Epidemiology of Ankle Arthritis: Report of a Consecutive Series of 639 Patients from a Tertiary Orthopaedic Center (2023)

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  • Iowa Orthop J
  • v.25; 2005
  • PMC1888779

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Epidemiology of Ankle Arthritis: Report of a Consecutive Series of 639 Patients from a Tertiary Orthopaedic Center (1)

Link to Publisher's site

Iowa Orthop J. 2005; 25: 44–46.

PMCID: PMC1888779

PMID: 16089071

Report of a Consecutive Series of 639 Patients from a Tertiary Orthopaedic Center

Charles L Saltzman, MD, Professor, Michael L Salamon, MD, G Michael Blanchard, MD, Thomas Huff, MD, Andrea Hayes, Joseph A Buckwalter, MD, and Annunziato Amendola, MD

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The purpose of our study was to identify the cause of symptomatic ankle arthritis in a consecutive series of patients presenting in a tertiary care setting. Between 1991 and 2004, 639 patients with Kellgren grade 3 or 4 ankle arthritis presented to the University of Iowa Orthopaedic Foot and Ankle Surgery service. The cause of the arthritis was determined based on medical history, physical examination, and imaging studies. To get a sense of the relative prevalence of the etiologies of lower extremity arthritis in our setting, we evaluated the cause of arthritis of all new patients presenting to the University of Iowa Orthopaedic Department from 1999-2004 with arthritis of the ankle, to those with arthritis of the hip or knee during one year. Of the 639 arthritic ankles, 445 (70%) were post-traumatic, 76 (12%) were rheumatoid disease and 46 (7%) were idiopathic (primary osteoarthritis). The post-traumatic ankle arthritis patients were most commonly associated with past rotational ankle fractures. The majority of ankle arthritis is associated with previous trauma, whereas the primary cause of knee or hip arthritis is idiopathic. Unique strategies to prevent or treat post-traumatic ankle arthritis are needed.


Primary or idiopathic osteoarthritis (OA) is the most common joint disease, and is a significant source of pain and disability for middle-aged and elderly people throughout the world. It occurs rarely in people under the age of 40. Secondary causes of joint degeneration include dysplasia, inflammatory conditions, traumatic injury, infection, hemophilia and vascular or neurological insults.1 Primary osteoarthritis is known to occur commonly in the hand, spine, hip and knee. However, it occurs much less frequently in the elbow, shoulder, wrist and ankle.2 The reasons for this are not completely understood, but differing anatomical, biomechanical, and biological factors likely contribute to this variability. Primary osteoarthritis is the most common indication for total hip and total knee arthroplasty, whereas post-traumatic arthritis is the most common indication for ankle arthrodesis.

Review of published reports of the treatment of ankle osteoarthritis indicate that primary osteoarthritis in the ankle is rare, and that secondary osteoarthritis that follows rotational ankle fractures or recurrent ligamentous instability is much more common.3,4,5,6 Some patients report sustaining no more than a single major ankle sprain, suggesting an undiagnosed chondral injury as the inciting event. The purpose of our study was to identify the cause of symptomatic ankle arthritis in a consecutive series of patients presenting in a tertiary care setting, and to compare the cause of ankle arthritis to that of the hip and knee. The purpose of this subset of data is to report a "snapshot" of a group of patients presenting to the University of Iowa Orthopaedic Department with lower extremity osteoarthritis and to compare the differences between these groups.


Between 1991 and 2004, 639 patients with Kellgren grade 3 or 4 ankle arthritis presented to the University of Iowa Orthopaedic Foot and Ankle Surgery service (Tables 1, ​,2,2, and ​and3).3). The cause of the arthritis was determined based on medical history, physical examination and imaging studies. Only ankles with Kellgren/ Lawrence grade 3 or 4 changes were included. The cause of ankle arthritis was determined whenever possible. If no cause could be elucidated, then by a process of elimination the case was classified as primary osteoarthritis.


All ankle arthritis patients presenting to the University of Iowa Orthopaedics Department

TypeNo.% of totalAvg. AgeSD Age

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September 1991 to August 2004


Subset with post-traumatic ankle arthritis

CausesNo.% of totalAvg. AgeSD Age
Tibial and fibular shaft184.054.911.5
Tibia fracture388.54916.3
Plafond fracture409.043.111.5
Rotational ankle16437.050.814.2
Talar fracture388.346.914.5
Osteochondritis dissecans214.744.612.62
Recurrent ankle instability6514.657.713.29
Single sprain with cont'd pain6113.75016.17

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Subset with primary ankle arthritis

CausesNo.% total
Congenital foot deformity715
Planovalgus foot613
Cavovarus foot1022
No foot deformity2350

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In addition, during a one-year period (April 1998- March 1999) we collected data on patients who presented to all of the University of Iowa Orthopaedic clinics with symptomatic Kellgren grade 3 or 4 arthritis of the hip, knee or ankle (Table 4).


Demographics of lower extremity arthritis in the hip, knee and ankle

Primary109 (65%)347 (82%)9 (19%)
Post-traumatic14 (8%)53 (12.5%)26 (54%)
Rheumatoid3 (2%)15 (3.5%) 7 (14.6%)
Neuropathic03 (0.7%)3 (6%)
Dysplastic18 (11%)2 (0.5%)3 (6%)
Avascular Necrosis18 (11%)2 (0.5%)0
Other5 (3%)2 (0.5%)1 (2%)

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(N=639 total)

April 1998 to March 1999


The majority of clinical and basic science research has focused on hip and knee osteoarthritis. The ankle joint has received relatively less attention. Ankle osteoarthritis has characteristics that distinguish it from osteoarthritis occurring in other joints, resulting in differences in prevalence, clinical presentation, natural history and possibly even response to treatment. This study is one of the first to characterize the epidemiology of ankle arthritis.

The ankle joint possesses unique epidemiological, anatomic, biomechanical and biologic characteristics when compared to other joints in the lower extremity. While primary hip and knee arthritis is common, ankle arthritis has been characterized as usually secondary, and the result of another initiating event or underlying pathologic process.7 These differences are supported by our data.

Ankle articular cartilage is different from that of the hip and knee in several ways. The anatomy and motion characteristics of the ankle joint are unique and the ankle has a much smaller articular surface area than the hip or knee. Ankle articular cartilage is thinner (1- 2mm) and better preserves its tensile stiffness and fracture stress with aging than hip articular cartilage. There are also metabolic differences between ankle and knee articular cartilage that may also help explain the relative rarity of primary ankle osteoarthritis. All of these differences may protect the ankle from developing primary osteoarthritis.8

Studying the prevalence of osteoarthritis is fraught with limitations and biases. Our data is limited in that our sample was gathered from patients presenting to a tertiary orthopaedic department with complaints of ankle pain, thus limiting the generalizability of our data. This approach has been used by others working in tertiary rheumatology clinics by Cushnaghan and Dieppe,2 and allows a sample of convenience.

Despite these limitations, our data helps define the etiology of ankle arthritis in the largest consecutive, unselected series of patients published. The prevalence of primary osteoarthritis in our sample was only 7.2%, and half of these patients had substantial malaligment of the hindfoot, predisposing the ankle joint to eccentric wear and degenerative disease. The data further suggests that the proper alignment and function of the subtalar joint remains crucial in the proper long-term durability of the human ankle.

Previous reports suggest that trauma is the most common cause of ankle osteoarthritis; this is supported by our data (70%). Among the prevalent sub-causes are recurrent ankle sprains and a single ankle sprain with continued pain. The former suggests the absolutely critical importance of spatially well-distributed loading of cartilage, whereas the latter likely represents unrecognized full-thickness cartilage injury. The differences in the causes of lower limb arthritis are striking. The one-year data also shows a much higher percentage of posttraumatic ankle osteoarthritis (54%) as compared to the hip (8%), and the knee (12.5%).

In conclusion, arthritis of the ankle is unique compared to the other major lower extremity arthritidies. The relatively young average age of presentation of painful, post-traumatic ankle OA to our tertiary center is concerning because of the lack of available long-lasting treatments. Future research is needed in order to help better understand the prevention and treatment of ankle OA, particularly in light of the burden of this disease to society and the health system.9


The work reported in this manuscript was supported by award P50 AR48939 from the National Institutes of Health, Specialized Center on Research for Osteoarthritis.


1. Praemer AP, Furner S, Rice DP. Musculoskeletal Conditions in the United States. Rosemont, Illinois: American Academy of Orthopaedic Surgeons; 1999. p. 182. [Google Scholar]

2. Cushnaghan J, Dieppe P. Study of 500 patients with limb joint osteoarthritis. I. Analysis by age, sex, and distribution of symptomatic joint sites. Ann Rheum Dis. 1991 Jan;50(1):8–13. [PMC free article] [PubMed] [Google Scholar]

3. Demetriades L, Strauss E, Gallina J. Osteoarthritis of the Ankle Joint. Clin Orthop. 1998;349:28–42. [PubMed] [Google Scholar]

4. Wyss C, Zollinger H. The causes of subsequent arthrodesis of the ankle joint. Acta Orthop Belg. 1991;57(suppl 1):22–27. [PubMed] [Google Scholar]

5. Taga I, Shino K, Inoue M, Nakata K, Maeda A. Articular cartilage lesions in ankles with lateral ligament injury: An arthroscopic study. Am J Sports Med. 1993;21:120–126. [PubMed] [Google Scholar]

6. Inokuchi S, Ogawa K, Usami N, Hashimoto T. Long-term follow up of talus fractures. Orthopaedics. 1996;19:477–481. [PubMed] [Google Scholar]

7. Saltzman C, Buckwalter J. Ankle Arthritis: Emerging Concepts and Management Strategies. Vol. 48. AAOS Instructional Course Lectures; 1999. p. 231. [Google Scholar]

8. Buckwalter J, Saltzman C. Ankle Osteoarthritis: Distinctive Characteristics. Vol. 48. AAOS Instructional Course Lectures; 1999. pp. 233–241. [PubMed] [Google Scholar]

9. Buckwalter J, Saltzman C, Brown T. The impact of osteoarthritis: implications for research. Clin Orthop. 2004;427(Suppl:S6-15) [PubMed] [Google Scholar]

Articles from The Iowa Orthopaedic Journal are provided here courtesy of The University of Iowa


Epidemiology of Ankle Arthritis: Report of a Consecutive Series of 639 Patients from a Tertiary Orthopaedic Center? ›

Clinically and radiographically determined ankle OA has a prevalence of 3.4% in the general population.

How common is arthritis in ankle? ›

Ankle arthritis occurs in roughly 1% of people, usually as a result of a trauma, such as a fracture or dislocation, years earlier. People under 40 who have had an ankle injury can occasionally get this condition, but most often it develops from a lifetime of use in older people.

Is ankle arthritis rare? ›

Unlike Hip and Knee arthritis, primary ankle arthritis is rare. Primary ankle arthritis indicates that there is no known underlying cause as to why the arthritis has developed.

What triggers arthritis in ankle? ›

It can result from a variety of causes, including trauma (such as a car accident), autoimmune diseases (such as rheumatoid arthritis) or infection. In most cases, ankle arthritis is due to the degeneration of the cartilage from an old injury.

What are the signs of arthritis in your ankles? ›

Foot and Ankle Arthritis Symptoms

Pain when you move it. Trouble moving, walking, or putting weight on it. Joint stiffness, warmth, or swelling. More pain and swelling after you rest, such as sitting or sleeping.

Is walking good for ankle arthritis? ›

Walking is recommended for people with arthritis as it's low impact, helps to keep the joints flexible, helps bone health and reduces the risk of osteoporosis. If you do experience pain or you're very stiff afterwards try doing a bit less, factor in more rest and check in with your GP, if you need to.

How fast does ankle arthritis progress? ›

Experts confirm that once OA starts, it may take years to reach a severe stage. However, in extreme cases, OA progresses rapidly to complete the destruction of the cartilage within a few months. Some of the factors that determine the rate of OA progression include: The severity of your symptoms at the time of diagnosis.

What is the solution for ankle arthritis? ›

Bracing and compression. Corticosteroid injection into the joints of the foot and ankle. Pain medication and anti-inflammatories. Physical therapy.

What age does ankle osteoarthritis start? ›

Osteoarthritis can affect anyone at any age, but it's most common in people over 45. It affects more women than men. The risk of developing osteoarthritis is commonly linked to: being overweight or obese.

How do you beat arthritis in the ankle? ›

At-Home Remedies
  1. Exercise. A regimen of comfortable, joint-friendly exercise can help alleviate symptoms and prevent further regression of ankle arthritis. ...
  2. Diet. Nutrition can be an integral part of treating ankle arthritis at home. ...
  3. Hot and Cold Treatments. ...
  4. Medication. ...
  5. Shoe Modifications. ...
  6. Physical Therapy. ...
  7. Surgery.
Jun 9, 2022

Can you reverse arthritis in ankle? ›

It is not possible to cure or reverse OA, but treatment can help relieve the pain and improve your mobility.

Does ankle arthritis go away? ›

Although there is no cure for arthritis, there are many treatment options available to slow the progress of the disease and relieve symptoms. With proper treatment, many people with arthritis are able to manage their pain, remain active, and lead fulfilling lives.

Does ankle arthritis come on suddenly? ›

If you suddenly experience ankle pain without any apparent reason or injury, it may have been brought on by some form of arthritis. For instance, osteoarthritis occurs when cartilage between bones wears down, causing them to rub together. This condition can sometimes cause sudden pain, often in the morning.

Does ankle arthritis show up on xray? ›

X-ray. To confirm a diagnosis of arthritis and determine the extent of the condition, doctors may recommend an X-ray of your foot and ankle. X-rays create pictures of the bones of the foot and ankle that doctors analyze for any visible changes in the spacing of the joints.

Does ankle arthritis come and go? ›

In most but not all cases, the symptoms of ankle osteoarthritis come and go, becoming worse and more frequent over months or years. Left untreated, ankle arthritis has the potential to severely impede mobility.

Do ankle braces help with arthritis? ›

With a good brace, deformity of the ankle can be corrected for arthritis patients. With the right orthosis, you may be painfree longer each day. This would allow you to walk further. You may also be able to manage more difficult surfaces such as uneven slopes or ramps.

What can be done for an arthritic ankle? ›

Foot and Ankle Arthritis Treatment Options
  • Activity modification.
  • Bracing and compression.
  • Corticosteroid injection into the joints of the foot and ankle.
  • Pain medication and anti-inflammatories.
  • Physical therapy.

What does arthritis pain feel like in the ankle? ›

Pain is one of the first warning signs of foot or ankle arthritis. This could feel like a burning sensation, or more like a dull ache. If the pain is caused by arthritis, it will often increase as you use the affected joints more.


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