Arthritis of the foot and ankle

What is osteoarthritis of the foot and ankle, and how common is it?

Osteoarthritis (OA) is joint pain and reduced function caused by a joint wearing down over time¹. In the foot it most often affects the big toe joint, where it's called hallux rigidus (a stiff, arthritic big toe)². In the ankle it's mostly a result of an earlier injury¹.

In older adults living in the community, about one in six had foot OA with symptoms, and the big toe joint was the most common site³. Ankle pain is common in older adults, but moderate to severe ankle OA is less common⁴. Not all foot or ankle pain is OA, so ongoing pain, stiffness or swelling is worth having assessed by a GP, podiatrist or physiotherapist.

What causes it, and who gets it?

Ankle OA is usually caused by an earlier injury, such as a broken ankle or several severe sprains, which is why it can affect people who are relatively young⁵⁶. Ankle OA with no history of injury is unusual, so it's worth asking your doctor whether an underlying condition needs checking⁷.

The cause of big toe OA is often unclear⁸. An earlier injury can bring it on, and so can repeated small knocks or conditions such as gout or rheumatoid arthritis².

In older adults, foot OA is more common in women, becomes more common with age, and is more common in lower socioeconomic groups³. Tell your clinician about any past ankle fracture, severe sprain or other injury, even from years ago.

What does it feel like, and how is it diagnosed?

Pain and stiffness are the main symptoms⁶. Joints can also be swollen, tender, hard to move, stiff in the morning and painful when you walk⁹. In the big toe, pain and stiffness are typically worse with stairs or running, and often better in stiff-soled shoes than in flexible ones such as sandals⁸.

Diagnosis is mainly based on an examination and questions about your pain and how it affects you, by a GP, podiatrist or physiotherapist⁹. An X-ray isn't always needed when symptoms are typical⁹¹⁰, though it can help rule out other causes¹⁰. It's fine to ask whether you need one.

What helps first?

Care usually starts without surgery: lifestyle changes, orthotics (shoe inserts or braces), pain relief and physiotherapy⁹. You can start with these:

• Wear supportive shoes. For the big toe or ankle, a stiff or rocker-bottom sole (a curved sole that helps you roll forward) and a roomy toe box can help, and flat, flexible shoes are best avoided⁸¹¹.
• Ease off, don't stop. Cut back on what bends your big toe sharply, such as stairs and running⁸.
• Look at your weight. If you're overweight, losing a little can reduce strain on your feet and ankles⁹.
• Use simple pain relief. Paracetamol and ice packs for swelling can help⁶. Check any pain medicine, including anti-inflammatories, with a pharmacist or GP first.
• Keep moving. A physiotherapist can show you stretching and strengthening exercises⁹¹¹. If you have a health problem or feel unwell, check with your GP before starting, and stop if pain comes on¹².

Inserts may not do as much as you'd hope. For big toe OA, arch-contouring orthoses and shoe-stiffening inserts probably make little or no difference to pain or function, and few non-surgical treatments have been well tested¹³. Footwear changes have been linked with less pain, though that link isn't proof¹⁴.

What helps if that isn't enough?

If your pain or function isn't improving despite footwear, exercise and pain relief, ask your GP, podiatrist or physiotherapist whether a referral for another opinion makes sense. Pain that stops responding to care is worth getting checked again for other causes¹⁵.

A single hyaluronic acid injection into the big toe joint doesn't seem to give a worthwhile benefit¹³. If other treatments don't work, surgery may be recommended⁹. Surgery carries risks, so before deciding, ask what benefit to expect, what the risks are and what recovery involves. It helps to take a list of what you've already tried.

What's the outlook, and can I stop it coming back?

It isn't clear yet how quickly foot and ankle OA changes over time, or whether any step prevents flare-ups or slows it down. What you can do is keep a simple record of your pain, stiffness and what you can manage, such as how far you can walk or how many stairs, so you and your podiatrist, physiotherapist or GP can see whether your care is helping. If things aren't improving, review the plan together rather than waiting it out.