What are the treatment options for an elderly female patient with osteoarthritis and worsening ankle pain, with radiographic findings of diffuse soft tissue swelling, spurring from the tip of the medial malleolus and talus, and bone spurs from the dorsal talonavicular and plantar calcaneal regions?

Treatment of Ankle and Foot Osteoarthritis with Multiple Bone Spurs in an Elderly Patient

Begin with a multimodal non-pharmacological and topical approach, reserving systemic medications for breakthrough pain only, given the high risk of adverse effects in elderly patients. 1, 2

Core Non-Pharmacological Treatments (Start Here)

Weight reduction if overweight or obese is the single most important modifiable factor, as sustained weight loss improves pain and function in osteoarthritis patients. 1 Although challenging to achieve, the benefits extend beyond joint symptoms with no downside risk. 1

Structured exercise programs should include both strengthening exercises and aerobic fitness training, as these reduce pain and improve mobility in osteoarthritis patients. 1 Specifically:

• Ankle and foot-specific range of motion exercises to maintain joint mobility 1
• Strengthening exercises for muscles supporting the ankle and foot 1
• Aerobic conditioning (walking, cycling, swimming) for 30+ minutes most days 1
• Exercise does not exacerbate joint damage and provides substantial pain relief without medication risks 1

Patient education is essential and should explain the nature of osteoarthritis, realistic expectations, and self-management strategies. 1 Formal arthritis education programs reduce pain and improve coping skills. 1

Assistive devices and footwear modifications:

• Shock-absorbing shoes or insoles to reduce impact on affected joints 1
• Walking stick or cane to offload the affected ankle 1
• Open-backed shoes to reduce pressure on posterior heel spurs 1
• Accommodative padding for areas of bony prominence 1

Thermal modalities including local heat application (warm soaks, heating pads) before exercise enhance joint mobility and provide muscle relaxation and pain relief. 1, 2

First-Line Pharmacological Treatment

Topical NSAIDs (diclofenac gel) applied 3-4 times daily to the ankle and affected foot joints should be the initial pharmacological approach. 1, 2 Topical formulations provide benefit for mild to moderate osteoarthritis pain while minimizing systemic exposure, which is critical in elderly patients with potential comorbidities. 2

Alternative topical option: Capsaicin cream 0.025-0.075% applied 3-4 times daily after the initial burning sensation subsides. 1, 2 This provides pain relief through a different mechanism than NSAIDs. 1

Oral acetaminophen (paracetamol) at regular dosing (not as-needed) up to 3-4 grams daily should be considered before oral NSAIDs. 1 This is the safest systemic analgesic option in elderly patients. 1

Second-Line Pharmacological Options (If Topicals and Acetaminophen Insufficient)

Oral NSAIDs or COX-2 inhibitors should be used only at the lowest effective dose for the shortest possible period. 1 Critical considerations in elderly patients:

• All oral NSAIDs increase cardiovascular risk, cause fluid retention, and have gastrointestinal and renal toxicity 1, 2, 3
• NSAIDs cause fluid retention which can exacerbate heart failure 2
• Renal complications are particularly problematic in elderly patients 2, 4
• Patients over 65 have enhanced susceptibility to gastrointestinal and renal side effects 4
• Always co-prescribe a proton pump inhibitor with any oral NSAID or COX-2 inhibitor 1
• Avoid in patients with heart failure, renal impairment, or cardiovascular disease when possible 2, 3

Carefully titrated opioid analgesics may be preferable to NSAIDs in elderly patients with significant comorbidities that contraindicate NSAID use. 2 However, patients must be carefully selected and monitored due to inherent adverse effects including falls risk, constipation, and cognitive impairment. 5

Intra-Articular Injections

Corticosteroid injections (triamcinolone hexacetonide) into the ankle joint are beneficial for moderate to severe pain, especially with inflammation or effusion. 1, 2 These provide temporary relief lasting weeks to months and can be repeated every 3-4 months as needed. 1

Hyaluronic acid injections can be considered when pain is inadequately controlled by other measures, though evidence is mixed. 2, 5 These may provide longer-lasting relief than corticosteroids in some patients. 5

Important caveat: For plantar calcaneal spurs specifically, local corticosteroid injections into the plantar fascia insertion can be effective, but immobilization may be needed for refractory cases. 1

Immobilization for Acute Flares

Fixed-ankle walker boot or cast immobilization should be considered for acute exacerbations not responding to initial treatments within 2-3 months. 1 This allows the inflamed tissues to rest while maintaining some mobility. 1

Monitoring and Red Flags

• Assess for worsening edema or heart failure symptoms if systemic analgesics are used 2
• Monitor for gastrointestinal symptoms (nausea, black stools, abdominal pain) with NSAIDs 3
• Reassess pain regularly using standardized tools to guide treatment adjustments 2
• Serial monitoring of renal function if NSAIDs are continued long-term 2, 4

Surgical Referral Indications

Refer to orthopedic or podiatric foot and ankle surgeon when:

• Joint symptoms substantially affect quality of life and are refractory to 6+ months of comprehensive non-surgical treatment 1
• Severe mechanical symptoms develop 1
• Progressive functional decline despite optimal medical management 6

Surgical options for ankle osteoarthritis include periarticular osteotomies (early stages with malalignment), ankle arthrodesis, or ankle replacement (end-stage disease). 6 For symptomatic bone spurs, surgical resection may be indicated if conservative measures fail. 1

Common Pitfalls to Avoid

• Do not use glucosamine or chondroitin as evidence does not consistently demonstrate benefit 1
• Avoid electroacupuncture (insufficient evidence) 1
• Do not inject corticosteroids into the Achilles tendon as this increases rupture risk 1
• Do not prescribe NSAIDs without gastroprotection in elderly patients 1
• Avoid prolonged immobilization as this worsens muscle weakness and proprioception 1