OCD of the Talus (Ankle)

Osteochondritis Dissecans is an acquired joint defect which involves the subchondral bone and the overlying articular cartilage. The cause of osteochondritis dissecans is not fully understood. Osteochondritis dissecans can often be a progressive pathologic process: evolving to joint deformity and occasionally bone and cartilage fragmentation to intra-articular cartilage instability. When osteochondritis dissecans affects the ankle it typically occurs on the inner or medial portion of the ankle (talus). The bone lesions on the lateral or outside portion of the talus are most often related to trauma. Most cases of osteochondritis dissecans of the talus occur around the time of skeletal maturity (10-14 years of age for girls and 12-16 years of age for boys). There is an increasing prevalence of this condition in athletic teenage girls. Relative to osteochondritis dissecans of the knee, the ankle lesions tend to be smaller, more difficult to diagnose and less likely to heal despite treatment efforts. The osteochondritis dissecans lesion is an area of the bone within a joint that has deterioration and softening and subsequent overlying cartilage damage. This can result in detachment of the softened bone and cartilage leaving a crater in the bone that is exposed to the joint surface and a loose fragment within the joint.


Although the exact cause of osteochondritis dissecans is unknown, there are several factors such as high demand impact sports, underlying disease conditions, local bone blood flow and genetic factors. Most cases of osteochondritis dissecans do not run in families. Increased incidence of osteochondritis dissecans in the ankle is seen in developing bone and joints that are subject to large amounts of physical activity. This includes the year around sports and significant impact activity such as running, gymnastics, soccer and basketball as well as training at a high level of intensity, that is, everyday with minimal rest between activities. Chronic repetitive micro trauma may lead to stress within the subchondral bone which results in bone necrosis, softening, desiccation and separation.


Osteochondritis dissecans of the ankle tends to have a low level of chronic persistent pain, a variable amount of swelling which is often intermittent and not severe. A history of locking, catching or ankle sprains on multiple occasions is common. There is often a history of multiple ankle problems that do not have a clear cause or diagnosis. Physical findings are relatively minimal with pain to palpation over the anterior aspect of the ankle. Rarely are there any limitations of joint range of motion. Routine x-rays of the ankle can easily miss a small osteochondritis dissecans lesion, so it often goes undiagnosed for a long period of time. Oblique and plantar flexion radiographs of the right ankle generally will improve the visualization of the osteochondral lesions often because they are in the posterior aspect of the talus. Even the smallest osteochondritis dissecans lesion will appear on a MRI of the ankle and talus region. MRI is the single best study for both the diagnosis and prognosis of the osteochondritis dissecans lesion of the talus. Occasionally other studies may be helpful such as a computed tomography (CT scan) to further define the anatomy of the lesion and occasionally a bone scan is helpful to judge the ability of the lesion to heal and help manage a treatment protocol.

Non-operative Treatment

The goal of non-operative treatment is to promote healing in the subchondral bone and prevent chondral collapse, subsequent fracture and significant crater formation. The treatment options depend on the skeletal maturity of the patient, size and stability of the lesion as well as the location of the lesion within the bone. Non-surgical treatment is the treatment of choice for small skeletal lesions in skeletally immature patients with no signs of instability on a MRI. Initial treatment has traditionally been non-operative. Symptoms often resolving after a period of non weight bearing and activity modifications but rarely does the lesion resolve radiographically. Non operative treatment usually requires the patient to be nonweightbearing for a minimum of 6 weeks with activity restrictions and the use of a cast and/or brace. These are typically monitored by interval radiographs and occasional use repeat MRIs. Lesions that are symptomatically resolved but not radiographically resolved need persistent follow up even if the child has returned to full physical activity. It is not uncommon for lesions that are unresolved radiographically to have reoccurrence of symptoms when activities resume or within 6-12 months of initial treatment. Other non-operative measures have been proposed such as electrical bone stimulators. To date there is no clear data regarding the benefits of these adjunct therapies. If non-operative treatments have failed to control symptoms after a period of 3-9 months other forms of more invasive treatment may be necessary.

Operative Treatment

The goals of operative treatment are the same as the goals for non-operative management. Some more advancement lesions need to be managed surgically. Operative treatment is the treatment of choice for patients with unstable or detached lesions or failed non-operative management and for patients that are at or past skeletal maturity. Surgical attempts to improve the healing of the osteochondritis dissecans lesion to the native bone, stabilize loose fragments or to replace defective tissue with either an autograft or allograft transfer osteochondral tissue. Operative treatment also provides the benefit of a more dynamic assessment of the lesion and the severity of lesion instability and assessment of injury to the overlying cartilage. The treatment for stable lesions with intact articular cartilage often involves drilling the subchondral bone with the intention of stimulating vascular ingrowth and subchondral bone healing. If the lesion is unstable or hinged, fixation is often indicated in an attempt to heal the lesion back to native bone. Occasionally bone grafting is indicated in unstable lesions that do not have significant joint congruity to allow restoration of articular congruency and enhance the healing potential. Fixation of these lesions can be performed using metal screws, wires, or bioabsorbable nails. Associated complications can include pin migration, adjacent cartilage damage, hardware failure, failure of healing and the need for repeat surgery. If the fixation of the lesion is not possible and the lesion needs to be debrided there are several salvage techniques for full thickness defects including marrow stimulation techniques (ie micro fracture), autogulous chondrocyte implantation, osteochondral autograft transplantation and osteochondral allograft transplantation. These techniques however have limited clinical outcome data in the adolescent and children. These techniques would also be applied to defects that are larger than 5mm2 . Most of these operative treatments are performed as an arthroscopic outpatient procedure. Often patients need to undergo a period of non-weight bearing with either cast or brace immobilization to promote healing for approximately 1-2 months after surgery.

Options for Procedures

Options for procedures are determined by the size and location of the lesion and also several patient characteristics.

Various Techniques

Debridement of the lesion is an operative procedure which removes the dead (necrotic) to promote healing stimulation of the lesion and underlying bone. Drilling is also an arthroscopic procedure to promote stimulation of the underlying bone.
A fragment of the lesion is sometimes loose and either removal or repair such as fixation with a screw is necessary.
Osteochondral allograft or autograft which is performed on large lesions is a procedure which is either done with using another piece of bone to fill in the lesion. Fresh osteochondral allograft is a procedure which is done on very large lesions. This procedure requires the fresh graft to be obtained by a donor and once graft is obtained needs to be done on “urgent” basis; usually within 10 days while the graft is still “fresh”.


Our understanding of Osteochondritis dissecans of the talus is continually evolving, but there is general acceptance that these lesions are similar to those found in other joints, including the knee. Therefore, the treatment algorithms are also similar. When initially assessing a child with evidence of this pathologic process, one should first consider the skeletal maturity. With that in consideration, embarking on a period of non-surgical management is ideal, but the results in the literature suggest that you should be prepared to proceed with surgical intervention if this treatment fails.

Surgical intervention itself is not always successful, but with the appropriate intra-operative algorithm and a conservative post-operative plan, many children can avoid a second surgery. As mentioned above, there are many back-up plans that can be undertaken given each child’s individual needs. With proper diligence most patients can be treated to full resolution of symptoms and radiographic appearance. It does behoove the treating physician to remain persistent in the treatment plan and for the child and parents to remain patient with the often slow healing process.

Roger M. Lyon, MD. Children’s Hospital of Wisconsin. Medical College of Wisconsin

16 Responses to “OCD of the Talus (Ankle)”

  1. I have OCD in both ankles, it hurts,hurts, hurts,. The right ankle appears to be much better, but the left ankle has had two surgeries and it hurts so terribly bad. The doctor removed a big piece of bone that was loose and laying over the old surgical site. Is there hope to get it fixed? How many surgeries can the talus go through? I have had arthroscopic surgeries, thus far.

  2. thank you for your useful discussion. i myself am a patient and will have my right ankle operated a week later. i hope to be healthy

  3. I have had 4 surgeries for my right ankle OCD and now no other option but a total ankle replacement. :( any advice

    • Same here, 14 yrs, 5 surgeries Inc microfracture, it just gets worse, (last op 3x worse!) I have now said ENOUGH! I am pushing for elective amputation as that seems the best way forward!

  4. Sorry to hear about your situation. Since every situation is different it is best to have your doctor address these questions. If they are not able to provide the needed answers/recommendations then face to face consultation with one of the specialists at a ROCK site may be helpful.

  5. Carol Yeater,
    I am sorry to hear about the trouble with your ankle. Every situation is different and I don’t know enough about your case to give you an opinion. There is not a limit to the number of operations but any operation needs to fully address the core problem to get to a solution. Please address this with your surgeon because they know your situation best. If you need another opinion one of the the ROCK members could either see you or at least get you to someone that could give some good advice. Good Luck.

  6. I had the surgery in Jan 2014 and its worse now than before surgery.

  7. Dr. Lyon, I’m glad that I came across your blog on ankle OCD where you offered insights on this condition for kids. I’m trying to make a decision whether or not to have surgery done on my 15-year old son’s right ankle. My son had been playing soccer for many years and this summer he was diagnosed with ankle OCD. The findings from the MRI he did this summer says “A 1.2 x 0.9 x 0.6 cm osteochondral lesion is seen involving the medial talar dome with mild thinning of the underlying cartilage and slight adjacent bone marrow edema.” After more than 3 months of physical therapy we did see some improvements, but the pain didn’t completely gone. He can walk (with slight rolling of his right foot) but feels pain when sprinting. Should we consider surgery or continue the conservative treatment?

  8. Charles,
    There are lots of factors that determine the success rate of treatments for ankle (talus) OCD. As an orthopaedic surgeon specializing in treating OCD lesions in children, not all treatments are 100% successful. Many cases of ankle OCD are difficult to fully resolve and some will need more than one surgery. Discussions with your surgeon should help figure out how to proceed if your previous surgery was not successful. Otherwise consultation with a physician specializing in treating OCD lesions (such as a ROCK member) may be helpful.

  9. Sandy,
    I am sorry to hear about your son. This is not an uncommon situation. Surgery can be a reasonable approach in cases where nonoperative treatments have not resulted in healing of the lesion after 3-6 months. There are different surgical procedures used to achieve healing of OCD lesions. If the surgical treatment is well matched to the specifics of the lesion the success can be around 80 to 90%. An orthopedic surgeon specializing in this condition (such as a ROCK member) is your best bet in getting the best treatment. Good luck to you and your son.

  10. I have been dealing with foot and ankle pain for the past my OCD of the talus was not discovered on x-ray,because of the constant pain I requested an MRI that when it was discovered. Cortisone shot,brace and boot did not work. Finally had surgery 3 months ago, as have now the pain is just unbearable so far two cortisone shot and physical therapy. My surgeon just repeated the MRI more building up of scar tissue noted on the MRI. I do not want to repeat surgery now. My question is how could I treat injury to avoid surgery, by the way I tried Accupuncture to see if it will help keep the swollen down. Any suggestions I am desperate now because I am on my feet all the time for work.
    Sheila Felix

  11. Dr. Lyon,

    My 12 y/o daughter was diagnosed with OCD of the talonavicular joint in December of 2014. The lesion on her talus is roughly 1 cm in size and she is experiencing significant pain when weightbearing. Her symptoms (pain, “catching” sensation in ankle) began in October 2014 but she continued to train in ballet until MRI images in December discovered the OCD lesion. We tried orthotics and activity restrictions for a few weeks but pain worsened. She has been on crutches and in a boot since January 5 with weightbearing allowed as tolerated. We had scheduled surgery for Feb. 25 but decided to cancel and try a period of non weightbearing for 6 weeks followed up by 3-6 weeks of progressive weightbearing to see if her bone could heal during this time. She will use an electrical bone stimulator during this time as well. X rays taken of her hands have shown she is not quite at skeletal maturity.
    Do you feel there is potential for her lesion to resolve in this period of time?
    Any advice you have would be greatly appreciated. From what we have been told, this condition is rare in this particular joint and have been unable to find much information on treatment/outcomes.

  12. Dear Shella Felix,
    I am sorry you are suffering from your talus OCD lesion. Your surgeon would be the best person to address these issue and questions you bring up. if the lesion has not healed and is still painful it may need further surgery. There are several option for treatment of pain but unless the lesion has healed at least partially the pain will likely continue. Surgical options in your case may include lesion removal and/or tissue replacement. Good Luck with your situation.

  13. Hope,
    I am sorry to hear about your daughters talus OCD. Your surgeon should be the best one to answer the questions you have because they know the specifics of your case. I do not know enough of the details to give you specific recommendations. In general talus OCD is difficult to get healed with or without surgery. There is probably a small chance of healing with the current plan of bone stimulator and restricted weight bearing. Surgery is often needed to better assess the lesion and determine the goal of either lesion healing or removal. Then applying the surgical technique which will be most successful achieving the goal. I wish you and your daughter the best in dealing with this situation.

  14. Hi doctor Roger Lyon

    besides gg for operation, are there any other non operative method ?

    By not gg for operation, will OCD lead to wear and tear evetually ?

  15. As a child I had lots of ankle problems they tried to correct it with first a brace, then a boot, then a cast, and finally I had surgery around 12 years old, I remember being told that the surgery could fix it forever or it could come back as an adult and I may have to have the surgery again. About 4 years ago the pain started up again. Finally last year I went in to see the doctor. The practice still had me on record as a patient but no record of what I had done, my parents couldn’t remember what it was called either. So I went in clueless. They did xrays and an MRI and concluded my pain is from arthritis and the limited mobility is because I had a tarsal coalition as a child. But I am positive that is not correct (the arthritis I know is true but I know I didn’t have a flat foot). The surgery may have been 17 years ago but I remember a little and what I remember is that they went in there to replace or repair some cartilage between two bones that were rubbing together that shouldn’t have been and that’s what was causing my pain, my constant twisting my ankle, and falls because my ankle would go out on me. I intend to see another doctor, but until then possibly you can give me hope as the OCD sounds to be dead on. IF I could get that cartilage issue fixed surgically again would it bring back more mobility allowing me to walk correctly dispersing my weight more evenly on my joints and giving my now arthritic joint some rest and relief. My doctor wants to fuse my ankle but once he told me it could cause arthritis in other joints I really don’t want to do that, I’m only 29 I really don’t want arthritis all over my foot and ankle by 35 if I can avoid it.

Leave a Reply

Skip to toolbar