Review Question - QID 218575

In a patient with persistent ankle pain after an inversion injury without ligamentous laxity, the most likely diagnosis is an osteochondral lesion of the talus (OLT).

OLTs are focal injuries to the talar dome. Lateral talar dome injuries are typically from acute trauma, whereas medial talar dome injuries are from overuse. Radiographs are typically the first step in management. Recent studies have shown that the lack of talar tilt on stress radiographs is inversely related to OLTs after ankle inversion injuries. The diagnosis is typically confirmed on MRI. Treatment ranges from non-operative for stable lesions, to cartilage restoration for larger or unstable lesions. Possible cartilage restoration techniques include microfracture, osteochondral autograft or allograft, cell-based repairs, and orthobiologic administration.

Park et al. reviewed 195 patients with a history of ankle inversion history to determine the relationship between ankle instability and OLTs. Radiographs and MRI were obtained on all patients. They found an inverse relationship between the amount of talar tilt on stress radiographs and the presence of an OLT on MRI. They suggest that bony constraint plays a role in the formation of OLTs.

Looze et al. provided an overview of the evaluation and management of OLTs. They state that many patients have a history of ankle sprain or fracture. Symptomatic nondisplaced lesions can be treated conservatively. Small lesions have favorable outcomes with microfracture. Many other treatments are possible for larger or uncontained lesions such as osteochondral autograft or allograft, cell-based repairs, and biologic adjuncts.

Incorrect Answers:
Answer 1: Tarsal coalitions may present with a history of ankle sprains but are unlikely in this patient with subtalar motion.
Answer 3: The anterior talofibular ligament is the most commonly injured ligament in ankle sprains. It would present with drawer laxity in plantarflexion.
Answer 4: Sprain of the calcaneofibular ligament is the second most injured ligament in ankle sprains but would present with laxity in dorsiflexion anterior drawer testing.
Answer 5: Tearing of the superior peroneal retinaculum causes peroneal tendon instability but would not cause an ankle effusion.