Ankle osteoarthritis: an online survey of current treatment practices of UK-based podiatrists and physiotherapists

Ankle pain has been estimated to account for around 3% of primary care consultations in adults aged over 50 years with those aged 71–80 years placing the greatest burden on GPs [1]. The population prevalence of symptomatic radiographic ankle osteoarthritis (OA) in the over 50 s is 3.4% [2]. Post traumatic (PT) OA is the predominant form of OA in the ankle, accounting for 70% of cases, followed by rheumatoid arthritis (12%) and primary/idiopathic OA (7%) [3].

Ankle OA is highly problematic with severe pain being the most disabling symptom, resulting in a substantial negative impact on a person’s physical and mental wellbeing [4]. Many people with ankle OA described their pain in emotive terms such as ‘terrible’ and ‘horrendous’ [4]. It is known that mental and physical disability from ankle OA is at least as severe as in those with end-stage hip OA [4].

International clinical guidelines recommend non-pharmacological interventions such as exercises and weight loss as first-line management for OA, regardless of joint site [5, 6]. In the UK, physiotherapists and podiatrists provide non-surgical treatment for ankle OA within the NHS or in private practice. Whereas several evidenced-based non-surgical management options for clinicians and patients are available for other joints [7], specific evidence for ankle OA interventions is sparse and people with ankle OA report mixed experiences of non-surgical management [4]. Extrapolating recommendations from other joints may not be appropriate and there is a lack of guidance for clinicians on treatment best practices [4]. We undertook a survey of UK-based physiotherapists and podiatrists to understand better how painful ankle OA is managed in current clinical practice.

Between 1^st June to 31^st August 2021, there were 506 views on the survey homepage, from which 100 responses were received. Two were invalid due to one respondent not being a UK resident and another not managing people with ankle OA. Of the 98 valid responses, 63 (64%) were from physiotherapists and 35 (36%) from podiatrists; 80 (82%) practised in England. Forty-nine (50%) of the respondents worked in the NHS, 34 (35%) in private practice, and nine (9%) in both the private and NHS sectors. The highest qualification was a diploma for 15 respondents (15%), a bachelor’s degree for 37 (38%), a master’s level qualification for 42 (43%) and a PhD for four (4%). Fifty respondents (51%) offered 3 or 4 treatment sessions and 53 respondents (54%) saw patients for 30–40 min at the first treatment session. Fifty (51%) of respondents treated one patient per week with ankle OA, 24% saw four or more patients (Table 1). Referrals were most commonly from general practitioners (n = 69, 70%) and orthopaedic surgeons (n = 66, 67%) (Table 1). Just under half the respondents (49%) worked in a multi-disciplinary team.

Pain reduction (n = 87, 89%) and improving quality of life (n = 82, 84%) were the most frequent treatment aims. Several outcome measures were used, most commonly patient satisfaction (n = 62, 63%) or a visual analogue scale (n = 51, 52%) or a numerical rating scale (n = 42, 43%) to measure pain. Physiotherapists and podiatrists relied upon various features to diagnose ankle OA, the three most common were reduced ankle range of motion (n = 90, 92%), the site of pain (n = 81, 83%), and imaging (n = 85, 87%) (Table 1).

The five most common modalities used by physiotherapists were patient education (n = 63, 100%), teaching self-management (n = 58, 92%), lifestyle modification (n = 54, 86%), ankle strengthening (n = 55, 87%), and proprioception exercises (n = 54, 86%) (Figs. 1, 2 & 3 and Table 2). For podiatrists, these were patient education (n = 35, 100%), ankle strengthening (n = 31, 89%), activity pacing (n = 28, 80%), lifestyle modification (n = 27, 77%), and gait training (n = 27, 77%) (Figs. 1, 2 & 4 and Table 2). Less than 30% of respondents in either professions opted for ankle bracing or taping as usual care. Physiotherapists used the treatment options of proprioception (p = 0.003), hip strengthening (p = 0.007), hydrotherapy (p = 0.031), self-management (p = 0.001) significantly more often than podiatrists. Taping (p = 0.025), bracing (p = 0.04), orthotics (p = 0.002), referral for surgery (p = 0.029), and corticosteroid injections (p = 0.004) were used significantly more often by podiatrists than physiotherapists.

This is the first survey to assess and compare current practice in managing ankle OA amongst physiotherapists and podiatrists in the UK. There is little guidance currently available to help allied healthcare professionals plan an evidence-based management plan of usual care for managing this condition; most guidance is for knee OA and hip OA.

Both professions always or usually used patient education, lifestyle modification, and ankle strengthening exercises, with physiotherapists additionally using self-management and proprioception exercises, whereas podiatrists additionally used activity pacing and gait training. Outside of these five, other commonly used ways to manage ankle OA by physiotherapists were hip strengthening (58%) and by podiatrists were orthotics (73%) and self-management (64%) (Table 2). These treatment choices align with the top three treatment aims in both professions to reduce pain, improve quality of life, and teach self-management. This consensus concurs with many general OA guidelines, such as National Institute for Health and care Excellence (NICE [6], and Osteoarthritis Research Society International (OARSI) which includes patient education, exercise and self-management [7] as core treatment options, although these guidelines are not specific to ankle OA. Additionally, our survey results align with the treatment research agenda from an international foot and ankle OA consortium which recommended understanding usual care of foot and ankle OA to inform the design of control interventions in clinical trials [8]. It is also in line with the modern rehabilitation model for chronic pain which suggests using education to improve the effectiveness of other treatment options, and adding active/self-management techniques as a part of usual care [9].

Some of the treatment options reported by physiotherapists suggest they extrapolated evidence from other joint sites and applied to ankle OA. Hip strengthening was commonly used by physiotherapists (58%) but not podiatrists (27%), which does not align with a systematic review recommending hip strengthening for the conservative management of knee OA but not ankle OA [10]. There were several treatment options which were used sometimes, rarely or never by physiotherapists or podiatrists including hydrotherapy, electrotherapy, dry needling/acupuncture, taping, and intra-articular injections of visco-supplementation or platelet-rich plasma (PRP). Possible reasons include lack of access to hydrotherapy, contradictory OA guidelines by NICE [5] and OARSI [7] about acupuncture for OA, a lack of injection skills, and either the limited availability of visco-supplementation products or PRP in the NHS or a lack of supporting evidence. The observation that few physiotherapists (4%) and podiatrists (15%) used electrotherapy to treat ankle OA contrasts with NICE [5] and OARSI [7] guidelines recommending transcutaneous electrical nerve stimulation (TENS) to alleviate pain. Less than a third of respondents in either professions opted for ankle bracing or taping as usual care. This is surprising, particularly with physiotherapists, since taping is commonly used to reduce ankle range of motion and improve joint stability [11]. The aim of ankle braces is similar [12] but the low uptake of bracing might be due to the survey not specifying the stage of ankle OA clinicians should consider when responding to these questions. It might be that some clinicians only consider ankle bracing in end-stage ankle OA. Orthotics were used significantly more by podiatrists (73%) than physiotherapists (37%), consistent with the finding of a survey of physiotherapists’ and podiatrists’ treatment of plantar fasciitis that foot orthotics were considered the specialist role of podiatrists [13]. It is possible that physiotherapists refer to other services for orthotics but our survey did not distinguish those fitting orthotics themselves and those referring to podiatric or orthotic services. The use of footwear, as opposed to orthotics, was not available as a treatment option in the survey and it is possible that respondents may have opted for this if it had been available. Interestingly, despite podiatrists being asked to contribute at the survey’s development stage, a ‘footwear’ option was not suggested and so was not included in the final version. Although this survey provides data from physiotherapists and podiatrists as to what is current practice for ‘usual care’ in ankle OA, this has not yet been robustly assessed for its efficacy and should be the target for future funding applications.

A survey on the management of foot and ankle OA by GPs in Australia found that pharmacological management was favoured over active and self-management techniques [14]. Our survey found medications were used by nearly half of both physiotherapists and podiatrists. There are approximately 1400 physiotherapists and 450 podiatrists registered as independent or supplementary prescribers in the UK. [15], but we did not ask whether medications were prescribed directly by the physiotherapist or podiatrist, or whether the patient was required to see another healthcare professional to obtain a prescription.

This study had some limitations. Only UK-based practitioners were included, limiting the generalizability of our findings. Our response of 98 is smaller than the 191–293 physiotherapists or podiatrists who responded to electronic surveys of the management of other musculoskeletal conditions [15‐18]. It is not possible to establish the exact response to the study owing to its online nature and the denominator who saw the survey invitation being unknown. This study did not identify the length of participants’ clinical experience which might have influenced responses if some treatments such as prescribed medications or intra-articular injections would be more likely be administered by more experienced practitioners. However, just over a third of physiotherapists and half of podiatrists had a master’s degree as their highest qualification which suggests a level of seniority and experience amongst many respondents and the possibility of bias towards these more advanced treatments. We did not make a distinction between foot orthoses, ankle orthoses and ankle foot orthoses (AFOs). Some clinicians might interpret these terms differently from our intended interpretation of an insole type of support. Lastly, due to the small sample sizes in each group, no comparison was made between private and NHS practice, nor in the practice between different countries of the UK.

The current practice for managing ankle OA amongst physiotherapists and podiatrists has been surveyed in the UK for the first time. The most common treatment aims in both professions were to reduce pain and improve quality of life. The most common treatment programme comprised 3–4 sessions, each lasting 30–40 min. The five most common modalities currently used by physiotherapists were patient education, self-management, lifestyle modification, ankle strengthening, and proprioception exercises. For podiatrists, the five most common were patient education, ankle strengthening, activity pacing, lifestyle modification, and gait training. This study provides a better understanding of how ankle OA is treated in current clinical practice and can inform future clinical trials to assess usual care and compare this with new treatment modalities.