What is the management approach for degenerative changes in the malleolus?

Management of Degenerative Changes in the Malleolus

The initial management of degenerative changes in the malleolus should focus on conservative measures including activity modification, appropriate footwear, and physical therapy, with surgical intervention reserved for cases that fail to respond to these approaches. 1

Diagnostic Approach

When evaluating degenerative changes in the malleolus, radiography should be considered the initial imaging study. Radiography can reveal:

• Osteoarthritis
• Calcified or ossified intra-articular bodies
• Osteochondral abnormalities
• Evidence of prior trauma 1

If multiple sites of osteoarthritis are present in the hindfoot, additional imaging may be needed to determine which joint is causing symptoms.

Conservative Management

Physical Interventions

• Activity modification: Reduce activities that cause pain
• Footwear modifications:
  • Open-backed shoes
  • Heel lifts or orthoses
  • Avoid flat shoes and barefoot walking 2
• Exercise therapy:
  • Eccentric strengthening exercises
  • Progressive strengthening in a phased approach:
    1. Initial (0-4 weeks): Pain control and protected range of motion
    2. Intermediate (4-8 weeks): Progressive strengthening
    3. Advanced (8-12 weeks): Functional exercises 2

Pharmacological Management

• NSAIDs for short-term pain relief:
  • Naproxen 500mg twice daily
  • Ibuprofen 1.2-2.4g daily
  • Use lowest effective dose for shortest duration 2
• Avoid corticosteroid injections near the ankle joint due to risk of tendon rupture 2

Advanced Interventions

Image-Guided Procedures

For persistent pain despite conservative management, consider:

• Image-guided anesthetic injections (with or without corticosteroid) to identify pain source and aid in surgical planning 1
• Cementoplasty for osteolytic lesions:
  • Minimally invasive procedure for pain palliation and bone consolidation
  • Involves percutaneous injection of polymethylmethacrylate into bone lesions
  • Particularly appropriate for bones subjected to compression forces 1
• Percutaneous osteosynthesis with screw fixation may be combined with cementoplasty for extensive osteolytic destruction 1

Surgical Considerations

Surgical intervention should be considered when:

• Conservative measures fail after 6-8 weeks
• Pain persists despite 3-6 months of well-managed conservative treatment 2

Special Considerations

Malleolar Fractures and Malunions

Malunion of malleolar fractures can lead to degenerative changes in the ankle joint. Long-term studies have shown:

• Anatomic reduction of the lateral malleolus is key to preventing degenerative arthritis 3, 4
• Incomplete reduction of the lateral malleolus and residual talar tilt are associated with late degenerative arthritis 3
• Despite anatomic reconstruction, degenerative changes may still occur in 37% of cases after 15 years 5

Accessory Ossification Centers

Unfused accessory ossification centers in the medial ankle can be misdiagnosed and should be distinguished from:

• Fractures
• Stress fractures
• Os subtibiale
• Pseudoarthrosis of the medial malleolus 6

Surgical treatment may be indicated for symptomatic ossicles, with options including:

• Open reduction and fusion with bone graft
• Focal drilling
• Removal of bony fragments 6

Follow-up and Monitoring

Regular assessment at 2,6, and 12 weeks is necessary to evaluate:

• Pain levels
• Range of motion
• Functional improvement
• Signs of instability 2

Prevention of Common Pitfalls

• Avoid prolonged immobilization beyond 3 weeks, which can lead to contractures
• Address biomechanical factors contributing to degenerative changes
• Don't delay referral for surgical evaluation when conservative measures fail 2

Return to full activity should be permitted only when the patient demonstrates:

• Complete resolution of pain
• Full range of motion
• Strength symmetry >90% compared to the uninjured side
• Successful completion of functional tests 2