Cartilage damage in ankle joint
- Related Injuries: Feet, Ankles & Lower leg
March 11, 2024
Hi, I had a bad sprain in my ankle after a climbing fall in November 2022 (16 months ago). I am still struggling with ongoing intermittent pain and discomfort in that ankle despite numerous extended periods of physio. An MRI showed that I had an edema in the bone and a 9mm cartilage tear. My physio thinks with rehab and plenty of exercises I should eventually be able to go back to running and climbing, but the orthopaedic surgeon who ordered the MRI said that running is not advisable (ever again!!) because I any further damage the cartilage. So far no one has said it needs surgery although if ongoing physio doesn’t help the surgeon may propose that.
What would your advised course of action be, and can I ever expect to return to running and climbing in the future?
It seems a bit extreme to say I can’t ever run again and I love running, but obviously I also don’t want to do more damage to my ankle or give myself early arthritis.
Molly
March 11, 2024
This is a great question, and whilst I think some OS need to stay in their lane with regards to rehab and beyond, there are some things that you simply can’t rehab your way out of…
And whilst I’m not saying that you might that person, but (and it is a big but) an MRI that shows swelling and a 9mm cartilage tear, does raise a few more questions. Primarily, where is the tear and is this an osteochondral defect? It sounds like it could be on your talus and the bruising is result of the OCD.
Do let me know more details as this could be an OCD or something else.
Guru Responded
March 11, 2024
1st MRI report (March) reads (translated from Spanish):
Alteration in the thickness and signal intensity of the anterior and posterior talofibular ligaments, with inflammatory changes in the adjacent soft tissues, in relation to grade II sprain. Focus of subcortical intramedullary edema in the anterior cuboidal slope and more significant in the inferior slope of the talus, in relation to the calcaneo-talar joint. Millimeter sclerotic lesion in the talus compatible with a bone island. Plantar fascia of preserved thickness and signal intensity. Achilles tendon without alterations. No signs of tarsal edema are observed. No soft tissue nodules were identified between the metatarsal heads that would suggest the presence of Morton’s neuroma. Degenerative changes in the metatarsophalangeal joint of the first toe, with minimal associated joint effusion. No signs of sesamoiditis are observed. Minimal posterior subtalar effusion. Inflammatory changes in the subcutaneous cellular tissue in the slope
external of the joint.
DIAGNOSIS
Distension of the talofibular ligaments, with inflammatory changes of the adjacent soft tissues, in relation to grade II sprain. Foci of subcortical intramedullary edema in the anterior slope of the cuboid and more significant in the anteroinferior slope of the talus.
2nd report (October) reads:
Edema and irregularity of the fibers of the anterior and posterior talofibular and calcaneofibular ligaments suggesting partial fiber injury.
Focus of 9 mm osteochondral lesion with subchondral edema and cortical irregularity on the talar slope of the posterior subtalar joint.
Mild tenosynovitis of the posterior tibial and both peroneal muscles.
No other significant bone, joint or musculotendinous abnormalities are identified.
I don’t really have any idea what it means, but so have physio jas explained that injured some of the ligaments and have a 9mm tear in my cartilage which has caused a bruise in the bone. She says with rehab we can probably build up enough strength to support the ankle back to running with plenty of training and that 9mm is only a small tear.
The OS said that the cartilage damage could get worse if I ever go back to running. He said it’s not at the point to do surgery yet.
A second physio has proposed PRP (plasma injections) but they are €250 a go and the OS said they usually don’t work because there isn’t a blood circulation for them to interact with in the cartilage so the cells just die. Do you have any knowledge or experience of how well plasma injections can work for cartilage – is it worth a try? And can this be rehabbed or do I need to consider surgery or (horror) give up running and/or climbing forever?
These are two pretty important sports for me so in my world giving them up forever isnt really an option I want to consider unless I really am going to do myself serious damage by continuing (to be clear, I’m not climbing or running at the moment. I tried a brief return to gentle climbing in may but as my ankle wasn’t improving I stopped).
All thoughts gratefully appreciated and sorry if this is too much info!
Holly
March 11, 2024
Thanks Holly – I think I’ve got full picture.
Essentially you’ve got a grade II partial tear of 2 out of your 3 (outside) ankle ligaments, which is fine and can be rehabbed pretty OK. You’ve also got a 9mm OCD, which is not so OK. What I can’t determine has this developed since the 1st MRI to the 2nd, as it’s doesn’t appear to have been reported – but the bruise has.
There’s a bit of difference when mentioning “cartilage” between the cartilage or meniscus in your knee (shock absorber) and the cartilage in your ankle on the surface of your talus – it’s not really a shock absorber, but makes the bones run smoothly. When you take a 9mm divot from this cartilage, the tissue around the edge finds it really difficult to transmit the load and allow the bruise to heal (under the divot)
The blood supply to the cartilage is really poor and it (the cartilage) doesn’t really grow back, especially in ultra weight bearing areas or with age..There is a lot of poor research with regards to PRP and what it can/can’t do, and so some of what your OS says has some truth. But PRP is better than some alternatives, however in weight bearing areas I can’t truly determine how it’s meant to stimulate tissue unless you have a period of being now weight bearing and then slowly reintroduce load. Many moons ago you would microfracture the OCD to allow fibrocartilage (a different poor distance cousin from the cartilage you need) to plug the divot – but again really poor results as it would just either breakdown and expose the divot or couldn’t handle the loading properties it should have.
But back to now….have you had a decent period in an aircast boot to limit motion and allow the bruise to settle? What is the current rehab plan? Have you had any other form of intervention?
The Guru
Guru Responded
March 12, 2024
The Guru Responds to Molly line by line:
Oh my gosh. Thanks so much for this detailed reply. I don’t know is the honest answer if the cartilage tear evolved from the first MRI to the second or was only picked up on the second.
“I only ask as this could represent an ongoing issue of rotational joint stability. The ligaments are good at controlling the side to side ankle motion but the subtalar joint may be compromised – another story…”
The problem is by the time the MRI picked up the cartilage issue I was a year post-injury. My physio then recommended 2 months wearing a protective boot and weight bearing as little as possible
“Good idea”
but I tried it for a while and felt like the boot was making it worse not better as it was kind of heavy on my foot (maybe wasn’t right boot) so although it gave some relief it also felt like in other ways it was making it worse.
“This is interesting as an aircast boot (or something similar) should not give any extra pain, and should only give relief. Therefore, to be worse from wearing it probably needs a better understanding, and might help explain more about the subtalar joint.”
I also felt like I’d made loads of progress with regaining range of motion in my tendons and this might set me back.
I then saw the traumatologist and he said there was no need to be non-weight bearing I should just limit how much I do.
“That’s OK as long as your pain scales were between 2-3/10”
In end we settled on a crutch to support the ankle and reducing my walking as much as possible for a month and then slowly built that up. After 8 weeks we reintroduced progressive load bearing and have recently been working on my proprioception balance and increasing the range of motion in the foot.
My current physio doesn’t think the cartilage is such an issue and that we just need to work on rehabbing the tendons and ligaments and building up the strength. She also seems to be exploring the possibility I’m dealing with chronic pain now more than an injury and that we should be working within a range of discomfort rather than trying to avoid any pain at all. The OS thinks it is pain from the cartilage injury. Im now very confused.
“Always a tough one when someone says something and the other person says the opposite…I think I’m with the surgeon on this one. It sounds very OCD”
The rehab of the ligaments seems to be helping with some of the pain. But I think I’m still getting background pain from the cartilage inside my ankle. So hard to know what the best course of action is!
“You may notice a difference in pain quality – dull, deep, toothache versus I can poke something superficial which is sharp and a little ‘boggy’.”
A new rehab doctor (provided by my medical insurance, who don’t cover my other physio) has suggested the PRP injections. Which ironically aren’t covered by the insurance.
“I’m definitely not sold on PRP, but also not ruling it out. I know this might be very left of field but I wonder if a steroid injection into your subtalar joint would be diagnostically acceptable – or even local anaesthetic (pretty rare today). I know that steroid isn’t a long term plan and is not great for joint surfaces but wonder if it would help your reach a conclusion sooner rather than later. And one major thought I’ve just had as you seeing an OS who specialises in foot & ankle? Have you tried or considered a trail of orthotics?”
In the meantime the traumatologist has recommended another MRI (at my suggestion!) to see if there’s been any improvement or deterioration since October. I’m due to get that in 2 weeks.
“Smart idea or wonder if SPECT/CT might be more precise for the OCD?”
I guess I will know more then but would still be interested to know if you think I should be more concerned about resting the cartilage or rehabbing the ligaments? And how will I know when I’ve rested the cartilage enough?
“As above SPECT/CT or pain on loading. Anything about 4/10 is a (relative) concern”
Thanks for all your help so far.
Holly
Guru Responded
March 27, 2024
Thanks so much! Ugh. Always more questions, apologies.
Re the pain – I would say its extremely variable. Most days its a 2-3, some days its a 1-2, and other days it can be a 5-6 briefly and sharply, or a 4-5 constantly for several hours, and I feel like I can’t put weight on it without pain. Often this is after some kind of exercise involving forward bending movement of the ankle, but often heel raises and lowering can trigger it too.
Pretty much consistently when I get up in the morning I’m limping a bit for at least 5 minutes til it settles down and it takes a bit of walking around and ankle exercises before I can put my full weight and range of motion through my foot without pain.
Its so variable and also sometimes hard to tell where the pain is coming from. The sharp pain I get on loading seems to be coming from the bone but its hard to know because it also feels a bit like a pinched nerve. Also it only happens occasionally and is usually sudden and unexpected. On prodding and poking my foot, my physio seems to think its a tendon/ligament issue and it does seem to dissipate on slow gentle movement through the movement that caused the initial pain.
Don’t know if that helps give a clearer picture? I’ve asked about Steroid injections but they don’t do them in the UK, apparently.
I just got the results back from the 3rd MRI – I’ve not yet seen the Orthopedic surgeon to discuss but the report is as below (via google translate!).
I’m actually back in the UK from next week so if you think it’s worth me popping in to see one of your physios, in addition to my regular physio in Valencia, let me know.
Thanks,
Holly Moy
“The subchondral area of 9 mm on the medial slope of the talar trochlea without cortical involvement or images suggesting unstable fragments. Degenerative-inflammatory changes in the posterior subtalar joint with cortical irregularity and edema on the talar surface. Edema and irregularity of the fibers of the anterior and talacral fibular ligaments. posterior and peroneocalcaneus that suggest partial fiber injury. Mild tenosynovitis of the posterior tibial and both peroneal bones. No other significant bone, joint or musculotendinous anomalies are identified”
March 28, 2024
Hi Holly
The saga (correctly!) continues..
So, the latest MRI does correspond with you what you feel, and I think it’s more subtalar related than ligamentous. I guess it’s relevant to say that disrupted alignment of ligamentous fibres on MRI do not always correspond to pain, and I think they maybe a product of ongoing subtalar joint instability and bruising. It looks as if the 9mm lump of floating tissue has gone but the divot remains, which shifts the load bearing capability of the talus (and so the joint) to sub optimal. Alignment is therefore key to improve the total surface area of the joint and distribute the load….all a little too technical and theoretical!
You can definitely get your STJ injected – Lorenzo does all of mine https://sportdoctorlondon.com/subtalar-joint-injection/ and if that is the cause of pain is super helpful.
Do come and see me next week – I’m Matt and I’m the Clinical Director here, I’m pretty sure I can help you and hopefully show you an escape route back to function. You can find me in either Fitzrovia, Chelsea or High Street Ken.
The Guru aka Matt Todman
