Przejdź do treściAn osteochondral lesion of the talus is damage involving the articular cartilage and the bone immediately beneath it. It often becomes apparent after an ankle sprain as deep joint pain that does not settle within the expected time. Recurrent swelling, catching or locking may also occur. Standard X-rays can be normal, so persistent symptoms may require more detailed imaging—most often MRI and, in selected situations, CT.
Not every osteochondral lesion requires surgery. Management depends on the size and depth of the defect, the condition of the subchondral bone, fragment stability, duration of symptoms, age and activity level, and whether ankle instability is also present.
What does “osteochondral lesion” mean?
The surface of the talus is covered by cartilage that forms a smooth part of the ankle joint. An injury can damage cartilage alone, cartilage together with the underlying bone, or create an osteochondral fragment. In some cases, a cyst develops in the bone beneath the lesion.
These injuries are commonly abbreviated as OLT, for osteochondral lesion of the talus. Finding an OLT on imaging is not, by itself, enough to determine treatment. The key question is whether the lesion actually explains the patient’s symptoms.
When should cartilage injury be suspected after an ankle sprain?
A typical ankle sprain should gradually improve. If deep pain inside the joint persists despite appropriate treatment—particularly with weight bearing, running, descending stairs or twisting movements—it is worth considering causes other than ligament injury alone.
Symptoms that may accompany an osteochondral lesion include:
- persistent or recurrent ankle pain after injury,
- pain felt deep within the joint rather than only around the lateral or medial malleolus,
- swelling after greater activity,
- catching, clicking or intermittent locking,
- restricted motion,
- difficulty returning to running or sport despite improvement in ligament stability.
If the problem began with a recent sprain, the initial assessment still needs to address the ankle injury as a whole. See: Ankle Injuries.
How is an osteochondral lesion of the talus diagnosed?
Clinical examination
The examination considers the location of pain, range of motion, swelling, ligament stability, foot and ankle alignment, and any mechanical symptoms. This matters because similar complaints can result from chronic instability after a sprain, syndesmotic injury, impingement, tendon disorders or degenerative joint disease.
X-ray
Radiographs are often the first imaging test, especially after injury. They may show a larger bony defect, a loose fragment, evidence of previous trauma or degenerative change. A normal X-ray does not exclude an osteochondral lesion, particularly when the defect is small or predominantly cartilaginous.
MRI
MRI provides useful information about cartilage, bone-marrow oedema, joint fluid, ligaments and other intra-articular structures. It is particularly helpful when pain persists despite normal radiographs or when associated injuries need to be assessed.
CT
CT depicts the bony architecture in detail, including the size of the osseous defect, cysts and fragment morphology. It may be useful before surgery or when the principal diagnostic question concerns the bony component of the lesion.
Is ultrasound enough?
Ultrasound is not the primary test for a complete assessment of cartilage over the talar dome because much of the articular surface lies deep within the joint and is obscured by bone. It can, however, help assess associated effusion, ligaments, tendons and other superficial structures. A normal ultrasound therefore does not exclude an OLT.
Does every lesion need surgery?
No. For a stable lesion without a loose fragment or another urgent indication, non-operative treatment is often a reasonable first step. This may include modifying activity and loading, temporary unloading or stabilisation in selected cases, and a progressive exercise programme to restore movement, strength and ankle control. Coexisting chronic instability should be addressed as part of the treatment plan.
In a prospective study of 40 patients involving 42 ankles, clinically meaningful improvement in pain while walking was achieved by 38% of patients after one year of non-operative treatment. The mean improvement for the group as a whole remained below the threshold considered clinically important, but lesion size on imaging did not increase during the one-year follow-up. This illustrates two points: conservative management can be a sensible first option for appropriately selected patients, but it will not provide sufficient improvement for everyone.
When does an orthopaedic surgeon consider surgery?
Surgery is considered mainly when symptoms persist despite appropriately conducted non-operative treatment, when significant mechanical symptoms are present, when a fragment is unstable, or when the characteristics of the lesion favour repair from the outset.
There is no single operation that suits every osteochondral lesion. Depending on the situation, options may include:
- arthroscopic debridement with stimulation of subchondral healing for selected small lesions,
- fixation of a preserved osteochondral fragment when its quality and morphology allow stable repair,
- osteochondral grafting or other restorative techniques for larger, deeper or previously unsuccessfully treated lesions,
- bone grafting when there is a substantial cyst or osseous defect.
The latest international consensus on moderate-to-large lesions emphasises that the choice between reparative and restorative procedures still relies partly on expert judgement because high-quality head-to-head trials of many techniques are lacking. Lesion size matters, but it should not be the only criterion used to choose an operation.
Can an osteochondral fragment be fixed rather than removed?
In selected cases, yes. If there is a sufficiently large and viable osteochondral fragment, fixation may be considered to preserve the native joint surface. A systematic review of 10 studies involving 241 ankles reported high rates of union and clinical improvement after fixation, but most of the evidence came from non-comparative studies. These results therefore do not prove that fixation is superior to all other treatment options.
What influences treatment selection?
- lesion size and depth,
- the presence of a subchondral cyst,
- stability and quality of an osteochondral fragment,
- lesion location,
- time since injury and previous treatment,
- age, activity level and patient expectations,
- ankle instability, limb alignment and other associated pathology.
For that reason, two patients with very similar MRI reports may require quite different management.
When is urgent assessment needed?
- the ankle is locked and cannot move freely after an injury,
- the limb cannot be loaded after a recent injury or there is obvious deformity,
- the foot becomes cold, pale or blue, or increasing numbness develops,
- the joint becomes hot, markedly swollen and red, particularly with fever,
- pain is rapidly worsening rather than gradually settling.
Common questions
Does an osteochondral lesion always occur after a sprain?
No, although ankle trauma is common in the clinical history. The lesion may become apparent immediately, or only later when deep weight-bearing pain persists after an apparently healed sprain.
Does a normal X-ray exclude cartilage damage?
No. Small osteochondral lesions may not be visible on standard radiographs. If symptoms persist, MRI or CT may be requested depending on the specific diagnostic question.
Is an MRI finding alone an indication for surgery?
No. The decision should integrate symptoms, clinical examination and imaging characteristics. An asymptomatic or incidental lesion is not the same clinical problem as an unstable fragment causing pain and mechanical locking.
Back to: Foot and Ankle Conditions
References
- Buck TMF, Steman JAH, Dahmen J, et al. Nonoperative Treatment for Osteochondral Lesions of the Talus Provides Clinical Improvement in the Minority of the Patients at Short-term Follow-up. Foot Ankle Int. 2025;46(7):699-706. DOI: 10.1177/10711007251330881.
- van Bergen CJA, Baur OL, Murawski CD, et al. Diagnosis: History, Physical Examination, Imaging, and Arthroscopy: Proceedings of the International Consensus Meeting on Cartilage Repair of the Ankle. Foot Ankle Int. 2018;39(1 Suppl):3S-8S. DOI: 10.1177/1071100718779393.
- Rubin J, et al. Surgical Intervention for Moderate-To-Large Lesions (1-2.9 cm²): Proceedings of the International Consensus Meetings on Cartilage Repair of the Ankle. Foot Ankle Spec. 2026. DOI: 10.1177/19386400261456897.
- Rikken QGH, Dahmen J, Stufkens SAS, Nakasa T, Kerkhoffs GMMJ. Fixation for osteochondral lesions of the talus leads to successful clinical outcomes in 9 out of 10 patients: A systematic review. J ISAKOS. 2025;11:100389. DOI: 10.1016/j.jisako.2025.100389.
This material is educational. Investigation and treatment should be selected from the clinical examination and the individual characteristics of the lesion.
Content prepared by: Tomasz Poboży - orthopaedic surgeon.