Chronic Ankle Pain / Sports Related Ankle Injuries

Osteochondral lesions of the talus (OCD, OLT)
Osteochondral lesions of the talus are “chips” of the joint surfaces of the tibia or talus (ankle joint bones) that involve both the bone and overlying cartilage lining surface of the joint. These lesions are localized areas of joint surface where the normal lining is lost and the surrounding surface of the joint is intact and normal. This is analogous to a divot in a golf fairway where the majority of the surface is normal and there is a small area of an abnormal surface present.

Many of these lesions are a result of trauma to the ankle and commonly are the cause of chronic pain after an ankle “sprain” that has not resolved within an expected time frame. Other lesions can cause continued pain without any specific incident that seems to be related to the onset of the pain.

For young patients, the pain associated with these lesions may resolve with conservative treatment (immobilization in a cast and non-wt bearing). Adults generally will not improve with conservative treatment and surgical treatment is usually recommended. The surgical options for this condition vary from arthroscopic minimally invasive techniques to open cartilage transplant procedures. Most patients’ initially benefit from an attempt at arthroscopic evaluation through two small incisions in the ankle and a procedure called “microfracture and debridement” which involves removing the damaged cartilage and using a pick to create holes in the underlying damaged bone to stimulate new substitute type cartilage to grow in the area of the defect abnormality. With this treatment, a period of 4 -6 weeks of non-weight bearing and immobilization in a boot is necessary to allow a new “substitute” type of cartilage to fill in the previous defect of the normal cartilage surface. Progressive treatment involving weight bearing in a boot, followed by weight bearing in a regular shoe, returns to low-impact activity, and finally returns to sport is allowed in a stepwise fashion. Immediately after surgery motion of the ankle is allowed and swimming and seated activity such as riding a bike is encouraged.

In some scenarios, the above procedure may not be indicated and alternative treatments are necessary to treat the cartilage defect. This is mainly after failure of a previous arthroscopic drilling procedure or a defect that involves to large of the normal cartilage surface to attempt such a procedure because of a high likelihood of failure. In this circumstance, cartilage may be harvested from one location (such as from the knee or from other parts of the ankle) and transplanted to the area of the defect. Alternatively, cartilage from a cadaver (allograft) may be utilized and transplanted to the region of the defect. Both of these procedures are much more involved and may have a more complex and lengthy recovery associated with them.

Dr. Vora has a special interest in these cartilage disorders of the ankle joint and utilizes arthroscopic or minimally invasive techniques whenever possible for such conditions to minimize recovery and maximize outcomes whenever possible. Dr. Vora has published and lectured on these conditions both locally and nationally and instructs other orthopaedic surgeons in the treatment of this condition and is currently involved in studies evaluating the treatments of this condition.

For more on this condition, also see:
Arthroscopy of the foot and ankle
 

Chronic ankle instability
Instability is the feeling patients’ experience of continued lack of stability or confidence in the ankle, feeling of giving way of the ankle recurrently, or the experiencing of continued recurrent ankle sprains that becomes a long-standing problem that has not improved with conservative treatment such as physical therapy or bracing of the ankle. This may occur during sporting activities but may also occur during every day activities, such as walking on uneven surfaces and without any specific trauma. Long-term instability has also been theorized to possibly lead to arthritis of the ankle joint secondary to the recurrent damage to the ankle and joint surfaces with each sprain and the cumulative wear of the ankle because of the lack of restraint of the ankle joint causing irregular rubbing of the cartilage surfaces. For these reasons, a reconstructive procedure to reconstruct the ankle ligaments by tightening back to the bone may be necessary when conservative treatment has failed. Some of the surrounding tissues are often used to reinforce the repair as well. The majority of patients simply need this type of procedure to improve their symptoms and restore stability of the ankle and has the advantage of maintaining the normal anatomy and structures of the ankle and surrounding tissues. In some patients with poor or severely stretched out ligaments which are not repairable, other tissue is necessary to reconstruct the ligaments of the ankle. Sometimes additional bone correction is necessary for patients with abnormal bone alignment of the heel. These procedures generally involve non-weight bearing for 6 weeks followed by 6 weeks of protected weight-bearing in a cast and at 12 weeks transition to regular shoes is possible. Return to sport is individualized based upon level and type of activity but can generally be expected to occur around 4 to 6 months after surgery.

Dr. Vora has a special interest in these ankle ligament reconstruction techniques. He is currently investigating a minimally-invasive reconstructive technique using specialized tissue graft taken from the knee region for select patients and for patients that have failed previous surgical reconstructions of the ankle. In addition, Dr. Vora utilizes arthroscopy (poke holes in the ankle) to evaluate the cartilage surface of the ankle to treat all associated injuries when reconstructing the ligaments and is evaluating the efficacy of such treatments in improving outcomes.

For more on this condition, also see:
Arthroscopy of the foot and ankle
 

Peroneal tendon injury
One cause of continued pain around the ankle region that may occur after a traumatic injury of the ankle (such as an ankle sprain) or without any specific injury that can be recalled are disorders of the peroneal tendons. These are two tendons that run on the outside part of the ankle behind the outside ankle bone (lateral malleolus) and extend from the outside part of the ankle down to the outside part of the foot. These tendons run in a sheath with are a tunnel that holds the tendons in their normal location behind the ankle bone. At times the tendon sheath may become torn causing the tendons to “pop” out of their normal position behind the ankle and cause abnormal rubbing on the lateral ankle bone (fibula) (peroneal tendon subluxation). This may additionally cause the tendons to tear due to the abnormal rubbing of the tendon on the bone. Alternatively, the tendon may tear without abnormality of the tendon sheath (peroneal tendon tear). These injuries generally do not resolve with conservative treatment and often surgery is necessary. The surgical treatments for these conditions when pain persists involve repairing the tendons whenever possible, or in scenarios where the tendon is not repairable, transferring the tendons and suturing them together to maintain functionality and balance of the foot. In addition, if the tendon sheath is torn and the tendons are not staying in their appropriate positions, this lining can be repaired to recreate the normal “tunnel” for the tendons to pass within smoothly. Sometimes a trough in the fibula bone needs to be created to assure a good “tunnel” has been created. The time frame for recovery is variable depending upon which of the above procedures is necessary but generally 6 weeks of non-weight bearing in a cast followed by 6 weeks of weight bearing in a boot is recommended. Return to sport is dependent upon the type of injury and treatment necessary and can be as little as 3 months or in some scenarios, a longer recovery can be expected.

One additional treatment that is may be beneficial for some patients is peroneal tendoscopy, a minimally-invasive procedure that can be utilized to look at the peroneal tendons through two small poke hole incisions in the skin and passing a camera and a probe into the tendon “tunnel” to examine the tendons thoroughly. This can help diagnose a tear of the tendons when this is suspected clinically but MRI or ultrasound testing have not been able to reveal a tendon tear. If a tear is identified, then a limited open incision over the area of the tear can be performed to repair the tendon in the methods described above. If no tear is present, open surgery is not performed minimizing potential complications and the tendon sheath can be “cleaned out” of scar tissue through the camera alone if necessary. Dr. Vora specializes in this minimally-invasive technique for the treatment of this condition when appropriate.

For more on this condition, also see:
Arthroscopy of the foot and ankle