What is the recommended management for a patient with chronic ankle pain and radiographic findings of heterotopic ossifications, but no acute fracture?

From the Guidelines

The recommended management for a patient with chronic ankle pain and heterotopic ossifications without acute fracture involves a stepwise approach, starting with conservative treatment including rest, activity modification, and non-steroidal anti-inflammatory drugs (NSAIDs) for 2-4 weeks, as suggested by the American College of Radiology 1.

Initial Management

• Conservative treatment should be implemented initially, including rest, activity modification, and NSAIDs such as ibuprofen (400-800mg three times daily) or naproxen (500mg twice daily) for 2-4 weeks to reduce pain and inflammation.
• Physical therapy focusing on ankle strengthening, range of motion exercises, and proprioception training is essential for functional improvement, as it helps in maintaining or regaining functional capacity and reducing inflammation, in line with the treatment goals outlined for chronic non-bacterial osteitis (CNO) management 1.
• Custom orthotics or bracing may provide stability and reduce pain during activities.

Further Management

• For persistent pain, corticosteroid injections (such as methylprednisolone 40mg with lidocaine) can be considered as a bridging option, awaiting the effect of other agents, throughout the treatment steps, as recommended for CNO management 1.
• If conservative measures fail after 3-6 months, surgical intervention may be necessary, including arthroscopic debridement or excision of the heterotopic ossifications.
• The treatment approach should prioritize relieving symptoms, maintaining or regaining functional capacity, reducing inflammation, and preventing the progression of structural musculoskeletal damage, as outlined in the expert consensus recommendations for CNO management 1.

Treatment Evaluation

• Treatment response should be evaluated at regular intervals, primarily based on clinical measures, but also integrating radiological and biochemical measures as appropriate, to declare sufficient or insufficient response based on improvement, no change, or worsening on relevant measures, with the individual patient context and predetermined treatment goals as reference 1.
• This approach is recommended because heterotopic ossifications represent abnormal bone formation in soft tissues following trauma or surgery, and management should address both pain control and functional limitations while avoiding unnecessary surgical intervention when possible.

From the Research

Management of Chronic Ankle Pain

• The patient's radiographic findings of heterotopic ossifications, but no acute fracture, suggest a chronic condition that requires a comprehensive management approach 2.
• A tissue-specific clinical examination is essential for diagnosing and managing chronic ankle pain, including passive and resistive tests to assess movement limitations and pain provocation 2.
• The examination should also include weight-bearing components, as limits and pain provocation are frequently produced only when the patient attempts to function in weight-bearing 2.

Pharmacological Management

• For patients with chronic ankle pain, oral paracetamol and/or ibuprofen may be considered for pain management, although studies suggest that there is no significant difference in analgesic effects between the two 3, 4.
• Acetaminophen may be considered as the mainstay for pain relief in patients with chronic ankle pain, given its efficacy and lower risk of side effects compared to other medications 5.

Non-Pharmacological Management

• Numerous non-surgical measures can be implemented in treating chronic ankle pain, including physical therapy, orthotics, and bracing 2.
• Surgical interventions may be considered for patients who are resistant to conservative care, although this should be determined on a case-by-case basis 2.

Diagnostic Approach

• A thorough evaluation and treatment of ankle injuries requires a focused history, physical examination, and imaging to determine the presence of any underlying conditions 6.
• The diagnostic approach should consider the patient's symptoms, medical history, and radiographic findings to develop an effective management plan 6, 2.