Osteochondral lesions of the ankle

In summary: an osteochondral lesion is damage to the cartilage of the talus, often following a sprain, which explains persistent ankle pain that fails to resolve. Diagnosis and treatment decisions require clinical judgement; a second opinion is highly beneficial. In Martorell, Barcelona (Teknon) and Igualada.

Osteochondral lesions of the ankle affect the cartilage and the underlying bone, almost always in the talus. They are one of the reasons why a sprain “that should have healed” continues to cause pain months later. Cartilage covers the joint surfaces and facilitates smooth, low-friction movement. When injured, it can also irritate the underlying bone and cause persistent discomfort.

Why it is important to consider it

The warning sign is clear: an ankle that, following a sprain, maintains deep pain, intermittent swelling or a sensation of locking. Recognising this prevents months of treatments that do not address the root cause. Diagnosis is completed with an MRI scan, and treatment depends on the size and stability of the lesion: ranging from conservative management and ultrasound-guided injections to arthroscopic surgery in cases that require it. Due to its complexity, a second opinion with the relevant imaging studies to hand is usually very helpful.

Not all lesions appear after a clear trauma. A direct impact or a twist can damage the cartilage directly, but repeated trauma, sporting overload or altered ankle stability can also play a part. In some cases, the lesion is detected whilst investigating pain of a less obvious cause.

What symptoms it may cause

The pain is usually felt on the inside or deep within the ankle, especially when bearing weight, running, jumping or walking downstairs. It may not be easy to pinpoint with a finger. Swelling after activity, stiffness, discomfort when turning the foot or a feeling that the joint is giving way may also occur.

Some people describe clicking, catching or locking. These symptoms alone do not confirm an osteochondral lesion, as they can appear in other ankle problems. It is therefore important to correlate what you are experiencing with the physical examination and imaging studies, particularly if the pain persists despite having treated the initial sprain.

How it is diagnosed

During the consultation, we review how the pain started, whether there was a sprain, what activities trigger it and how it has evolved. We also examine mobility, swelling, ligament stability, tender points and gait. Comparing it with the other ankle can provide useful information.

X-rays allow us to assess the bones, alignment and some indirect signs, but the cartilage is not always clearly visible. Ultrasound can be useful for assessing tendons, ligaments and other superficial structures, and also for guiding certain procedures when indicated. MRI helps evaluate the cartilage, the underlying bone and any associated lesions. In selected cases, the assessment may be completed with a computed tomography (CT) scan.

Depending on the case, we also analyse foot posture and biomechanics. It is not a necessary test for everyone, but it can help determine if there is an overload or axial misalignment contributing to the symptoms. The size, location and, above all, the stability of the lesion are important factors in deciding the treatment.

What treatment options are available

Treatment is approached in a progressive and individualised manner. If the lesion is stable and symptoms allow, it can begin with a temporary reduction in activities that provoke pain, regaining mobility and physiotherapy. Strengthening and ankle control are also addressed, especially if there is instability following repeated sprains. In some cases, an orthosis or a plantar support is considered, in accordance with the examination.

Ultrasound-guided injections may form part of the treatment in specific situations, but they are not automatically necessary nor do they repair all lesions. It is essential to explain beforehand what their objective is and whether they fit the diagnosis. Progress is monitored based on symptoms and, when necessary, with further imaging.

If pain persists, the lesion is unstable or there is a loose fragment interfering with movement, surgery may be considered. Surgery is usually performed using arthroscopic techniques to inspect the joint and treat the defect according to its characteristics. The specific procedure is not the same for everyone: it may include debridement of the damaged tissue or techniques aimed at stimulating repair, among other options.

The surgical indication depends on age, activity level, the condition of the cartilage, the presence of instability and other foot or ankle conditions. Surgery should not be decided based solely on an imaging scan. It is important to assess whether what is seen truly explains the pain and to discuss the objectives, alternatives and recovery process before making a decision.

When to seek a consultation

Request an assessment if the pain continues after a sprain, if the ankle swells repeatedly, locks or limits your usual activities. It is also advisable to consult if you have repeated episodes of instability or if previous tests do not explain your symptoms. Bringing your X-rays, MRI scans and previous reports facilitates a more comprehensive case review.