Introduction 

Post-traumatic arthritis (PTA) is a secondary type of osteoarthritis (OA). This form of osteoarthritis is triggered by direct trauma or an injury to the specific joint as opposed to regular osteoarthritis, which is caused by wear and tear and developed for no clear reason (referred to as primary osteoarthritis).  

Around 12% of all cases of osteoarthritis are caused by trauma or injury.¹ The majority of ankle osteoarthritis is caused by injury–approximately 90% is post-traumatic. This varies for different locations in the body, and only 2-10% of osteoarthritis in the hip and knee is due to traumatic stress.³  

Primary osteoarthritis mostly affects older adults and develops gradually, but post-traumatic ankle arthritis (PTAA) is more common in younger populations and progresses more rapidly.²

How do injuries lead to post-traumatic ankle arthritis?

The ankle joint is a hinge-type joint formed by three bones, the tibia and fibula (from the leg) and the talus (from the foot), allowing for a wider range of movement of the foot. Joints, where bone surfaces meet, are covered by smooth articular cartilage, which provides cushioning and allows movement. Without articular cartilage, friction will be present between the bone surfaces as you move, resulting in pain because the bone contains many nerve endings.³

Injuries can include direct ankle trauma or any injury that destabilises the joint by harming the ligaments, tendons, bones, etc. These injuries can alter the distribution of forces within your ankle joint, which can cause some areas to experience higher forces than others. Overuse of your ankle joint means too much pressure is placed on it, which can bruise the cartilage. More serious injuries can cause fragments of cartilage to become loose, resulting in pain as the joint moves.¹ 

Cartilage cannot heal itself like other tissues, such as bones, as they are avascular, which means they have no blood supply. This means that any damage, such as holes in the cartilage surface, will be filled with scar tissue, which has inferior properties compared to healthy articular cartilage. 

Post-traumatic arthritis does not develop instantly after an injury. You may notice symptoms even 2-5 years after the injury occurred.⁴ Post-traumatic arthritis can heal spontaneously or become chronic if symptoms are still present after 6 months. It is thought that inflammation occurring after the injury plays a key role in the onset of chronic post-traumatic arthritis.¹ 

Causes of post-traumatic arthritis in the ankle 

Post-traumatic ankle arthritis can be caused by a single trauma or repeated traumas over time. Here are some examples of traumas that can lead to PTAA:

• Severe injuries: fractures, breaks and dislocations
• Repetitive stress: physical activities, such as sports or occupations, likely to cause fractures or ligament and tendon injuries²
• Previous surgeries or procedures on the ankle: they can alter the distribution of forces within the joint, causing excess force on specific points of the joint

It is important to remember that an ankle injury does not necessarily mean you will develop post-traumatic arthritis. However, there are certain risk factors, called predispositions, that increase your likelihood of developing post-traumatic arthritis when combined with an ankle injury.² However, this is just a likelihood, and even if you could relate to all of the predispositions and injure your ankle badly, you may never develop post-traumatic arthritis.⁵

• Age: cartilage becomes more susceptible to damage with age²
• Gender: people assigned female at birth are more likely to develop PTAA²
• Genetics: certain genes can make cartilage more prone to damage²
• Body weight: obesity places excess stress on the joints²
• Joint injury: the more severe the injury, the more likely you are to develop PTA in the future²
• Joint Instability: unstable joints are more likely to be injured and experience wear and tear⁶
• Occupational exposure: repetitive motion or vibrations at work can lead to repetitive strain on your joints²
• Other medical conditions: some conditions such as rheumatoid arthritis or lupus can increase the risk of developing PTA⁵

Symptoms of post-traumatic ankle arthritis 

There are many symptoms of PTA that a healthcare professional would look for, and many cross-over with primary osteoarthritis:¹

• Pain in the ankle joint, particularly during movement 
• Swelling and tenderness around the ankle 
• Stiffness and reduced range of motion 
• Difficulty walking, pain or an inability to bear weight on the affected ankle 
• Joint instability

Diagnosis of post-traumatic ankle arthritis

If you are experiencing any of the symptoms above, it is important to visit a healthcare professional. Here are some ways to determine if you have post-traumatic ankle arthritis:

Medical history and physical examination 

The healthcare professional may ask you the following:

• If you’ve injured your ankle or foot in the past, as well as how it was treated and when the injury occurred
• Your sporting and occupational history 
• They may look at the way you walk (gait analysis) and examine your shoes for uneven wear and tear to ensure they are providing sufficient support for your foot or ankle

Imaging tests

If you are showing symptoms of post-traumatic arthritis, the healthcare professional may require imaging techniques for further diagnosis:²

• X-rays: an arthritic joint may show narrowing of the joint space between bones (indicating cartilage loss), changes in the bone (such as fractures) or formation of bone spur. Healthcare professionals will likely perform the X-rays when you are standing as this shows the severity of arthritis, as well as any joint deformity
• CT and MRI scans: to look at the condition of bone and soft tissues
• Arthroscopy: it involves the insertion of a small camera into the foot or ankle joint, which then displays an image on the monitor, providing access to view the joint and the health of articular cartilage

Laboratory tests

Blood tests can rule out other potential diagnoses, such as rheumatoid arthritis 

Treatment options

Treatment plans always need to be personalised to the individual case. It is important to remember that what works for one person may not work as well for somebody else, and vice versa. 

Non-surgical approaches 

Conservative, non-surgical approaches are the preferred option, particularly for early-stage post-traumatic arthritis, as they are far less invasive and disruptive.² 

Pain management 

These are temporary measures, but they can provide pain relief and reduce inflammation. Non-steroidal anti-inflammatory drugs (NSAIDs), including ibuprofen and naproxen, can be taken to reduce swelling and relieve pain. Cortisone is an anti-inflammatory that can be injected into an arthritic joint.

Physical therapy 

It can be beneficial to improve strength and flexibility, which may help to deal with the pain. Physiotherapists can develop a personalised exercise programme aimed at regaining range of motion, strength and coordination, as well as weight management.

Assistive devices 

Physiotherapists can help you find ways to unload your ankle joint mobility assistive devices, including canes, mobility chairs, etc.  

Shoe inserts, called orthotics, or custom-made shoes with stiff soles and rocking bottoms, can minimise the pressure placed on your ankle joint, decreasing pain. If you have any deformities of your ankle or foot, the shoe insert may tilt the foot or ankle back straight, creating less pain in the joint 

Surgical interventions 

In cases where non-invasive treatments fail, surgical options can be beneficial. This is particularly true when cases are more severe. However, it is important to talk to a healthcare professional and then discuss all the potential options for you and which ones would be best for your case. 

Although they have high success rates, there may be complications, resulting in less beneficial results. Hence, surgery is only used when other interventions have failed.

Arthroscopic debridement 

It removes the lost cartilage, inflamed synovial membrane, and bone spur from around the joint. It is performed via arthroscopy, so it is relatively less invasive than other surgeries and particularly effective with mild post-traumatic ankle arthritis. This surgical intervention can have a long return to sports time, even up to 6 months.²

Joint fusion (arthrodesis) 

It is useful for end-stage post-traumatic ankle arthritis when other approaches have failed.² The goal is to fuse the bones to make one continuous bone, reducing pain by eliminating the movement.

Total ankle replacement (arthroplasty)

The damaged joint is replaced with an artificial joint and is often used for severe cases where other interventions have failed. 

Lifestyle changes and home remedies

Along with treatments and surgical options, some lifestyle remedies can be beneficial to prevent and manage post-traumatic ankle arthritis.

• Weight management can help to reduce stress on the ankle joint, resulting in less pain and increased function. Obesity has been shown to have an inflammatory effect in increasing arthritis
• Low-impact exercises help to increase the range of motion and flexibility, as well as strengthen muscles in your ankle. However, it is important to consult a physician or physiotherapist for exercises specific to you and to let them know if your joint pain is aggravated by the exercises
• Proper footwear and orthotic inserts for support, such as braces, inserts or custom-made shoes, can lower the pain
• Avoid high-impact activities, such as jogging or tennis, as these can make your symptoms worse. Lower-impact activities, such as swimming or cycling, can be more beneficial

Prevention techniques 

The best way to prevent post-traumatic ankle arthritis is to prevent injuring your ankle. Some ways to do this are to make sure to always warm up and stretch properly before exercising and wear any advised protective gear for particular sports. 

If you do injure yourself, it is crucial to get the right treatment to decrease your risk of developing post-traumatic ankle arthritis. 

If you are experiencing joint pain or post-traumatic ankle arthritis, it can feel very isolating and difficult if you are unable to enjoy activities that you have previously enjoyed. If you are experiencing any low moods or anxiety, it is important to seek help, as healthcare providers can treat or refer arthritis patients to mental health professionals and community resources. 

Summary

Post-traumatic ankle arthritis is a form of osteoarthritis triggered by injury to the ankle. This injury ultimately damages the articular cartilage that covers the joint and smoothens movement.

• It does not develop instantly after an injury and can heal spontaneously or become chronic
• Risk factors include age, gender, genetics, body weight, joint injury and instability, occupational exposure and medical conditions like lupus
• The main symptoms are pain during movement, swelling and tenderness, stiffness, difficulty walking and joint instability
• The diagnosis is based on medical history and examination, imaging tests like X-rays, and blood tests
• Non-surgical approaches are the preferred option for treatment, especially at early stages. They include pain management, physical therapy and assistive devices. Lifestyle changes are also recommended
• Surgery is performed in severe cases. Three options are available: arthroscopic debridement, joint fusion, and total ankle replacement