Diagnosing ankle arthritis

Diagnosing ankle arthritis involves more than simply looking at an X-ray. A specialist assessment considers your symptoms, previous injuries, activity requirements, ankle alignment and the condition of the surrounding foot and ankle.

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Imaging is important, but the findings need to be interpreted alongside your clinical symptoms and examination.

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Mr Shelain Patel is a Consultant Orthopaedic Foot & Ankle Surgeon in London and Consultant at the Royal National Orthopaedic Hospital (RNOH), specialising in ankle arthritis, ankle replacement and complex foot and ankle reconstruction.

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What happens during an ankle arthritis assessment?

A specialist consultation usually begins with a detailed history.

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You may be asked about:

• where the pain is located

• how long symptoms have been present

• previous ankle injuries

• previous fractures

• previous surgery

• recurrent ankle sprains

• instability

• walking distance

• sporting activities

• footwear

• previous treatments

• your expectations and priorities

 

Your ankle and foot will then be examined.

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Clinical examination

The examination may assess:

• ankle movement

• areas of tenderness

• swelling

• ankle stability

• hindfoot alignment

• foot posture

• tendon function

• walking pattern

• calf strength

• the movement of neighbouring joints

 

It is important to assess the entire foot rather than looking at the ankle joint in isolation. Problems involving the subtalar joint, midfoot, Achilles tendon, tendons or ankle ligaments can influence symptoms and treatment decisions.

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Weight-bearing X-rays or CT scans

X-rays are usually the most important initial imaging investigation for established ankle arthritis, but some surgeons including Shelain Patel may decide on using standing CT scans as a detailed alternative. Weight-bearing imaging allow assessment of the ankle while it is under load.

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They can demonstrate:

• narrowing of the joint space

• loss of cartilage indirectly

• osteophytes

• cysts

• changes in bone

• deformity

• previous fractures

• alignment of the ankle

 

Weight-bearing images can provide information that may not be apparent on non-weight-bearing X-rays.

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Assessing ankle alignment

Alignment is particularly important when assessing advanced ankle arthritis. The ankle may develop deformity as arthritis progresses, or there may already be deformity resulting from an old fracture or ligament injury.

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The position of the ankle and hindfoot can influence:

• symptoms

• walking mechanics

• progression of arthritis

• suitability for ankle replacement

• the need for additional corrective procedures

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CT scans

CT provides detailed information about the bones and can be particularly useful when there has been previous trauma or surgery, or when planning complex surgery.

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A CT scan may help assess:

• complex fractures

• bone loss

• deformity

• the extent of bony changes

• previous metalwork

• the anatomy of the ankle and hindfoot

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MRI scans

MRI provides detailed information about soft tissues and bone marrow. It may be useful when the diagnosis is uncertain or when there is concern about associated problems such as:

• osteochondral lesions

• tendon pathology

• ligament injury

• stress injury

• bone marrow changes

• other causes of ankle pain

 

MRI is not always necessary when advanced ankle arthritis is already clearly demonstrated on weight-bearing X-rays.

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Assessing the rest of the foot

The ankle does not function independently of the rest of the foot.

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A specialist assessment may therefore consider:

• subtalar arthritis

• midfoot arthritis

• hindfoot alignment

• flat foot

• cavus foot

• Achilles tendon function

• posterior tibial tendon function

• peroneal tendons

• ankle ligaments

 

This broader assessment is particularly important when considering surgery.

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Diagnosing post-traumatic ankle arthritis

If you have previously fractured or severely injured your ankle, old imaging and operative records can be useful.

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Post-traumatic arthritis may be associated with:

• previous fracture

• cartilage injury

• malalignment

• retained metalwork

• previous infection

• ligament damage

• altered ankle mechanics

The original injury can therefore be important when determining the most appropriate treatment.

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Read more about [post-traumatic ankle arthritis].

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Planning treatment

Once the diagnosis has been established, treatment can be tailored to your symptoms and circumstances.

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Treatment may include:

• physiotherapy

• footwear modification

• orthotics

• activity modification

• medication

• injections

• treatment of associated instability

• corrective osteotomy

• ankle replacement

• ankle fusion

• complex reconstruction

 

The presence of arthritis on an X-ray does not automatically mean that surgery is necessary.

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How is suitability for ankle replacement assessed?

Ankle replacement requires careful assessment of the ankle and the surrounding foot.

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Factors considered may include:

• severity of arthritis

• ankle alignment

• bone quality

• deformity

• stability

• previous surgery

• previous infection

• activity requirements

• associated foot and ankle problems

 

Where appropriate, additional procedures may sometimes be considered alongside ankle replacement.

Read more in the [complete ankle replacement guide].

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Frequently Asked Questions

Is an X-ray enough to diagnose ankle arthritis?

Often, weight-bearing X-rays provide the key information, particularly when arthritis is advanced. CT or MRI may be required in selected patients.

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Do I need an MRI for ankle arthritis?

Not necessarily. MRI is most useful when additional information about cartilage, bone or soft tissues is required.

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Why are weight-bearing X-rays important?

They show the ankle under load and can demonstrate joint-space narrowing and alignment that may not be fully apparent on non-weight-bearing images.

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Do I need a CT scan before ankle replacement?

CT may be used for detailed assessment and surgical planning, depending on the circumstances and the surgeon's preferred planning process.

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Can ankle arthritis be diagnosed without an X-ray?

Symptoms and examination may suggest arthritis, but imaging is generally important for confirming the diagnosis and assessing the extent of joint changes.

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Book a consultation

If you have persistent ankle pain or stiffness, particularly following an old injury or fracture, a specialist foot and ankle assessment can establish the cause of your symptoms and determine whether further imaging or treatment is appropriate.

[Book a consultation with Mr Shelain Patel]