My relationships with GPs are frequent and valuable and constructive.
This is why I’d like to summarize below some of the key issues on which we exchange views, especially after they suggest their patients an orthopedic consult and a specialist’s thorough diagnosis.
Also, since the topic of specialist prescriptions seems relevant now more than ever (according to the news introduced by the last Spending Review on health care), I like to think I can be of some help by giving advice on the most effective clinical trials to be prescribed in the event of suspected osteoarthritis of the ankle, that, above all, won’t violate the new proposed rules.

Osteoarthritis of the ankle is a disease, which is very different from the most widespread ones affecting other joints such as the hip and knee.
Their epidemiology and etiology is profoundly different. Indeed, as for the hip and knee, more often than not, we find ourselves with an elderly patient, in whom the arthritis is just one of the many typical problems of aging.
In these cases, the choice of treatment is influenced by the degree of arthritis, as well as by careful evaluations of general health and possible comorbidities.

For the ankle, instead, age is not a determining factor. Let’s explain why. First of all, the ankle joint is congruent, making it inherently stable. This means that in standing (static) position, ligaments do not exercise any function: they work only in dynamic. Any abnormal stresses of the joint surfaces are extremely reduced.
Then the ankle is a functional entity highly resistant to the degenerative arthritic process. On the contrary, it is very fragile in the case of previous fracture or instability that might compromise its anatomical integrity (post-traumatic arthritis).
This explains the different epidemiology: it involves patients with a history of cartilage and ligament injuries, fractures or systemic inflammatory diseases (rheumatoid arthritis, hemochromatosis, etc.). For this we are often faced with subjects who are young and in the prime of their working lives.

What impacts can this disease have on our patients?
An American study, led by Professor S. Raikin, revealed the importance of this disease (Level of Evidence: 2). According to validated clinical scores, the osteoarthritis of the ankle would afflict the lives of affected patients to an extent equal to that of arthrosis of the hip and superior to that of arthrosis of the knee.
So, as you can imagine, we are facing a serious disease, with a functional impotence and an important social cost in terms of absences from work due to illness. Those affected are people that, with time, develop a reduction of movement and multiplanar deformities, often (but not only) equinus.
Arthritic ankles, therefore, can evolve, creating severe deformities.
The main symptoms are pain and limping with also an involvement of the neighboring joints. For example, it is not uncommon to see a recurvatum knee in a patient with significant equinus ankle deformity.

Therefore, it is correct to consider that osteoarthritis of the ankle is a disease in which degeneration and symptoms are not limited to the affected joint, but rather, its manifestations are often supra-segmental.
To promptly treat the osteoarthritis of the ankle means, therefore, to preserve the health of the other joints.

What’s the best way to study and observe it?

As we said, it is undoubtedly an important topic especially at this time when the health authorities impose – sometimes rightly, sometimes with guilty superficiality – an accurate review of the costs.
The ankle must be examined in weight-bearing condition, in particular when it is arthritic. For this reason, a weight-bearing X-ray of foot and ankle is without doubt the best test for the patient before an orthopedic examination. This, combined with an appropriate clinical evaluation, should be good enough for a specialist to make the diagnosis.
In the cases with surgical indication, it will be the orthopedic surgeon himself to request a CT scan of the ankle, to check the quality of the bone on which he must operate.
MRI scan, on the contrary, is of marginal utility in the study of this disease.
However, often patients can’t be calm until they are prescribed one of them. Unfortunately, it is commonly thought that this investigation always clarify all doubts, ensuring a proper diagnosis. It’s wrong! In these cases, communicating with the patient, explaining why you are prescribing some examination or another is fundamental, though sometimes not enough to reassure a suffering patient rightly concerned.

Also for these reasons I thought it appropriate to deal extensively with the subject of medical imaging on my website, which you can refer to also as a source of reassurance for your patients, encouraging them to look there for the answers to all their questions and understandable doubts.

Keep always in mind that when you come across a patient who has major pain in the ankle, difficulty in walking (limping) and wearing work (accident-prevention) shoes, the first rule is to carefully evaluate their history, their everyday life. A history of systemic inflammatory diseases or ligament injuries or ankle, talus and calcaneus fractures should immediately make you think of osteoarthritis of the ankle. So a weight-bearing X-ray of foot and ankle is what the specialist needs to make the diagnosis.

A reference center for the treatment of osteoarthritis of the ankle, even now a niche disease often ignored, is necessary for a patient who wishes to exercise their right to receive the best care.