Ankle Osteoarthritis
Ankle osteoarthritis refers to osteoarthritis (OA) affecting the ankle complex, which includes two synovial joints: the talocrural joint and the subtalar joint. Osteoarthritis can affect both medial and lateral compartments of these joints. The condition involves degenerative changes in cartilage and underlying bone and can lead to substantial pain and functional limitation.
Why the ankle is less prone to osteoarthritis
The ankle is much less commonly affected by osteoarthritis than other large joints such as the hip and knee. Several anatomical and biomechanical factors may help explain this:
Articular cartilage: The cartilage in the ankle has a different composition and loading profile than cartilage in other joints, making it relatively resistant to degeneration.
Joint movement and stability: The ankle has a unique biomechanical structure with relatively constrained motion, which helps distribute load more evenly across the articular surfaces.
Ankle design and stability: The talus is firmly contained on three sides by the fibula, tibial plafond and medial malleolus and is reinforced by strong ligaments. This creates efficient load distribution and reduces wear.
Common causes of ankle osteoarthritis
Although the ankle is less susceptible to osteoarthritis, several factors can contribute to development of the condition:
Trauma: Injuries such as ankle fractures or severe sprains are the most common cause of end-stage ankle osteoarthritis. Repeated microtrauma or poor healing after injury can accelerate degeneration.
Arthropathies: Systemic inflammatory conditions such as rheumatoid arthritis or gout can affect the ankle and lead to secondary osteoarthritis.
Chronic ankle instability: Recurrent instability can contribute to abnormal loading and degeneration.
Malalignment: Malalignment of the ankle or foot, such as flatfoot or varus/valgus deformity, may create abnormal loading and increase osteoarthritis risk.
Medical conditions: Conditions such as hemophilia can cause recurrent joint bleeding, damaging cartilage and contributing to osteoarthritis over time.
Clinically Relevant Anatomy
Ankle osteoarthritis can affect the main ankle joints: the talocrural joint, or true ankle joint, and the subtalar joint. A third joint, the distal tibiofibular joint, also contributes to ankle mechanics but to a much smaller degree and therefore receives less emphasis here[1][2][3].
When considering the anatomy of a specific joint, it is important to include the influence of adjacent structures such as the knee and foot. This is particularly relevant because differences in foot and knee biomechanics can influence the development of ankle osteoarthritis[4]. The complex anatomy of the foot, with 28 bones, 30 joints and more than 100 ligaments, plays a major role in balance, gait and loading and therefore influences both the talocrural and subtalar joints[5].
Anatomy of the Talocrural Joint
The talocrural joint is a synovial hinge joint that permits dorsiflexion, up to approximately 20 degrees, and plantarflexion, up to approximately 50 degrees. The articular surfaces are covered with hyaline cartilage to reduce friction and absorb load. Distally, the tibia and fibula are held together by strong ligament complexes, including the medial deltoid ligament and the lateral ligament complex. These structures form a stable mortise in which the talus sits. Injury to these structures, such as during an ankle sprain, can contribute to later osteoarthritis[3].
Structures of the Talocrural Joint:
The roof of the joint is formed by the distal inferior surface of the tibia.
The medial side of the joint is formed by the medial malleolus of the tibia.
The lateral side of the joint is formed by the lateral malleolus of the fibula.
The talus has a cylindrical articular surface that fits tightly within the mortise formed by the tibia and fibula. The articular surface of the talus is wider anteriorly than posteriorly. This contributes to increased joint stability in dorsiflexion because the wider portion of the talus becomes more securely locked within the ankle mortise.
As a synovial joint, the talocrural joint contains a synovial membrane that produces lubricating fluid and a fibrous capsule that provides structural support. These tissues function in the same way as in other synovial joints and play an important role in movement and joint protection[3].
The Role of the Talus in Loading and Stability
The talus is a key structure in ankle biomechanics, and its position and interaction with adjacent bones and ligaments are essential for stability. The cartilage covering the talar articular surface distributes load evenly and reduces wear. Loss of this cartilage, as occurs in osteoarthritis, increases friction, pain and functional limitation.
This anatomical understanding helps explain how structural and biomechanical changes can contribute to ankle osteoarthritis. For example, ligament injury or subtle changes in talar alignment can create uneven loading and accelerate degeneration.
Subtalar Joint: Structure and Function
The subtalar joint, also known as the talocalcaneal joint, is a critical component of ankle and hindfoot biomechanics and plays an important role in the foot's ability to adapt to different surfaces. The joint lies between the large posterior calcaneal facet on the inferior surface of the talus and the corresponding posterior facet on the superior surface of the calcaneus[3].
Anatomical Structure
The subtalar joint is a synovial condyloid joint that permits both gliding and rotational movement. This enables the complex movements required for normal foot function:
Inversion: Movement in which the sole turns inward, approximately 0–35 degrees.
Eversion: Movement in which the sole turns outward, approximately 0–25 degrees.
These movements are essential for balance, shock absorption and adaptation to uneven surfaces. The orientation of the joint provides a unique biomechanical advantage that supports both mobility and stability.
Supporting Structures
The subtalar joint is stabilized by a network of strong ligaments that limit excessive movement and provide structural integrity:
Anterior talocalcaneal ligament: Stabilizes the anterior part of the joint.
Posterior talocalcaneal ligament: Supports the posterior part of the joint.
Lateral talocalcaneal ligament: Limits excessive lateral movement and supports the outer side of the joint.
Medial talocalcaneal ligament: Supports the medial side of the joint.
These ligaments work together to allow the joint to tolerate loads from walking, running and other activities while protecting it from injury.
The Role of the Subtalar Joint in Movement
The subtalar joint links the talus and calcaneus, and its primary function is to adapt the position of the foot relative to the ground:
During inversion the ligaments become tensioned to stabilize the joint and allow controlled movement.
During eversion some ligamentous structures relax, allowing greater flexibility and adaptation.
The joint's unique design enables the foot to maintain balance and adapt to changing biomechanical demands, from static standing to dynamic activities such as running and jumping.
Clinical Relevance
Changes in subtalar-joint function caused by osteoarthritis, injury or ligament dysfunction can affect the biomechanics of the entire foot. For example, reduced subtalar movement may lead to compensatory movement in other joints, including the talocrural joint or even the knee, potentially creating additional load and pain.
The subtalar joint is also a common source of pain in conditions such as:
Post-traumatic osteoarthritis: Following fractures or injury to the calcaneus or talus.
Inflammatory conditions: Such as rheumatoid arthritis or other systemic inflammatory disease.
In these conditions, thorough assessment of the subtalar joint is important for developing an appropriate treatment plan.
The Role of Muscles in Ankle Biomechanics and Osteoarthritis
The muscles acting on the foot and ankle are essential for stability, mobility and force transmission, even though they may not be directly responsible for the primary pathological development of ankle osteoarthritis. In rehabilitation, understanding their function is important for designing targeted treatment plans. Muscle dysfunction or imbalance may also contribute to secondary biomechanical problems.
Posterior Compartment Muscles – Superficial Layer
Gastrocnemius
Function: Plantarflexion of the ankle and flexion of the knee.
Clinical relevance: Shortness or increased tension in the gastrocnemius can limit dorsiflexion and lead to compensatory movement at the subtalar or midfoot joints.
Rehabilitation: Emphasis on eccentric strengthening and flexibility exercises to improve ankle function.
Plantaris
Function: Weak plantarflexion and knee flexion.
Clinical relevance: Although small and sometimes absent, the plantaris may contribute to pain when overloaded.
Rehabilitation: Soft-tissue techniques may be considered when the muscle is overactive or symptomatic.
Soleus
Function: A primary plantarflexor, particularly during weight-bearing activities.
Clinical relevance: The soleus plays an important role in stability during walking and running.
Rehabilitation: Strengthening with an emphasis on controlled movement to improve force transmission.
Posterior Compartment Muscles – Deep Layer
Popliteus
Function: Internal rotation of the tibia and stabilization of the knee joint.
Clinical relevance: Important for knee-ankle interaction, particularly in the presence of malalignment.
Rehabilitation: Exercises that improve knee and ankle control.
Flexor Hallucis Longus
Function: Flexion of the great toe and support of the medial longitudinal arch.
Clinical relevance: Dysfunction may contribute to biomechanical imbalance and increased midfoot loading.
Rehabilitation: Strengthening and mobility exercises for the great toe.
Flexor Digitorum Longus
Function: Flexion of the toes and support of the longitudinal arch of the foot.
Clinical relevance: Contributes to dynamic ankle stability.
Rehabilitation: Focus on coordinated movement of the toes and ankle.
Tibialis Posterior
Function: Inversion of the foot and support of the medial arch.
Clinical relevance: Weakness may contribute to overpronation and increased risk of degenerative loading.
Rehabilitation: Specific strengthening and stabilization exercises for tibialis posterior.
Lateral Compartment Muscles
Peroneus Longus
Function: Eversion of the foot and stabilization of the lateral arch.
Clinical relevance: Dysfunction may contribute to lateral ankle instability.
Rehabilitation: Proprioceptive training and strengthening exercises.
Peroneus Brevis
Function: Eversion and support of the lateral foot.
Clinical relevance: Contributes to prevention of inversion ankle sprains.
Rehabilitation: Emphasis on exercises that improve lateral stability.
Anterior Compartment Muscles
Tibialis Anterior
Function: Dorsiflexion and inversion of the foot.
Clinical relevance: Important for control during walking and running.
Rehabilitation: Eccentric strengthening and proprioceptive control.
Extensor Hallucis Longus
Function: Extension of the great toe and dorsiflexion of the ankle.
Clinical relevance: Supports dynamic stability of the foot.
Rehabilitation: Focus on coordination and strengthening exercises.
Extensor Digitorum Longus
Function: Extension of the toes and dorsiflexion of the ankle.
Clinical relevance: Dysfunction may alter foot biomechanics.
Rehabilitation: Integrated strengthening and motor-control exercises.
Peroneus Tertius
Function: Weak dorsiflexion and eversion.
Clinical relevance: May contribute to lateral ankle stability.
Rehabilitation: Proprioceptive training and strengthening.
Epidemiology and Etiology of Ankle Osteoarthritis
Epidemiology
Osteoarthritis (OA) is the most common joint disease worldwide, but ankle involvement is relatively uncommon compared with the hip and knee. Only around 1% of OA cases involve the ankle, making it comparatively rare in this anatomical region[^11].
Age distribution: Ankle OA typically affects middle-aged and older adults, but younger people may also develop the condition, particularly after trauma or other secondary causes. OA before the age of 40 is uncommon but possible.
Risk factors: Several factors may contribute to development of OA, including:
Inflammatory processes
Trauma and injuries
Infections
Vascular or neurological conditions
Poor biomechanics, for example excessive loading caused by muscle weakness, joint laxity or overweight.
These factors may progressively impair joint function, and physiotherapy has an important role in addressing biomechanical loading factors. This may help slow functional decline and improve the patient's function and quality of life[^12][^13].
Post-Traumatic and Secondary Osteoarthritis
Whereas idiopathic OA, where no specific cause is identified, is common in other joints, ankle osteoarthritis frequently has a secondary cause. This was demonstrated in a study by Saltzman et al., which analyzed causes of ankle osteoarthritis in patients treated at the University of Iowa Orthopaedic Department between 1999 and 2004[^14]. The results were:
70% of cases were post-traumatic, often following fractures, ligament ruptures or severe ankle injuries.
12% of cases were related to rheumatoid arthritis, a systemic inflammatory condition affecting multiple joints.
Only 7% of cases were classified as idiopathic osteoarthritis, with no identifiable underlying cause.
These figures highlight how ankle osteoarthritis differs from OA in other joints. Unlike the hip and knee, where idiopathic OA often predominates, ankle OA has a much higher proportion of cases caused by external factors, particularly trauma.
Secondary Causes of Ankle Osteoarthritis
Post-traumatic osteoarthritis: The most common form, developing after injuries such as:
Ankle fractures
Severe sprains
Repeated microtrauma
Inflammatory joint disorders: Rheumatoid arthritis and similar conditions that cause systemic inflammation.
Biomechanical loading factors:
Foot or ankle malalignment, such as pes planus (flatfoot) or pes cavus (high arch).
Overweight, which increases joint loading.
Weakness in the muscles that stabilize the ankle.
Neurological and vascular factors:
Conditions such as Charcot foot can predispose to osteoarthritis because of poor stability and support.
Reduced blood supply may impair healing and accelerate degeneration.
Infections: Septic arthritis can damage joint surfaces and lead to later osteoarthritis.
Clinical Features and Presentation of Ankle Osteoarthritis
As with osteoarthritis in other joints, ankle OA follows a recognizable pattern of subjective and objective findings. These symptoms provide important information about disease severity and its effect on quality of life. The most common manifestations are summarized below.
Principal Manifestations of Ankle Osteoarthritis (adapted from Abhishek & Doherty²⁰)
Symptom/Manifestation | Description |
Joint pain | - Usually affects 1–3 joints at the same time - Gradual and slow development - Variable intensity, sometimes intermittent or recurrent - Worsens with weight bearing, especially walking or running - Initially relieved by rest but may progress to night pain in severe cases |
Stiffness | - Short-lasting morning stiffness (<30 minutes) - Stiffness after periods of inactivity |
Swelling | - Some patients report mild swelling or deformity - The joint may have a small, often cool effusion |
Age | - Primarily affects people over 40 years of age |
Systemic symptoms | - Absent |
Appearance | - Visible bony and soft-tissue swelling - Deformity may develop over time - General muscle atrophy around the joint - The joint is often held in a protective resting position |
Palpation | - Absence of warmth even when swelling is present - Joint-line and periarticular tenderness - Effusion is usually cool and small |
Movement | - Coarse crepitus during movement - Reduced range of motion (ROM) - Weakness of muscles surrounding the joint |
Subjective markers | - Morning stiffness - Occupations involving heavy manual work - Constant low-grade pain with periods of more intense pain - Deep, aching pain - Grinding or clicking sounds from the joint - Relief with heat - Worsening with stairs or running |
Further Detail on Clinical Features
Joint pain: Pain is often the most prominent complaint in patients with ankle osteoarthritis. It may affect activities such as walking, running or prolonged standing, and in severe cases can progress to night pain that disturbs sleep¹⁹. Pain intensity can range from mild to severe, and some patients experience episodic flares.
Stiffness: Short-lasting morning stiffness is characteristic, but stiffness after inactivity can also be problematic²⁰. This may make it difficult to initiate movement, particularly after longer periods of rest.
Swelling and Appearance: Although swelling is often mild, it can cause substantial discomfort. Swelling may be visible around bony or soft-tissue structures²⁰. Generalized muscle atrophy may also develop around the joint, further contributing to functional impairment.
Movement Restrictions: Patients with ankle osteoarthritis often have substantially reduced ankle range of motion, particularly in dorsiflexion and plantarflexion²¹. Crepitus during movement is also common and may be accompanied by weakness of surrounding muscles.
Functional Limitations: Many patients report difficulty with everyday activities such as climbing stairs, running or performing work that requires prolonged standing. These limitations can significantly affect quality of life²¹.
These clinical features highlight the importance of early diagnosis and targeted treatment, whether conservative or surgical, to reduce symptoms and preserve functional capacity.
Differential Diagnoses in Ankle Osteoarthritis
When a patient presents with symptoms suggestive of ankle osteoarthritis, it is essential to distinguish mechanical from inflammatory causes. This is particularly relevant at the ankle because inflammatory disorders can contribute to joint degeneration and may require a different treatment strategy. Identifying the underlying cause can guide management and improve outcomes.
Common Differential Diagnoses in Ankle Osteoarthritis
Inflammatory causes
Rheumatoid arthritis
An autoimmune inflammatory condition that commonly involves multiple joints, including the ankle.
Symptoms include diffuse swelling, warmth, morning stiffness lasting more than 30 minutes and systemic symptoms such as fatigue and fever¹².
Diagnostic tests: Serological markers such as anti-CCP and rheumatoid factor, together with inflammatory markers including CRP and ESR.
Psoriatic arthritis
May affect both peripheral joints and the spine and is often associated with characteristic skin changes from psoriasis and asymmetric joint swelling.
Symptoms can include enthesitis, dactylitis and axial involvement¹³.
Diagnostic tests: There is no single specific blood test, but MRI may demonstrate enthesopathy and erosions.
Ankylosing spondylitis
A seronegative spondyloarthritis that may involve the ankle as well as the spine.
Symptoms include stiffness and pain in the spine and peripheral joints, often worsening with inactivity.
Diagnostic tests: HLA-B27 testing and MRI for sacroiliitis.
Gout
Accumulation of urate crystals in the joint can cause acute pain, warmth and swelling in the ankle.
Diagnostic tests: Synovial-fluid analysis demonstrates urate crystals, and serum uric acid may be elevated¹⁴.
Mechanical causes
Post-traumatic osteoarthritis
Secondary to previous injury such as an ankle fracture or severe sprain.
Symptoms: Gradual onset of pain and stiffness, often unilateral.
Diagnostic tests: X-rays may show sclerosis, joint-space narrowing and osteophytes.
Joint instability
Common in people with chronic ankle instability following repeated sprains.
Symptoms include recurrent episodes of giving way, pain and swelling after activity¹⁵.
Diagnostic tests: Clinical tests such as the anterior drawer test and stress radiographs.
Osteonecrosis (avascular necrosis)
Loss of blood supply to the talus can lead to collapse of the articular surface.
Symptoms include gradually worsening pain, often without a specific history of trauma.
Diagnostic tests: MRI is the gold standard for early diagnosis.
Subtalar osteoarthritis
Can be difficult to distinguish from talocrural osteoarthritis. Symptoms include pain with inversion and eversion.
Diagnostic tests: Specific loading tests and diagnostic imaging.
Other causes of ankle pain
Achilles tendinopathy
Localized pain at the posterior ankle, aggravated by loading.
Clinical examination: Tenderness on palpation and pain during heel raises.
Tarsal tunnel syndrome
Compression of the tibial nerve causes neuropathic pain, often accompanied by paresthesia.
Diagnostic tests: Tinel's sign and nerve-conduction studies.
Plantar fasciitis
Typically causes heel pain but may be perceived as ankle pain.
Symptoms: Morning stiffness and pain with the first steps after rest.
Correctly identifying the cause of ankle symptoms is essential because treatment differs substantially between inflammatory and mechanical conditions. Inflammatory causes may require medications such as DMARDs or biologic agents, whereas mechanical causes may be managed with physiotherapy, orthoses or surgery.
When ankle osteoarthritis is suspected, other causes should be excluded through a combination of careful history taking, physical examination and diagnostic imaging²⁰. Early and accurate diagnosis can support targeted treatment and help prevent further joint damage and functional decline.
Standardized Outcome Measures
Effective assessment of pain, function and mobility is important for evaluating disease severity and treatment response in patients with ankle osteoarthritis. The following outcome measures provide a broad assessment and are commonly used in clinical practice:
1. Visual Analogue Scale (VAS)
VAS measures pain intensity using a 10 cm line on which the patient marks their pain level from "no pain" (0) to "worst imaginable pain" (10).
Relevance: Useful for evaluating changes in pain over time and response to treatment.
Advantages: Simple to use and requires minimal training.
Limitations: Subjective and may be influenced by the patient's understanding of the tool¹.
2. Goniometer
A goniometer measures range of motion in the talocrural and subtalar joints in degrees, including dorsiflexion, plantarflexion, inversion and eversion.
Relevance: Essential for evaluating mobility restrictions associated with ankle osteoarthritis.
Advantages: Objective and accurate when performed correctly.
Limitations: Requires training and consistency between measurements².
3. Intermittent and Constant Osteoarthritis Pain Index (ICOAP)
ICOAP evaluates both constant and intermittent pain associated with osteoarthritis.
Relevance: Provides insight into how different pain patterns affect daily activities.
Advantages: Specifically designed for people with osteoarthritis.
Limitations: Can be time-consuming for the patient to complete accurately³.
4. Algofunctional Index (AFI)
AFI assesses pain and functional limitations through six questions relating to daily activities such as walking and stair climbing.
Relevance: Useful for assessing how osteoarthritis affects function.
Advantages: Simple to administer and focused on functional limitations.
Limitations: Not specifically developed for ankle osteoarthritis⁴.
5. Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC)
WOMAC is a comprehensive outcome measure assessing pain, stiffness and functional limitations.
Relevance: Widely used in clinical practice to evaluate treatment response.
Advantages: Well validated and clinically applicable.
Limitations: Can be time-consuming to complete⁵.
6. Dynamic Gait Index (DGI)
DGI assesses balance and gait function under different conditions, such as walking on uneven surfaces or while moving the head.
Relevance: Identifies gait disturbances associated with osteoarthritis.
Advantages: Useful for tailoring rehabilitation programs.
Limitations: Requires specific equipment and experience for correct administration⁶.
7. Oswestry Disability Index (ODI)
ODI evaluates functional limitations in daily activities and provides insight into how osteoarthritis affects quality of life.
Relevance: Although developed for spinal conditions, it may also provide information about disability in patients with ankle osteoarthritis.
Advantages: Easy to administer and has high validity.
Limitations: Not specific to the ankle joint⁷.
8. Foot and Ankle Disability Index (FADI)
FADI assesses foot and ankle disability based on patient self-report.
Relevance: Directly relevant to functional problems associated with ankle osteoarthritis.
Advantages: Specifically focused on the foot and ankle and provides detailed insight into the patient's functional challenges.
Limitations: Subjective and dependent on the patient's ability to accurately describe function⁸.
These outcome measures provide a thorough assessment of how ankle osteoarthritis affects the patient's life. Combining subjective and objective tools supports accurate evaluation and individualized follow-up. The choice of measure should reflect the patient's specific problems and treatment goals.
Medical Treatment of Ankle Osteoarthritis
Treatment of ankle osteoarthritis varies according to severity and type. Management includes medical, non-surgical and surgical approaches aimed at reducing pain and inflammation and improving function.
Medical and Non-Surgical Treatments
Anti-inflammatory medications
Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen and naproxen, may help reduce pain and inflammation.
Relevance: May be useful during periods of inflammatory symptom exacerbation associated with osteoarthritis.
Advantages: Widely available and can provide relatively rapid symptom relief.
Limitations: Long-term use may cause gastrointestinal problems and increase the risk of cardiovascular adverse effects¹.
Corticosteroid injections
Corticosteroids may be injected directly into the joint to reduce marked inflammation and pain.
Relevance: May be useful during acute symptomatic flares of osteoarthritis.
Advantages: Can provide rapid symptom relief.
Limitations: Repeated use should be approached cautiously because of potential adverse effects on cartilage and joint structures².
Hyaluronic Acid Injections (Viscosupplementation)
Hyaluronic acid is injected into the joint with the aim of supplementing the lubricating and shock-absorbing properties of synovial fluid.
Relevance: May reduce pain and improve function in some patients with mild to moderate osteoarthritis.
Advantages: Minimally invasive and may provide prolonged symptom relief in selected patients.
Limitations: Effectiveness varies and treatment may be costly³⁴⁵.
Physiotherapy and Assistive Devices
Individualized orthoses, such as insoles and ankle braces, may help reduce joint loading and improve biomechanics.
Relevance: May reduce pain and improve gait function.
Advantages: Non-invasive and complementary to other treatments.
Limitations: May be insufficient as a stand-alone treatment in advanced osteoarthritis⁶.
Surgical Treatments
When conservative treatment does not provide sufficient relief, surgery may be considered. The choice of procedure depends on the location and severity of osteoarthritis and the patient's functional requirements.
Arthroscopic Joint Lavage and Debridement
Arthroscopy may be used to remove loose cartilage fragments, osteophytes and inflamed tissue.
Relevance: May be considered in mild to moderate osteoarthritis with mechanical symptoms.
Advantages: Minimally invasive with a relatively short recovery period.
Limitations: Generally not effective for advanced osteoarthritis⁷.
Arthrodesis (Joint Fusion)
The joint is surgically fused to eliminate painful movement in the affected region.
Relevance: Can be effective for severe osteoarthritis in which joint movement causes substantial pain.
Advantages: High success rate for pain relief.
Limitations: Reduces mobility and may contribute to secondary problems in adjacent joints⁸.
Total Ankle Replacement
The damaged joint is replaced with an artificial prosthesis designed to preserve movement and function.
Relevance: Suitable for selected patients who wish to preserve ankle mobility.
Advantages: Preserves movement and provides pain relief.
Limitations: The prosthesis has a limited lifespan and revision surgery may eventually be required⁹.
Medical management of ankle osteoarthritis should be individualized according to disease severity, symptoms and functional goals. Non-surgical approaches should generally be considered first, with surgical options reserved for patients who do not respond adequately to conservative management.
Physiotherapy Management of Ankle Osteoarthritis
Recent studies indicate that moderate physical activity is safe and effective in the management of ankle osteoarthritis (OA). Physical activity can reduce pain, strengthen the muscles around the ankle, improve range of motion and enhance balance, coordination and stability. Together, these changes can improve overall function. Exercise should ideally be performed with guidance from a physiotherapist to optimize effectiveness.¹²⁷
Exercise
Exercise is most effective when it combines the following components:
Strength training: Exercises targeting the gastrocnemius, soleus, tibialis anterior and peroneal muscles are recommended, for example using elastic resistance bands. This can improve ankle stability and muscular support.
Endurance training: Aerobic activities such as cycling and appropriately selected walking or running-based exercise can improve cardiovascular fitness and general health. Activity selection should be adapted to symptoms and joint tolerance.
Mobility exercises: Range-of-motion exercises including plantarflexion, dorsiflexion, inversion and eversion are recommended to maintain and improve ankle mobility.
Balance and proprioceptive training: When ankle instability is present, balance-challenging exercises using tools such as an Airex pad or balance board may be included. Plantarflexion, dorsiflexion, inversion and eversion can also be integrated into neuromuscular training.²²
Functional exercises: Exercises such as single-leg standing, walking on different surfaces, sit-to-stand or floor-transfer practice and stair climbing are recommended. These activities combine strength, balance and coordination in functional movement patterns.²²
Hydrotherapy
Hydrotherapy is recommended in international guidance and can be particularly useful when pain makes land-based exercise difficult. Swimming and water-based exercises, including ankle plantarflexion, dorsiflexion, inversion and eversion, may reduce pain, promote relaxation and improve mobility.²¹
Passive Mobilization
Passive joint mobilization, including anterior and posterior glides of the ankle, may be useful when combined with active exercise therapy. These techniques can help reduce pain and restore joint mobility.²¹
Massage
Massage of the muscles around the ankle has limited evidence for directly treating ankle osteoarthritis. However, gentle and progressive soft-tissue treatment of painful areas may provide temporary symptom relief.²¹
Thermotherapy
Heat may be useful for warming stiff joints before exercise, while cold packs may be used when inflammatory symptoms are present.²¹
Electrotherapy
Electrotherapy has not consistently demonstrated effectiveness for ankle osteoarthritis but may be considered as an adjunct for severe pain when it helps the patient participate in exercise.²¹
Laser and TENS
Both laser therapy and TENS (transcutaneous electrical nerve stimulation) have been investigated in osteoarthritis management. Evidence for laser is weaker than for TENS, and these modalities should be viewed as adjuncts rather than core treatment.²⁸
External Support Devices
Although evidence for braces, taping and insoles specifically in ankle osteoarthritis is limited, these devices may provide pain relief and improve biomechanics in selected patients.²¹
Patient Education and Self-Management
Patient education and support for self-management are strongly recommended. The physiotherapist should explain the importance of regular exercise for maintaining function and reducing avoidable joint deterioration.²⁹³⁰
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