Ankle Conditions
Persistent pain after an ankle sprain deserves a proper diagnosis – impingement, cartilage lesions and OCD are treatable conditions, not inevitable consequences.
The ankle: more than just a sprain
Ankle sprains are the most common sports injury – but persistent pain months after a sprain is not normal. Up to 50% of patients with ongoing ankle pain after injury have an underlying structural problem: osteochondral lesions of the talus (OLT), anterior or posterior impingement, chronic ligament instability, or scar tissue formation. These conditions are diagnosable and treatable.
The ankle joint (tibiotalar joint) is a highly congruent hinge joint with limited tolerance for malalignment. Even small cartilage defects can cause significant symptoms because the contact pressures in the ankle are among the highest in the body. Early diagnosis and appropriate treatment of cartilage lesions can prevent progression to ankle arthritis.
- Anterior ankle impingement (footballer's ankle)
- Posterior ankle impingement (Os trigonum syndrome)
- Osteochondral lesions of the talus (OLT)
- Osteochondritis dissecans (OCD)
- Chronic lateral ankle instability
- Peroneal tendon pathology
Ankle impingement
Anterior impingement (footballer's ankle) causes pain at the front of the ankle during dorsiflexion (squatting, climbing stairs, downhill walking). Bone spurs on the anterior tibia or talus neck – often from repetitive microtrauma – mechanically block full dorsiflexion. Arthroscopic removal of osteophytes and scar tissue gives excellent results, with 80–90% success rates and return to sport within 6–8 weeks.
Posterior impingement causes pain at the back of the ankle during plantarflexion (ballet, football shooting motion). The most common cause is an Os trigonum – an accessory bone behind the talus present in 7–25% of people. Arthroscopic removal of the Os trigonum or elongated posterior process gives excellent results, with return to sport within 6–10 weeks.
Osteochondral lesions of the talus (OLT)
OLT are damage to the cartilage and underlying bone of the talus, most commonly on the medial dome. They occur in up to 38% of ankle sprains and are a frequent cause of persistent ankle pain. Treatment depends on lesion size and depth: small lesions (<1.5 cm²) are treated with bone marrow stimulation (microfracture or AMIC); larger lesions require matrix-associated autologous chondrocyte implantation (MACI) or osteochondral transplantation. Systematic reviews confirm good outcomes for all techniques when correctly indicated.
Chronic ankle instability
Repeated ankle sprains can lead to chronic lateral instability due to incompetent lateral ligaments (ATFL, CFL). Conservative treatment (proprioceptive training, strengthening) is the first-line approach and successful in the majority of patients. When conservative management fails, anatomical ligament reconstruction (Broström-Gould procedure) is the gold standard, with excellent outcomes and low recurrence rates.
Frequently asked questions
My ankle still hurts months after a sprain – is that normal?
No. Persistent pain beyond 6–8 weeks after an ankle sprain warrants further investigation. Osteochondral lesions, impingement, chronic instability and scar tissue are common causes that are missed without appropriate imaging (MRI, CT). Early diagnosis improves treatment outcomes.
What is an Os trigonum?
An Os trigonum is an accessory bone behind the talus, present in 7–25% of people. It is a normal anatomical variant that can cause posterior ankle pain in athletes with repetitive plantarflexion (dancers, footballers). Arthroscopic removal gives excellent results.
Can cartilage in the ankle heal?
Ankle cartilage has limited self-healing capacity. Modern surgical techniques (microfracture, AMIC, MACI, osteochondral transplantation) can restore a functional cartilage surface. Early treatment of focal defects gives the best results and can prevent progression to ankle arthritis.
References & Evidence
- Zengerink M, Struijs PA, Tol JL, van Dijk CN. Treatment of osteochondral lesions of the talus: a systematic review. Knee Surg Sports Traumatol Arthrosc 2010;18:238–246. PMID: 19859695
- van Dijk CN, Tol JL, Verheyen CC. A prospective study of prognostic factors concerning the outcome of arthroscopic surgery for anterior ankle impingement. Am J Sports Med 1997;25:737–745. PMID: 9397259
- Zwiers R, Wiegerinck JI, van Dijk CN. Treatment of posterior ankle impingement. Arthroscopy 2018;34:594–601. PMID: 29169835
- Ramponi L, Yasui Y, Murawski CD, et al. Lesion size is a predictor of clinical outcomes after bone marrow stimulation for osteochondral lesions of the talus: a systematic review. Am J Sports Med 2017;45:1698–1705. PMID: 27619967
- Vuurberg G, Hoorntje A, Wink LM, et al. Diagnosis, treatment and prevention of ankle sprains: update of an evidence-based clinical guideline. Br J Sports Med 2018;52:956. PMID: 29514819
- Calder JD, Sexton SA, Pearce CJ. Return to training and playing after posterior ankle arthroscopy for posterior impingement in elite professional soccer. Am J Sports Med 2010;38:120–124. PMID: 19966104
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