Non-Surgical Treatments


Weight loss & activity modification
Weight loss is crucial in the non-operative management of ankle pain, whether from arthritis or something less severe like an osteochondral lesion. Due to the mechanics of the ankle joint, for every pound increase in weight your ankle feels approximately 2-3 pounds of force with each step. So losing 20 or 30 pounds can decrease the force across your ankle by 60-90 pounds!

A physiotherapist or personal trainer can guide patients through a low impact exercise regime to help attain their weight loss goals. Diet is crucial for weight loss especially in order to obtain and maintain the weight loss goal. Your family physician should be able to help you out with weight loss resources in the community.

Activity modification is also helpful temporarily or permanently when treating conditions of the ankle non-operatively. For example, running on an arthritic ankle will lead to further symptoms and degeneration so low impact activities such as cycle should be considered.

Physiotherapy
Physiotherapy is crucial for management of ankle pain. It works. Very often pain around the ankle is a result of imbalance of the muscles that support the core (abdomen & back), hips and knees. Physiotherapists are experts at assessing and treating these imbalances. Once a program is learned often it can be continued at home as part of your regular fitness regime 3-5 times per week.

Pain Medications
Over the counter pain medications can help a great deal with ankle pain. Traditionally, Tylenol (acetominophen) has been used as a first line treatment for arthritis pain, for example. However, recently there has been some question as to the value of Tylenol for arthritis pain and back pain. Some well-designed placebo controlled studies have shown minimal benefit of Tylenol when compared to placebo for arthritis pain.

Anti-inflammatory medications (NSAIDs) such as Advil (ibuprofen) are very useful to control both inflammation and pain. There are a number of products on the market, over the counter and prescription that can be suggested by your surgeon or family physician. They differ in their strength as well as their side effect profile. One over the counter medications that is stronger that Advil and you may find useful is Aleve (naproxen). If is similar to Advil but lasts longer. There are also prescription strength anti-inflammatory medications that you may want to discuss with your surgeon or family physician such as toradol, Vimovo or Celebrex, for example. There are also topical anti-inflammatory creams available that can allow for treatment of the pain/inflammation with less risk of systemic side effects.

There are some side effects to any medication but in particular with anti-inflammatories you should speak with your family physician if you have a history of ulcer, heart disease, high blood pressure or kidney problems, to name a few. Depending on your condition you may only need pain medications or anti-inflammatories for a short course. For example, an acutely inflamed knee without major internal injury may respond to a short course of anti-inflammatories and physiotherapy which limits the potential side effects of long term anti-inflammatory use.

Eventually, if the pain becomes more severe, it cannot be managed with over-the-counter medications or anti-inflammatories. Sometimes, stronger pain medications such as narcotics are required. These medications should be used as a last resort. There are many more side effects, and these medications can be quite addictive. A consultation with a surgeon is recommended if the pain is severe enough to require narcotic medications.

Glucosamine/Chondroitin
These supplements can be purchased in many supermarkets and health food stores. There is no good evidence in well controlled scientific studies of significant pain relief or improvement in function with use of these supplements. At this time there are no high quality scientific studies to demonstrate a significant effect of other natural medications on arthritic pain or function.

Bracing
Sometimes a simple brace can offer support to a painful ankle. Many patients can start by purchasing an inexpensive over the counter brace, and these braces can be quite helpful. However, in some cases, a patient may benefit from a custom brace. These braces are designed as stabilizing supports or unloading devices in order to offload some of the force across a painful joint. Ask your physician whether you are a candidate for a custom brace. These braces are quite expensive, but most extended health care plans will cover the majority of the cost.

Orthotics
Occasionally, orthotics can be helpful in treating painful feet, ankles, knees or hips. Deformities of the lower extremities such as flat feet or bowed legs can increase the stress on a painful joint. Proper foot wear and orthotics can help manage some of the pain. Ask your physician whether you are a candidate for custom foot orthotics or a change in footwear.

Injections
There are different types of injections that can be provided to help manage your pain. Depending on the type and severity of your condition, injections can have variable effectiveness. Ask your physician whether you may benefit from different types of injections.

a) Corticosteroids
These “steroid” injections can be very useful to help treat joint pain. The benefits from a steroid injection are generally short lived. Patients usually notice pain relief for approximately 3-8 weeks. These injections can be useful if you have an important event coming up or a holiday where you may need quicker, but short term pain relief. In an non-arthritic ankle, repeated injections should be avoided and injections should not be provided at greater than 3 or 4 month intervals.

b) Viscosupplementation (Hyaluronic Acid)
These injections are like a lubricant that is put directly into the joint. They contain hyaluronic acid which is a natural substance found in a healthy joint. There are many studies showing the benefits of viscosupplementation in a degenerative joint. Up to three quarters of patients notice some benefit. Repeat injections can be done when the pain starts to return. Patients usually notice 3-6 months of pain relief, but some patients notice improvement for longer periods of time.

Unfortunately, the cost of these injections are not covered under the medical services plan. Depending on the brand of injection material used, the cost can range from $350-$550. Most extended health care plans will cover the majority of the cost.

c) Platelet Rich Plasma (PRP)
There are many studies documenting the effectiveness of PRP when treating joint pain as a resulting of degenerative change. The doctor is injecting a high concentration of your own platelets into the joint. Platelets are a normal component of blood, and they assist with blood clotting. However, they also contain many growth factors that can help with pain relief in degenerative or painful joints. Many studies show the pain relief with PRP can be similar to the results achieved with injection of hyaluronic acid.

The procedure involves the drawing of a blood sample from the patient. The blood is then spun in a device called a centrifuge. This separates the components of the blood. The doctor will then take the platelets from this sample and inject it into the joint. Patients must avoid anti-inflammatory agents, such as Advil and aspirin for at least a week prior to their injection as these medications can deactivate the platelets.

PRP is also not covered under the medical services plan. The costs range from $500-$650. Some extended health care plans will cover the cost of this treatment.

d) Stem Cell Treatment
The use of stem cells to treat joint disease is a relatively newer treatment available to patients. At this time, this is not offered locally. Some patients travel to the US to pursue stem cell treatment. Talk to your doctor to see if you are a candidate. There are no long term studies documenting the benefits of this treatment. Early results seem promising, but more research is needed. These injections are very expensive (e.g. $4000-8000 USD) and with limited data caution should be used prior to investing in this treatment.

Risks or Complications
Whenever a doctor uses a needle to inject a substance into a joint, there are potential risks. There is a risk of infection, but luckily the risks are very small. After any injection, some patients notice an increase in pain and swelling for a very short period of time. This is usually normal. However, if the pain and swelling are quite severe, there are difficulties with bending or standing on the leg, there is redness, or a fever develops then this is ABNORMAL. This is a sign that an infection is developing and you should go to an emergency department right away.

Some patients develop local reactions to the substance that was injected into the joint. Some patients can experience allergic reactions to various hyaluronic acid injections. These reactions are very rare.