What is the diagnosis for a patient with right ankle pain, given findings of a healed fracture of the lateral malleolus, mild marginal spurring, and degenerative changes at the tibiotalar joint, including subcortical cysts and sclerosis in the lateral tibial plafond and lateral talar dome?

From the Guidelines

The patient's current ankle pain is most likely due to post-traumatic degenerative changes, and an MRI is recommended to further evaluate the osteochondral abnormalities of the ankle, as it has been shown to be effective in determining osteochondral injury instability with a sensitivity of 97% 1. The ankle X-ray from April 15,2025 shows several findings consistent with post-traumatic degenerative changes. There is evidence of healed fractures of both the lateral and medial malleoli, with mild spurring at the lateral malleolus tip and an ossicle below the medial malleolus representing previous fracture sites. The tibiotalar joint shows degenerative changes with subcortical cysts and sclerosis in the lateral tibial plafond. The lateral talar dome has subcortical lucency that could represent either a degenerative cyst or an osteochondral defect. Small calcaneal spurs are present with minimal soft tissue swelling. No acute bone abnormalities were identified. Some key points to consider in the management of this patient's condition include:

• The use of MRI to evaluate osteochondral abnormalities, as it has been shown to perform similarly to arthroscopy in one multimodality study 1
• The importance of determining osteochondral injury instability, which can be done with high sensitivity using MRI 1
• The potential for MRI to stage osteochondral lesions preoperatively, with an accuracy of 81% 1
• The possibility of using high-resolution MRI with a microscopy coil to detect small, clinically relevant features of talar osteochondral lesions that may be missed on standard MRI 1 Treatment options might include anti-inflammatory medications, physical therapy, supportive footwear or bracing, and possibly intra-articular injections if symptoms are severe. Weight management and activity modification may also help reduce pain from these degenerative changes.

From the Research

Ankle Pain and Degenerative Changes

• The patient's ankle pain is associated with degenerative changes at the tibiotalar joint, as indicated by subcortical cysts and sclerosis of the lateral tibial plafond, and subcortical lucency in the lateral talar dome, which may be due to a degenerative cyst or osteochondral defect 2, 3.
• The presence of remote fractures of the lateral and medial malleoli suggests a history of traumatic injury, which is a common cause of end-stage arthritis of the tibiotalar joint 2.
• The patient's condition is characterized by minimal soft tissue swelling and no acute bony abnormality, indicating a chronic rather than acute condition.

Treatment Options

• Nonsurgical treatment options for end-stage arthritis of the ankle include bracing, shoe-wear modifications, and selective joint injections 2, 4.
• For patients who fail to respond to nonsurgical modalities, the two primary treatment options are arthroplasty and arthrodesis, each with its own proponents and inherent risks 2, 4.
• Realignment surgery, such as supramalleolar osteotomies, may be an alternative treatment option for patients with asymmetric ankle osteoarthritis, particularly those with varus or valgus hindfoot deformities 5.

Management of Osteoarthritis

• The management of osteoarthritis (OA) involves a range of options, including nonsteroidal anti-inflammatory drugs (NSAIDs), corticosteroid injections, orthotics, and ankle braces 4.
• Acetaminophen may be considered as a first-line pharmacologic therapy for OA, although its efficacy and safety compared to NSAIDs are still debated 6.
• The choice of treatment for OA should be individualized, taking into account the patient's specific condition, medical history, and lifestyle.