I have right ankle pain after prior ankle arthroscopy, debridement, and Broström ligament repair; does the Magnetic Resonance Imaging show any tear of the anterior talofibular or calcaneofibular ligaments, an osteochondral lesion of the talar dome, or other pathology, and what is the recommended management?

MRI Interpretation: Post-Broström Repair with Persistent Ankle Pain

Direct Answer to Your Question

Your MRI shows no tear of the anterior talofibular or calcaneofibular ligaments, no osteochondral lesion of the talar dome, and the only significant pathology is mild posterior tibial tendinosis with tenosynovitis—the ligament repair appears intact and your pain is likely related to the tendon pathology rather than ligament failure. 1

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Detailed MRI Findings Interpretation

Lateral Ligament Complex Status

• No ligament tears are present: The increased signal and caliber in your anterior talofibular and calcaneofibular ligaments represent expected postoperative changes, not re-injury 1
• MRI has 97% diagnostic accuracy for detecting anterior talofibular ligament tears and 88-92% accuracy for calcaneofibular ligament tears when compared to arthroscopy, making this a highly reliable assessment 1
• The suture artifact and mild inhomogeneity you see described are normal findings after Broström repair and do not indicate failure 1
• The posterior talofibular ligament attenuation is an old injury that does not require intervention, as this ligament is rarely the primary source of instability 1

Talar Dome Assessment

• No osteochondral lesion is present: Your talar dome is intact with no evidence of cartilage or bone injury 1, 2
• This is important because osteochondral lesions can be a hidden source of persistent ankle pain after lateral ligament injury, but you can definitively rule this out 2

The Actual Source of Your Pain

• Mild posterior tibial tendinosis with tenosynovitis is your most likely pain generator 1
• MRI demonstrates 83.9% sensitivity and 74.5% specificity for detecting tendinopathy 1
• This tendon pathology was likely present before surgery or developed due to altered biomechanics during your recovery period 1

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Recommended Management Algorithm

Conservative Treatment (First-Line)

You should pursue 6-8 weeks of structured physical therapy targeting posterior tibial tendon rehabilitation before considering any additional interventions. 3, 4

• Eccentric strengthening exercises for the posterior tibial tendon 3
• Semirigid or lace-up ankle support during activities, which decreases recovery time and facilitates return to function 3
• Immediate weight-bearing as tolerated rather than prolonged immobilization 3
• Avoid cryotherapy alone, as 27 randomized trials (n=1670) show it does not significantly reduce pain or improve function when used in isolation 3

If Conservative Treatment Fails After 6-8 Weeks

• Consider ultrasound-guided or fluoroscopy-guided intra-sheath anesthetic injection into the posterior tibial tendon sheath for both diagnostic confirmation and therapeutic benefit 1
• If injection provides temporary relief, diagnostic tenography can be considered, with one study showing 47% of patients achieving prolonged symptom relief 1

Surgical Consideration

• Surgery is NOT indicated based on your current MRI findings 3, 4
• Your Broström repair is intact with only 6% failure rate reported in the literature, and failure typically presents with frank instability rather than isolated pain 4
• The three documented failures in the literature occurred after traumatic re-tears with obvious instability on examination 4

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Critical Clinical Pearls

What This MRI Rules Out

• Ligament repair failure: No fiber discontinuity means your surgery was successful 1
• Osteochondral injury: A common missed diagnosis that would require different management 2
• Syndesmotic injury: Your tibiofibular ligaments are intact 1

Common Pitfall to Avoid

• Do not interpret postoperative ligament signal changes as failure: Increased caliber and intermediate signal in repaired ligaments is expected and does not indicate re-tear when fiber continuity is maintained 1, 5
• Normal ATFL thickness is 2.19 ± 0.6 mm and CFL is 2.13 ± 0.5 mm; post-surgical thickening without discontinuity represents healing scar tissue 5

Expected Timeline

• Return to sport rate after Broström repair is 94% with mean follow-up of 42 months 4
• Your posterior tibial tendinosis should respond to conservative treatment within 6-8 weeks if addressed appropriately 1, 3

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Next Steps

Begin physical therapy focused on posterior tibial tendon rehabilitation with immediate protected weight-bearing in a lace-up ankle support, and reassess in 6-8 weeks. 1, 3, 4

• If pain persists despite appropriate rehabilitation, proceed to diagnostic injection of the posterior tibial tendon sheath 1
• Do not pursue repeat surgery unless you develop frank instability with positive anterior drawer testing at 4-5 days post-injury (84% sensitivity, 96% specificity) 6, 3
• The mild Achilles tendinosis noted incidentally should be monitored but does not require specific intervention at this time 1