Osteochondral Lesion of the Talar Dome

Injuries > Ankle > Osteochondral Lesion of the Talar Dome

(Also known as Talar Dome Lesion, Osteochondral Lesion, Osteochondral Fracture, Osteochondral Defect)

What is an osteochondral lesion of the talar dome?

An osteochondral lesion of the talar dome is a condition characterized by damage to the cartilage and / or bone surfaces of the upper (superior) aspect of the talus bone (i.e. the talar dome) in the ankle.

The ankle joint is formed by the articulation of the tibia, fibula and talus bones (figure 1). In a normal ankle, joint surfaces are smooth and there is cartilage between the bone ends which allows for efficient shock absorption and smooth movement. The small talus bone of the ankle is responsible for transferring weight bearing forces from the shin to the foot (figure 1). If these weight bearing forces are excessive and beyond what the bone can withstand, bony damage to the superior aspect of the talus and its overlying cartilage may occur (especially when combined with twisting forces or forced end of range ankle movements). This is known as an osteochondral lesion of the talar dome and can range from bruising of the cartilage to a complete fracture of the talus. Occasionally a bony fragment may separate from the talus and float within the ankle joint.

Relevant Anatomy for an Osteochondral Lesion of the Talar Dome

Figure 1 – Relevant Anatomy for an Osteochondral Lesion of the Talar Dome

Causes of an osteochondral lesion of the talar dome

An osteochondral lesion of the talar dome typically occurs during a traumatic injury to the ankle, such as an ankle sprain (particularly involving significant weight bearing forces), a traumatic landing from a height (particularly involving forced end of range ankle movements) or a motor vehicle accident. It may also be more common in those patients with poor foot biomechanics or inappropriate footwear.

Signs and symptoms of an osteochondral lesion of the talar dome

Patients with this condition typically experience deep ankle pain (usually at the front of the ankle) that increases with weight bearing and twisting activities, such as standing, walking and running excessively (especially on hard or uneven surfaces, or up or down hills or stairs), jumping and landing, lifting and carrying heavy objects and change of direction sports or activities. It is also common for symptoms to increase after activity with rest (especially at night or upon waking the following morning). Symptoms usually vary depending on the severity of injury and may include: pain (around the ankle), swelling, stiffness, pain on firmly touching the talus bone (usually at the front of the ankle – figure 1) and occasionally clicking, catching or locking of the ankle. In more severe cases, patients may walk with a limp or may be unable to weight bear due to pain.

Diagnosis of an osteochondral lesion of the talar dome

A thorough subjective and objective examination from a physiotherapist is important in diagnosing an osteochondral lesion of the talar dome. Investigations such as an X-Ray, MRI, CT scan or bone scan are usually required to confirm the diagnosis and rule out other pathologies.

Treatment for an osteochondral lesion of the talar dome

Prognosis for an osteochondral lesion of the talar dome

Patients with this condition usually make a full recovery with appropriate management (whether surgical or conservative). Return to activity or sport can usually take place in a number of weeks to many months and should be guided by the treating physiotherapist and specialist. In patients with severe injuries involving damage to other bones, soft tissue, nerves or blood vessels, recovery time may be significantly prolonged. All patients with an osteochondral lesion of the talar dome may have an increased likelihood of developing arthritis of the ankle, particularly in those with more severe injuries, those who require surgery or those who do not complete a high quality rehabilitation program.

Physiotherapy for an osteochondral lesion of the talar dome

Physiotherapy treatment is vital for all patients with an osteochondral lesion of the talar dome to hasten the healing process, ensure an optimal outcome and reduce the likelihood of recurrence. Treatment may comprise:

soft tissue massage
joint mobilization
dry needling
electrotherapy (e.g. ultrasound)
the use of crutches, a walking stick or other walking aid
the use of a protective boot
ankle taping, Achilles tendon taping or arch support taping
ankle bracing
the use of heel wedges
the use of a compression bandage
ice or heat treatment
exercises to improve flexibility, strength, core stability and balance
hydrotherapy
education
activity and lifestyle modification advice
biomechanical correction
prescription of orthotics or footwear advice
a gradual return to activity program
a gradual return to running program
anti-inflammatory and supplement advice (e.g. fish oil, glucosamine and chondroitin)
weight loss advice where appropriate

Contributing factors to the development of an osteochondral lesion of the talar dome

There are a number of factors that may increase the likelihood of this condition occurring. These factors need to be assessed and corrected (where possible) with direction from a physiotherapist to ensure an optimal outcome and may include:

muscle weakness (particularly of the calf, peroneals, quadriceps and gluteals)
muscle tightness (e.g. calf)
poor core stability or balance
being overweight
poor nutrition or inappropriate diet
a sedentary lifestyle
joint stiffness
poor foot posture (e.g. flat feet)
inappropriate footwear
excessive weight bearing or twisting activities
participation in high impact/velocity landing sports (e.g. snow skiing, snowboarding, gymnastics)
fatigue
inappropriate surfaces for training or activity
inadequate warm up

Other intervention for an osteochondral lesion of the talar dome

Despite appropriate physiotherapy management, a small percentage of patients with this condition do not improve adequately. When this occurs the treating physiotherapist or doctor can advise on the best course of management. This may involve further investigation such as an X-ray, CT scan, MRI or bone scan, pharmaceutical intervention, corticosteroid injection, the use of supplements such as fish oil, glucosamine and chondroitin or a review by a specialist who can advise on any procedures that may be appropriate to improve the condition. Surgery, plaster cast immobilisation, the use of crutches or a protective boot may be indicated in patients with more severe injuries or in those cases that are unresponsive to conservative measures. A review with a podiatrist may also be indicated for the prescription of orthotics and appropriate footwear advice.

Exercises for an osteochondral lesion of the talar dome

The following exercises are commonly prescribed to patients with this condition. You should discuss the suitability of these exercises with your physiotherapist prior to beginning them. Generally, they should be performed 2-3 times daily once the physiotherapist and/or orthopaedic specialist have indicated it is safe to do so and only provided they do not cause or increase symptoms.

Your physiotherapist can advise when it is appropriate to begin the initial exercises and eventually progress to the intermediate and advanced exercises. As a general rule, addition of exercises or progression to more advanced exercises should only take place provided there is no increase in symptoms.

Initial Exercises

Foot and Ankle Up and Down

Move your foot and ankle up and down as far as you can go without pain and provided you feel no more than a mild to moderate stretch (figure 2). Repeat 10 – 20 times provided the exercise is pain free.

Exercises for an Osteochondral Lesion of the Talar Dome - Foot and Ankle Up and Down

Figure 2 – Foot and Ankle Up and Down

Foot and Ankle In and Out

Move your foot and ankle in and out as far as you can go without pain and provided you feel no more than a mild to moderate stretch (Figure 3). Repeat 10 – 20 times provided the exercise is pain free.

Exercises for an Osteochondral Lesion of the Talar Dome - Foot and Ankle In and Out

Figure 3 – Foot and Ankle In and Out

Calf Stretch with Towel

Begin this stretch in long sitting with your leg to be stretched in front of you. Your knee and back should be straight and a towel placed around your foot as demonstrated (figure 4). Using your foot, ankle and the towel, bring your toes towards your head as far as you can go without pain and provided you feel no more than a mild to moderate stretch in the back of your calf, Achilles tendon or front of your ankle. Hold for 5 seconds and repeat 10 times at a mild to moderate stretch provided the exercise is pain free.

Exercises for an Osteochondral Lesion of the Talar Dome - Calf Stretch with Towel