Ultrasound guided ankle steroid injections

What is ankle osteoarthritis?

Ankle osteoarthritis is a degenerative condition characterised by the thinning or loss of the special protective tissue lining the bone surfaces at the joints (the articular cartilage). This is sometimes associated with inflammation of the thin layer of cells lining the joint surface (synovium). The inflammation process here is called synovitis and can result in acute episodes of joint pain, swelling and restriction of movement. Osteoarthritis is one of the most common conditions in our practice, reported to affect approx. 15% of people around the world.

Relevant ankle joint anatomy

The main ankle joint is formed by three bones: the tibia, fibula, and talus. It is responsible for both upward and downward movement of the foot, known as dorsiflexion and plantarflexion. Articular cartilage lines the joint, providing smooth and frictionless movement. Adjacent to the main ankle joint are two other joints. The higher one is called the inferior tibiofibular joint and ensures stability between the tibia, fibula, and ankle. The lower joint is formed by the articulation between the talus and calcaneum and is responsible for the inward and outward movement of the foot, called “the subtalar joint”.

What are the risk factors for ankle osteoarthritis?

There is no definitive cause of osteoarthritis; however, there are some recognised risk factors:

Previous injury. Approximately 75% of ankle osteoarthritis cases have a history of previous injury. These could be fractures that extend to the joint surface or injuries to the ligaments of the ankle resulting in joint instability and osteoarthritis.
Excessive sports activities (like football) can put extra stress on the joint and predispose to osteoarthritis.
Age. The incidence of osteoarthritis, in general, increases with age.
Increased body mass index (BMI).
Altered foot or ankle mechanics. Changes in foot or ankle mechanics can occur due to developmental problems such as tarsal coalition or acquired problems like tendinosis. These changes can affect the foot's biomechanics, increasing stress on the ankle joint.
Conditions that can alter foot mechanics and contribute to ankle arthritis include:

What are the features of ankle osteoarthritis?

Ankle osteoarthritis symptoms include:

Ankle pain. This can be felt as deep dull pain or ache within the joint. Occasional flares with more intense and sharp pain can also happen, usually due to synovial tissue inflammation episodes (synovitis).
Ankle joint swelling.
Ankle stiffness, particularly after periods of rest or inactivity.

How to tell if I have ankle osteoarthritis?

The typical history is a dull joint ache that develops slowly over a few years. Although the pain may start intermittently, it can persist as the condition worsens. Joint swelling can occur, especially after physical activity, and stiffness may be felt after rest.

Ankle osteoarthritis vs subtalar joint osteoarthritis

Subtalar joint arthritis typically arises below and at the outer aspect of the ankle joint. It can be associated with inflammation within a small adjacent space called the sinus tarsi. Differentiating the two conditions can be challenging. Imaging (like X-ray and MRI) can be useful for the assessment. In addition, performing staged ultrasound-guided injections (to the ankle joint and, if necessary, to the subtalar joint) is useful in differentiating the two conditions. Ultrasound guidance ensures accurate delivery of the medicine to the exact targeted site.

How to diagnose ankle osteoarthritis?

Ankle osteoarthritis is initially suspected after clinical assessment by a foot specialist. Imaging is vital in diagnosing and ruling out other causes of ankle symptoms. The initial test would be an ankle X-ray. This can provide the diagnosis and assess the severity of the arthritis. Your GP can request an X-ray, which can be promptly performed in most NHS clinics or hospitals. In addition, your doctor may order specific blood tests to assess for different types of arthritis, such as inflammatory arthritis (rheumatoid arthritis being the most common example), or other conditions, such as gout. More advanced imaging, such as MRI, can be used if the X-ray doesn't confirm the diagnosis.

What is the treatment for ankle osteoarthritis?

Like other degenerative joint conditions elsewhere within the body, treatment for ankle osteoarthritis starts with conservative management, including activity modification and physiotherapy. The latter aims to maintain muscle strength and joint movement. Other measures to reduce joint inflammation, like ice packs and anti-inflammatory tablets like ibuprofen, can also be used.

Can I have a steroid injection for ankle arthritis?

Cortisone is a potent anti-inflammatory medication commonly used to manage symptoms of osteoarthritis. Its anti-inflammatory properties effectively manage synovitis and reduce joint pain and swelling.

Indications for an ankle steroid injection include:

Pain that interferes with sleep.
Pain that limits your daily activities
Severe symptoms that are preventing you from achieving effective rehabilitation.

What are the available injections for ankle arthritis?

Ultrasound guided ankle steroid injections

We advise performing ankle joint injections under ultrasound guidance. This ensures accurate delivery of the medicine to the inflamed joint. Evidence shows that ultrasound-guided injections result in better pain relief, fewer side effects and better improvement in function compared to non-guided injections.

Ultrasound-guided ankle Hyaluronic acid injection.

Hyaluronic acid is a substance that simulates the natural lubricant fluid within the joint. Hyaluronic acid injections have been proven effective in reducing joint pain and swelling, especially for physically active individuals with a normal body mass index. Using ultrasound guidance, similar to corticosteroid injections, ensures accuracy and efficacy.

Frequently asked questions about Ankle steroid/cortisone injections.

What is a cortisone injection?

Cortisone is a strong anti-inflammatory medicine routinely used to manage inflammatory conditions (like bursitis and arthritis). It reduces the inflammation in the injected area (for example, the ankle joint) and allows for effective rehabilitation. To learn more, please see our FAQs.

Should ankle joint injections be done using ultrasound guidance?

This is our routine practice, as plenty of evidence supports ultrasound guidance when performing injections into joints. Performing ankle injections under ultrasound/imaging guidance allows for direct visualisation of the needle to ensure accurate placement into the area of pain/inflammation. Ultrasound guidance results in more accurate, less painful, and faster procedures, with better outcomes than these injections without guidance. Ultrasound guidance avoids sensitive structures (like nerves and vessels) during the procedure.

How long will the effect of a cortisone injection last?

Current evidence suggests that cortisone can improve pain and function for up to 3 months, but in some cases, it can last longer. Pain relief duration depends on the condition's diagnosis and severity. The steroid injection will provide a window of opportunity to undergo effective rehabilitation and attempt to address the underlying cause to enhance the pain relief achieved from the injection.

How soon will a steroid injection start to work?

A steroid injection usually takes a few days (1-3) before you notice the effect, although sometimes the pain relief can start on the same day. The injected area will often feel sore for the first few days. This is referred to as (steroid flare) and can be seen after a steroid injection.

Do steroid injections just hide/mask the pain?

Steroid injections do not just mask or hide the pain, but they act by reducing the inflammation in the targeted area, thus providing a strong and local anti-inflammatory effect to help control the symptoms and allow the patient to manage the condition, usually by undergoing effective rehabilitation.

How many steroid injections can I have?

If possible, we advise reducing the number of cortisone injections by combining any injection therapy with an effective physiotherapy programme to address the underlying cause. Repeated steroid injection into the same area should be avoided if the previous injection was less than 3-4 months ago.

What if injection therapy is not helping?

In cases of significant osteoarthritis affecting the ankle joint and failing ultrasound-guided injection treatment, you may require a surgical referral to a specialist foot and ankle orthopaedic surgeon to discuss the surgical treatment options.