Osteochondral lesion of the talus (talar dome lesion, ankle OCD): deep ankle pain after a sprain

What it is

The talus is the bone at the bottom of the ankle joint, and its rounded top (the talar dome) is covered in smooth joint cartilage. An osteochondral lesion is damage to that cartilage and the bone just beneath it. Osteochondral lesion of the talus, shortened to OLT, is the term a 2019 international consensus agreed; older names include osteochondritis dissecans of the talus, osteochondral defect and talar dome lesion.

NHS England's summary says these lesions can cause pain, clicking, grinding or instability of the joint, and that cartilage, which has no blood or nerve supply, has a limited ability to repair itself.

Sources 1, 2

What causes it

Most people with a lesion have had an ankle injury, often a sporting one. Lesions are thought to follow damage to the joint surface or its blood supply after an injury, or to arise without a clear injury, which is called osteochondritis dissecans.

Sources 1, 3

How often it follows an injury: it depends how hard you lookMixed evidence

There's no single figure, because it depends on the injury, the scan and when it's done.

• NHS England's summary, citing a 2015 review: in 6.5% of new ankle sprains, 20.5% of sprains looked at later, and 57% of ankles with long-term disability.
• On a detailed (3-tesla) MRI within days of an acute ankle ligament injury in athletes: a lesion on the talus in 24 of 171 injuries (14%), and 85% of all the lesions found were in the cartilage only.
• In a review of 20 studies of 1,707 broken ankles: 45% had a cartilage or bone-and-cartilage lesion when the joint was examined straight after the injury, and 43% of those lesions were on the talus.
• An editorial's estimate: up to 70% of sprains and fractures may lead to these lesions. That's higher than the measured figures above.

Sources 1, 4, 5, 3

Who gets itEmerging evidence

Mostly young, active people: NHS England's summary says most lesions occur between the second and fourth decades of life, at an average age of 27, and twice as often in men.

Teenagers get it too. In a US health system with over a million children, ankle OCD was diagnosed in 4.6 per 100,000 children aged 6 to 19 each year: 6.8 per 100,000 at 12 to 19 against 1.1 at 6 to 11, none under 6, and girls 1.6 times as often as boys. 72% were on the inner side of the talus, and none were in both ankles.

Sources 1, 6

The signs

Deep ankle pain that lingers after a sprain or a fracture, or comes on gradually, with stiffness, swelling after activity, less activity than before, and sometimes clicking, catching, grinding or a feeling the ankle might give way.

NHS England's summary calls these lesions one of the most important causes of pain that lingers after a sprain, and says the diagnosis is often delayed. A 2024 editorial says a lesion is easily mistaken for a simple sprain if scans are unclear or not done.

Sources 1, 3, 7

When to suspect it after a sprain

NHS ankle sprain leaflets say most sprains improve within 6 to 12 weeks, though some pain and swelling can last 3 to 6 months, and that pain or swelling still there after 6 to 12 weeks is a reason to contact your GP. The NHS says to see a GP for ankle pain that hasn't improved after 2 weeks of looking after it at home, is getting worse, or keeps coming back.

Sources 8, 9, 10

What scans show, and what a finding does and doesn't meanEmerging evidence

X-rays can show larger lesions but miss many. In 103 people with long-standing ankle pain, computed tomography (CT) and MRI found or ruled out lesions better than the history, examination and X-rays, and the two scans did equally well.

A lesion on a scan isn't automatically the cause of pain. In 108 MRI scans of ankles with no symptoms on the outer side, 16 (15%) showed a lesion on the talus. Bone bruises (swelling inside the bone on MRI) are common after sprains, and a review found they usually fade within 6 to 12 months without any specific treatment.

Your specialist decides with the symptoms, the examination and the scan together, including the lesion's size, which affects how well surgery works.

Sources 11, 12, 13, 14, 15

How it usually goes without surgeryEmerging evidence

In a 2023 review of 30 studies (868 patients) treated without surgery, the 16 studies that could be pooled gave a success rate of 45%. Arthritis progressed on X-ray in 9%, and the lesion looked unchanged on MRI in 84%.

Lesions causing few symptoms didn't get worse in two series: in 48 people followed for over 4 years, 86% of ankles were pain-free or less painful and MRI showed no real progression; and in 142 people who had no immobilisation or activity limits, average pain fell from 3.8 to 0.9 out of 10 over about 6 years, with no arthritis progression, and only 9 reported limits on sport. In children, 44% of 192 lesions did well without surgery. These are mostly small, older series of mixed quality, and people whose pain carried on went on to surgery, which is why the success rates look modest.

Sources 16, 17, 18, 19

Non-surgical care first for mostEmerging evidence

Non-surgical care is the first treatment for most lesions: less physical activity and weight-bearing, physiotherapy and insoles, with about 50% success in the studies one review summarised, and 45% in the pooled review above.

In children, the published protocols used about 6 weeks of immobilisation (3 to 8), in a cast in some studies, then about 5 months (4 to 6) of restricted weight-bearing and sport, and 44% of 192 lesions did well. Lesions causing few symptoms didn't worsen over 4 to 6 years whether or not activity was restricted. No trial has compared different non-surgical approaches.

Sources 7, 16, 19, 17, 18

Rehab: no trials, so NHS protocols set the shapeEmerging evidence

No trial has tested exercise for these lesions. NHS protocols after surgery set a shape that non-surgical rehab can borrow: movement first, then strength (heel raises from two legs to one), balance and reach, then impact only once criteria are met.

One NHS trust's criteria before impact are full ankle movement without pain or swelling, an even forwards and backwards reach on each leg on the star excursion balance test, 10 leg presses at body weight, 10 good single-leg squats and 25 pain-free single-leg heel raises, with sport-specific training 4 to 6 weeks after running starts. A review of 227 articles found rehab plans after surgery vary widely and are mostly based on time rather than criteria. The plan below uses the criteria as its stage gates.

Two pieces are borrowed from ankle instability trials and labelled: the heel-raise progression off a step comes from a trial in 39 people with unstable ankles, and the advice to keep balance work going comes from a trial in 522 athletes, where an 8-week home balance programme after a sprain cut repeat sprains from 33% to 22% over a year.

Sources 20, 21, 22, 23, 24

Surgery: marrow stimulation (microfracture)Emerging evidence

For lesions that keep causing symptoms despite non-surgical care, NHS England describes the first operations as clearing the damaged area, with or without drilling or microfracture of the bone underneath, or bone grafting, and more complex resurfacing only if those fail. Marrow stimulation means clearing the damaged area and making small holes in the bone so that healing cells fill the defect with repair tissue.

In adults with first-time lesions, a review of 52 studies found pooled success of 82% in 317 ankles after marrow stimulation, and no operation better than another; an earlier review found 85% success across 18 treatment groups. In 50 people followed for 8 to 20 years (12 on average), 78% had a good or excellent result, 94% had gone back to work and 88% to sport, and arthritis had progressed one grade in a third.

The repair tissue is fibrocartilage, which bears weight less well than the original cartilage and may wear over time, a review in children explains. The trial evidence is thin: a Cochrane review found only one small trial, of 15 people.

Sources 1, 7, 25, 26, 27, 19, 28

Lesion size, and other operationsEmerging evidence

Larger lesions do less well with marrow stimulation. In 120 ankles, lesions of 150 mm² or more failed in 80% (20 of 25), and a review of 25 studies suggests marrow stimulation suits lesions under about 107 mm² or 10 mm across. Larger lesions, or ones that don't heal, may need grafts of bone and cartilage or other resurfacing.

In children, a review found success in 77% after marrow stimulation, 79% after fixing a loose piece back, 95% after drilling through the bone from below (in 22 lesions) and 67% after grafts (in 9), from small series of mixed quality.

Sources 15, 14, 1, 19

Return to sport and work, and complicationsEmerging evidence

After marrow stimulation, 88% went back to sport at any level and 79% to their previous level, usually 13 to 26 weeks after surgery, across 61 studies of 2,347 lesions. Across 18 studies, 93% went back to work, after 2 to 11 weeks. The studies were of low quality.

Complications happened in about 1 in 20 operations, across 6,962 operated lesions; nerve injury was the commonest, and none was life-threatening.

Sources 29, 30, 31

Weight-bearing after microfracture, and microfracture with ligament repairEmerging evidence

In a randomised trial of 81 ankles with small to mid-sized lesions, putting weight through the foot from 2 weeks gave the same results at about 3 years as 6 weeks without weight. NHS protocols differ: one usually allows weight as tolerated from the start, another touching or partial weight at first, building to full weight from about week 6. So the guide says: as your team allows.

In a trial of 71 people with an unstable ankle and a small cartilage lesion, adding microfracture to ligament reconstruction made no difference to function, pain or complications at 2 years, and recovery was slower.

Sources 32, 20, 21, 33

Cell implants and injections: limited evidenceMixed evidence

NHS England doesn't routinely fund autologous chondrocyte implantation (growing your own cartilage cells and implanting them) for these lesions, because the evidence isn't strong enough. A review found only limited comparative evidence for adding biological treatments to marrow stimulation. In a meta-analysis of 4 trials of platelet-rich plasma (PRP), the pooled gain in ankle function was uncertain (its range included no effect) and results varied widely, though the authors were positive. They're add-ons with uncertain benefit, not cures.

Sources 1, 34, 35

Protection without surgery (written steps)

From a review in children, another review and one series, with our suggestions marked.

• 1. Your specialist sets how much protection you need. In children, published protocols used a boot or cast for about 6 weeks (3 to 8), then about 5 months of restricted weight-bearing and sport. Adults are usually asked to cut back activity and weight-bearing, with physiotherapy and sometimes insoles.
• 2. Some people with mild symptoms do well with no boot and no activity limits: follow the advice you're given (our suggestion).
• 3. Keep fit with upper-body and trunk work, and with cycling or swimming if allowed (editorial, as in our knee OCD guide).
• 4. Follow-up scans are the specialist's call. A lesion often looks the same on MRI even when the symptoms settle, so judge progress by your symptoms and the stage gates.

Sources 19, 7, 18, 16

After ankle arthroscopy and microfracture, as your team allows (written steps)

From the Derby and Burton and the Robert Jones and Agnes Hunt NHS protocols, and a trial. Your own team's plan comes first.

• 1. Weeks 0 to 2: weight-bearing as your surgeon advises. One NHS trust usually allows weight as tolerated, with crutches if they help; another starts with touching or partial weight. Keep the foot raised, with about 10 minutes on your feet in each hour at first. Gentle ankle movement without weight, and thigh, hip and circulation exercises. A physiotherapy appointment within 2 weeks.
• 2. Weeks 2 to 6: wean off the crutches and walk normally; ankle movement and strength, first without weight and then with more weight as pain allows; a light exercise bike. From about week 3 in one protocol, mini-squats and low step-ups with part of your weight. This is stage 1 moving into stage 2.
• 3. Weeks 6 to 12: a clinic review at about 6 to 8 weeks; full movement, balance work and heel raises from two legs to one; full weight-bearing from about week 6 in one protocol. This is stage 2.
• 4. From about 12 weeks in one protocol: gentle impact and a walk-to-jog programme once the stage gates are met. The other starts straight-line jogging from month 2, agility and sport drills from month 3, and sport from month 4 onwards when strength, flexibility, balance and power allow. Your team decides which applies to you. This is stage 3.
• 5. In a trial of 81 ankles with small to mid-sized lesions, putting weight through the foot from 2 weeks did as well as waiting 6 weeks, but follow your own team's plan.

Sources 20, 21, 32