Osteochondral Lesion of the Talus (OLT)
Tracey A. Littrell, DC, DACBR, DACO, CCSP
Published: September 2018
Journal of the Academy of Chiropractic Orthopedists
September 2018, Volume 15, Issue 3
This is an Open Access article which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. The article copyright belongs to the author and the Academy of Chiropractic Orthopedists and is available at: https://ianmmedicine.org. © 2018 Litrell and the Academy of Chiropractic Orthopedists.
AP Ankle Oblique Ankle
A 48-year-old female patient reported persistent mild ankle pain and stiffness to her chiropractor approximately 6 weeks following an incident she described as “rolling” her ankle when stepping off a curb. The patient’s activities of daily living were minimally impacted by her symptoms; she reported her symptoms as “annoying” and “achy” following walking.
The dorsoplantar (anteroposterior) and oblique ankle radiographs revealed an ovoid lucent defect with a well-defined inferior sclerotic border in the superior-medial talar dome; the lateral ankle radiograph revealed a subtle surface depression at the superior-posterior talus. No osseous fragmentation and no soft tissue edema was identified. A large calcaneal heel spur was noted at the insertion of the plantar aponeurosis.
Osteochondral lesion(s) of the talus (OLT) is an all-encompassing term for any injury involving both the subchondral bone and the articular cartilage of the talar dome, including bone bruise (contusion), osteochondritis dissecans, and osteochondral fracture.1 With such an expansive categorization, OLT may occur in up to 70% of acute ankle sprains and fractures.2 Prior to the availability of cartilage-sensitive advanced imaging procedures, OLT was often not recognized unless the radiographic findings were pronounced or the patient underwent surgery for complications associated with the causative injury. The most common cause of OLT is trauma, but congenital variants and malformations, ligamentous laxity due to connective tissue disease or prior trauma, and conditions or treatments that carry an increased risk for osteonecrosis are also known etiologies for OLT.2
The physician should have a high index of suspicion when a seemingly typical ankle injury doesn’t heal as she or he expected. Most patients with OLT report non-specific ankle region symptoms and few significant alterations of daily living activities. Patients most frequently report ankle swelling, stiffness, and/or weakness, particularly following prolonged activity, such as standing, walking, running, or other weight-bearing activities.1,2 Physical examination of the patient with OLT may be frustratingly non-specific, with many patients demonstrating poorly localized symptoms to palpation or provocative examination. Positive responses to anterior drawer tests, inversion and eversion testing, and findings of ligamentous laxity and hindfoot malalignment may be present, not necessarily as consequences of OLT, but as risk factors that proceed the ankle injury with the complication of OLT.1,2
When OLT is suspected, well-positioned weight-bearing dorsoplantar (anteroposterior), oblique, and lateral radiographs are useful in revealing fracture, joint misalignment, and osteoarthrosis, but are not sensitive to OLT, with estimates of 50-70% of cases missed with radiographic evaluation.1,2 Computed tomography (CT) is an excellent tool for the assessment of cortical injury, comminution, osteophytes, and loose bodies; but CT fails to give the necessary details of cartilaginous injuries. Magnetic resonance imaging (MRI) is the procedure of choice for assessing suspected OLT. MRI is sensitive to bone marrow edema and cartilaginous trauma.
Treatment for OLT may be conservative or surgical. Conservative treatment with rest, restricted activities, joint immobilization, and weight-bearing as tolerated may be effective for up to half of asymptomatic patients. Surgical interventions consist primarily of bone marrow stimulation procedures for lesions with diameters less than 15 mm, and replacement procedures (cartilage autografts from the patient’s own knee), for larger lesions.1
As this patient’s OLT was symptomatic and her activities of daily living were impacted, she was referred for orthopedic surgical consultation and underwent an osteochondral autograft.
1. Posadzy, M., Desimpel, J. & Vanhoenacker, F.M. (2017). Staging of Osteochondral Lesions of the Talus: MRI and Cone Beam CT. Journal of the Belgian Society of Radiology, 101(S2), 1. DOI: http://doi.org/10.5334/jbr-btr.1377
2. Gianakos, A. L., Yasui, Y., Hannon, C. P., & Kennedy, J. G. (2017). Current management of talar osteochondral lesions. World Journal of Orthopedics, 8(1), 12–20. http://doi.org/10.5312/wjo.v8.i1.12