you take responsibility for your health and wellbeing with support from those involved in your care. You must discuss your osteoarthritic condition with the team involved with your care (GP, physiotherapist, surgeon etc) and make sure you have a clear understanding of your condition and the proposed treatment plan.
Osteoarthritis surgical management
Surgery is usually for people who have severe symptoms and have tried other treatments without success. Different surgical options will vary depending on the joint involved and the extent of the involvement. In the early stages of some osteoarthritic conditions, it may be possible to preserve the joint.
Osteoarthritis non-joint replacement surgery
Arthroscopy—An arthroscopy is a type of keyhole surgery that can be used to assess and treat arthritis joints.
Osteotomy—An osteotomy involves re-aligning the forces through a joint by surgically carrying out a controlled break of a bone. This is most commonly carried out around arthritic knee joints in a younger age group.
Open debridement—This is a surgical procedure to remove bone formation around an arthritic joint to improve the range of movement and pain. This is not a suitable operation for most joints and is mainly carried out for arthritis affecting the big toe.
Fusion—In some joints, the best way of improving the symptoms of arthritis is to fuse the joint stiff. This procedure is most suited to the joints of the foot and ankle. It means the joint will be less painful and more stable but it will lose all movement.
Osteoarthritis joint replacement surgery
Joint replacement surgery replaces the damaged joint or its surface. The arthritic cartilage and bone is removed and replaced with a mechanical joint made of metal with a plastic joint surface. This may be an appropriate treatment option for some patients with ankle joint arthritis.
What are the possible complications of foot and ankle surgery?
If you are generally healthy the risk of a serious complication from an operation is very small. Complications can be increased in patients who smoke, have a poor blood supply to their feet or have a history of diabetes.
Every care is taken to prevent complications and it is important to elevate the foot and ankle in the post-operative period to reduce the risks of swelling and wound complications. Superficial infections can be treated with antibiotics and occasional deep infections will require further surgery. Some people may have swelling and stiffness which can take 12 months to settle following surgical intervention.
Bleeding and wound haematoma can also develop. A wound haematoma is when blood collects in a wound. It’s normal to have a small amount of blood leak from the wound after any surgery, and this usually stops within a couple of days. But occasionally blood may collect under your skin, causing a swelling. This can cause a larger but temporary leakage usually a week or so after surgery, or it may need a smaller second operation to remove the blood collection.