What does my ankle MRI showing subacute impaction injury, Achilles tendinopathy, and plantar fasciopathy mean and how should I treat it?

Understanding Your Ankle MRI Findings

Your MRI shows three distinct but related overuse injuries that require a structured conservative treatment approach starting with eccentric exercises, activity modification, and physical therapy, with surgery reserved only if symptoms persist beyond 6 months. 1, 2, 3

What Each Finding Means

1. Subchondral Flattening of Medial Talar Dome (Subacute Impaction Injury)

• This represents a bone bruise or stress injury to the top of your talus bone (ankle bone) where it meets the tibia, with associated bone marrow swelling and cyst formation 1
• The "subacute" timing suggests this injury occurred weeks to a few months ago, not acutely 1
• MRI is the gold standard for detecting this type of radiographically occult injury, with 98% sensitivity and 93% specificity for bone marrow edema 1
• This finding indicates you need protected weight-bearing and activity modification to allow bone healing 1

2. Mild Achilles Tendinopathy

• This represents a failed healing response in your Achilles tendon with abnormal tenocyte proliferation and collagen fiber disruption, not primarily an inflammatory condition 2, 3
• The pathology exists on a continuum from reactive tendinopathy (early thickening) through tendon disrepair to degenerative changes 2
• Pain is likely due to neovascularization and ingrowth of new nerve fibers associated with the degenerative process 2

3. Plantar Fasciopathy (Acute-on-Chronic)

• Thickening of the plantar fascia origin beyond 5mm with adjacent soft tissue edema confirms plantar fasciopathy 4
• The "acute-on-chronic" designation means you have underlying chronic degeneration with a recent flare-up 4, 5
• This commonly causes heel pain, especially with first steps in the morning 5

Treatment Algorithm

Phase 1: Conservative Management (First 3-6 Months)

For the Talar Impaction Injury:

• Activity modification with protected weight-bearing until bone marrow edema resolves 1
• Avoid high-impact activities (running, jumping) that load the ankle joint 1
• Consider a walking boot for 2-4 weeks if pain is significant 1

For Achilles Tendinopathy (Highest Evidence):

• Eccentric exercise is the primary treatment with the highest evidence-based effectiveness 1, 2, 3, 6
• Perform eccentric heel drops: stand on edge of step, lower heel below step level slowly, use opposite leg to return to starting position 1
• Deep transverse friction massage of the gastrocnemius-soleus complex 1
• Stretching of the calf muscles 1, 3
• Heel lift orthotics to unload the tendon for pain relief 1
• Correct any overpronation or pes planus with shoe orthotics 1

For Plantar Fasciopathy:

• Physical therapy with stretching exercises 4, 5
• Night splints to maintain dorsiflexion 5
• Supportive footwear with arch support 5
• Avoid walking barefoot, especially on hard surfaces 5

Phase 2: If No Improvement After 6-8 Weeks

For Achilles Tendinopathy:

• Extracorporeal shock wave therapy (ESWT) - second-line treatment with good evidence 2, 3, 6
• Glyceryl trinitrate (nitric oxide) patches 3, 6
• Peritendinous injections at the interface between Achilles tendon and Kager's triangle if physical therapy fails 3, 6
• Avoid corticosteroid injections - they may provide short-term relief but are not effective long-term and can weaken the tendon 2

For Plantar Fasciopathy:

• Ultrasound-guided corticosteroid injection at the plantar fascia origin 4
• ESWT 4, 5
• Dry needling under ultrasound guidance 4

Phase 3: Surgical Consideration (After 6 Months of Failed Conservative Treatment)

• Surgery is indicated only after 6 months of non-operative management 3, 6
• For Achilles: open debridement of diseased tendon; augmentation may be necessary if >50% of tendon requires excision 5
• For plantar fascia: endoscopic or open plantar fascia release 5
• For talar lesion: arthroscopic debridement and microfracture if symptomatic 1

Critical Pitfalls to Avoid

• Do NOT use NSAIDs or corticosteroid injections for Achilles tendinopathy - they provide only short-term relief and do not address the underlying pathology 2
• Do NOT continue high-impact activities with the talar bone injury - this can progress to osteochondral defect requiring surgery 1
• Do NOT expect rapid improvement - tendinopathy recovery typically takes 3-6 months even with optimal treatment 2, 3, 6
• Understand that symptoms may recur with either conservative or surgical approaches 3

Monitoring and Follow-up

• Clinical assessment is primary - improvement in morning stiffness, pain on palpation, and functional activities indicates healing 2
• Repeat imaging is generally not necessary unless symptoms worsen or fail to improve after 3-6 months of appropriate treatment 1, 4
• Ultrasound can monitor Achilles tendon thickness and plantar fascia thickness as objective measures of treatment response 7, 4