What is the most common cause of ankle pain in adults aged 65 years and older?

Most Common Cause of Ankle Pain in the Elderly

Osteoarthritis is the most common cause of ankle pain in elderly patients, with post-traumatic osteoarthritis being the predominant form affecting the tibiotalar joint. 1, 2

Epidemiology and Etiology

• Post-traumatic osteoarthritis represents the most frequent etiology of ankle osteoarthritis, distinguishing it from other weight-bearing joints where primary osteoarthritis predominates. 1, 2
• Osteoarthritis affects 50% of adults aged 65 and older, increasing to 85% in those 75 and older, though these statistics primarily reflect knee and hip involvement. 3
• The ankle joint is less commonly affected by primary osteoarthritis compared to knees and hips, but when ankle arthritis occurs in the elderly, it is typically secondary to previous traumatic injury. 1, 2

Clinical Presentation and Diagnosis

• Joint pain and dysfunction from substantial joint degeneration characterize ankle osteoarthritis, with symptoms potentially being independent of radiographic severity in many older adults. 1, 4
• Look for a history of prior ankle trauma (fractures, severe sprains, or ligamentous injuries) as the precipitating event, which may have occurred years or decades earlier. 1, 2
• Morning stiffness lasting less than 60 minutes that improves with activity suggests osteoarthritis rather than inflammatory arthritis. 3

Important Differential Considerations

• Always consider referred pain from the hip or lumbar spine when evaluating ankle pain, particularly if ankle radiographs are unremarkable. 5
• Rule out septic arthritis if there is joint effusion, warmth, erythema, or systemic signs before initiating any corticosteroid therapy. 6
• Gout commonly affects the first metatarsophalangeal joint but can involve the ankle; pseudogout may also affect the ankle joint. 7
• Inflammatory arthritis (rheumatoid arthritis) typically presents with bilateral symmetrical small joint involvement and morning stiffness exceeding 60 minutes. 3, 7

Management Approach

First-Line Non-Pharmacologic Interventions

• Initiate patient education about joint protection, strengthening exercises targeting ankle and lower extremity musculature, and aerobic fitness training as tolerated. 3
• Weight loss is critical for overweight patients, as obesity increases joint loading and accelerates cartilage damage. 3, 5
• Bracing, shoe wear modifications, and orthotic devices that correct alignment can improve joint position sense and reduce mechanical stress. 5, 2

Pharmacologic Management

• Start with topical NSAIDs as first-line pharmacologic therapy, particularly in patients ≥75 years old where topical agents are strongly preferred over oral NSAIDs. 6
• Add oral NSAIDs (naproxen 500 mg twice daily or meloxicam 7.5–15 mg daily) only if topical therapy fails to achieve adequate pain control after 2–4 weeks. 6

Injection Therapy

• Consider intra-articular corticosteroid injection for acute exacerbations with effusion when oral/topical analgesics provide inadequate relief after 2–4 weeks of optimized therapy. 6
• Always aspirate and analyze synovial fluid before injecting corticosteroids to exclude infection. 6
• Limit injections to no more than once every 3 months, with a maximum of 3–4 injections per joint per year to minimize cartilage damage risk. 6

Surgical Options

• For end-stage ankle arthritis unresponsive to conservative measures, the two primary surgical options are total ankle arthroplasty and ankle arthrodesis (fusion). 2
• Key surgical risks include early implant loosening requiring revision after arthroplasty and acceleration of adjacent joint degeneration after arthrodesis. 2

Critical Pitfalls to Avoid

• Never administer corticosteroid injections without first excluding septic arthritis; failure to do so can lead to devastating outcomes. 6
• Do not attribute all ankle pain to local pathology without evaluating the hip and lumbar spine, as referred pain is common. 5
• Avoid dismissing osteoarthritis symptoms as "normal aging"—symptomatic osteoarthritis requires active management to prevent functional decline. 3
• Do not use medications alone as primary therapy; always combine pharmacologic interventions with non-pharmacologic measures. 3