Ankle Problem - Looking for Wisdom

[Ronsonic]

Been diagnosed with a "pothole" in the cartilage of my right ankle. Yes, that's what the doctor called it. He also called it an osteochondral lesion. Looking at the MRI even I can tell it ain't right.

Apparently you only get so many sprains, strains, twists and rolls of the ankle before it adds up to real damage.

I can road ride with little problem just some aching afterward. But walking, esp up or down hills or steps is an adventure. I'm also staying out of the woods away from ruts, roots and rocks.

For the time being he's recommending a course of hyaluronic acid injections. Then consider surgical options down the road.

So. Searching here found nothing. Anybody dealing with this sort of problem? Are we on the right track? What think the assembled wisdom and experience here?

[Louis]

I don't have anything specific or knowledgeable to say regarding your condition, other than to provide this data point: When I sprained my right ankle (pretty badly) about 10-15 years ago it took a long, long time - over a year - for me to be back to about, say, 98% of "normal." It doesn't bother me anymore, but it did for ages.

Good luck.

[Hombre]

Using stabilization exercises helps. Although different, I have a torn meniscus and have been using various forms of stabilization to take some of the pressure on the knee.
I find that with my cartilage injury that rotational and lateral movements really irritate my knee. Also walking on uneven surfaces from hiking or similar activities can have the same affect.

I've been taking glucosamine and chondroitin to supplement some of the inflammation, but mind you these aren't miracle pills and only so much can be absorbed into your body.

[Hilltopperny]

Been diagnosed with a "pothole" in the cartilage of my right ankle. Yes, that's what the doctor called it. He also called it an osteochondral lesion. Looking at the MRI even I can tell it ain't right.

Apparently you only get so many sprains, strains, twists and rolls of the ankle before it adds up to real damage.

I can road ride with little problem just some aching afterward. But walking, esp up or down hills or steps is an adventure. I'm also staying out of the woods away from ruts, roots and rocks.

For the time being he's recommending a course of hyaluronic acid injections. Then consider surgical options down the road.

So. Searching here found nothing. Anybody dealing with this sort of problem? Are we on the right track? What think the assembled wisdom and experience here?

Well I too have osteochondritis dissecans after a bad slip and fall on ice. Mine formed on the talor dome and I no longer have any cartilage as it tore off. My doctor scoped it out and cleaned it up while drilling the lesion. I am 3 years post initial injury and have had my foot and ankle rebuilt after the initial scope and a third time under the knife to remove the hardware and another scope.

I recently had a mri and now there is something abnormal forming in the same area. I'd suggest that you postpone any surgery for a while and see if it is something you can live with. I had a few other things happen as a result of the accident, but I have a hard time walking on uneven surfaces and can feel any type of change in the ground. It causes me quite a bit of pain and discomfort to stay on my feet and I no longer hike or climb anything.

I do still ride my bike as much as possible. The little to no impact excersize helps strengthen the ligaments and tendons and keeps my leg from completely withering away due to atrophy. Hopefully yours can be repaired as long as you have some cartilage left. It may just need to be scoped and cleaned up to remove any loose cartilage or reattach the existing cartilage.

As far as the hyaluronic acid injections go, I've only heard of them being used for knees and other joints. My mother in laws boss used them regularly for his knee and was very happy with the results. He said they worked great, but not to over do it. Good luck with your treatment and let me know how the injections work if you get the chance. I'm interested to hear how it works with the ankle and otseochondrial lesion.

[Ronsonic]

Thanks for the feedback. Hilltopperny, you pretty well confirmed my reluctance to go surgical unless I really can't live with it. Apparently my ankle is less damaged than yours so the shots may do the job. I will certainly let you know how this goes.

I'm going to be off the mountain bike for awhile, that's for sure. But on the road I can control my foot position pretty well. It screws up everything else as far as fit and even saddle comfort, but whatchagonnado, quit riding?

Best of luck with your recovery.

[R3awak3n]

I have a similar problem from when I broke my ankle a couple of years ago. Sometimes I have no pain, when I ride I usually have no pain its all good. But long walks and hiking and stuff like that really put a hurt on it. I had 2 surgeries on it to fix the broken ankle and the doctor told me it will probably not ever be 100%. Was he right.

[Ronsonic]

Wanted to update this, from discussion in the thread and a couple of PMs, I'm not the only one with a notchy ankle bearing.

It is pretty typical, damage to the cartilage at the top of the talus bone. Doc recommended we try a series of injections of hyalgan before considering surgery or drilling. It's been used with good effect on damaged knees. It's use on ankles isn't as well documented but there are a number of papers and some experience. The program was for three injections two weeks apart.

I've just gotten my second injection today. The previous one from two weeks ago has had a positive result. Much less pain and stiffness no more sharp spasms of ouch when I break my ankle's new rules. Still achy, especially when walking after a ride but not crippling. Yesterday's 20 miler was uneventful and I had no trouble walking today. Today's shot hurt as bad or worse than the first one, both left me feeling a bit sick, but it works so I'm looking forward to the final result. I'll keep you posted.

[Hilltopperny]

Thanks for the update Ron.

[Ronsonic]

It's now been a few months since finishing up the series of HA injections.

Damn those things hurt. Shot of novacaine to start and then freeze spray along with the big needle going in. Still, ouch.

The ankle is greatly improved. Not good as new, or even good condition used. But functional without serious pain - mostly I'm just aware of it in a way that i'm not aware of my other ankle. Need to watch how I use it a bit, but not bad.

So, if anyone was wondering, I recommend this as a first step in case of moderate damage. And worth trying before drilling, 'scoping, etc..

[Hilltopperny]

I actually tried this about a month ago. Even after the scope and drill it has seemed to alleviate most of the pain on the top of my foot. I still have plantar fasciitis and other reoccurring pains, but the constant pain from bone on bone contact at the talor dome seems to have subsided some. Hopefully it lasts...

[jmoore]

My 12yo son has this exact same issue. OCD of the talar dome. We had him in a boot for 2 months with no change. Granted he is still playing competitive sports, so his issue is different. We opted for surgery to try for the quickest solution. He had surgery in Feb and they drilled the lesion and injected some concentrated t-cells they took from his hip. He is walking with no pain now, but he is very careful to follow dr's instructions for activity. He has not had any pain after the initial healing of the surgery.

We are going back to the DR this week to check progress and see if he can resume light activity. Fingers crossed.

I know that there are several levels of intrusiveness on the surgery, depending on how much cartlidge damage there was. He had no damage, so only drilling for him. Dr also said that he would not be 100%. Probably 90-95% was best case.

[11.4]

I've worked with a couple athletes who have dealt with this same problem, and with several who had the same issue in different locations.

Between my experience and that of a number of specialists we've worked with, here are a few points we seem to have found consistent agreement on:

1. Chondroitin/Glucosamine and Hyaluronic acid injections or supplements can slightly stabilize what's left, but it doesn't rebuild and it doesn't reshape the joint. (Part of the damage is erosion in a location, part is a reshaping over time in adjacent areas to accommodate whatever was going wrong.) It's usually the first step in a physician's recommendation because it can somewhat minimize pain in day-to-day activity, but it won't restore a healthy joint.

2. There are new immune therapies using T-cells and other stem cell therapy that are in trials, but it isn't clear whether they can restore an athletic joint. That's a very different target than simply reducing pain and making a walkable joint. There's nothing that suggests that these therapies will regrow a joint for extensive physical activity if you don't start with that.

3. Surgery tends to be a reshaping of the joint surface, mostly by reshaping where the joint has already reshaped over time. It helps the joint track better and thereby wear less and hurt less, but if you were deteriorating before, that trend is likely to continue. It's also a long and slow recovery -- measured in many cases in years. And if the surgery requires opening the achilles tendon to get to the injury, it's even slower.

4. What this tends to suggest is that you want to work on stabilization and positioning around the joint. Cartilage doesn't gain strength to speak of, but you want to ensure the joint moves the way it's supposed to. That means a lot of muscular strengthening throughout the foot and calf, ensuring that your whole leg is aligned and not forcing abusive movement in the heel, and that you have a very stable platform for your foot. The source of your problem may have arisen from an instability in the hip, a knee that didn't track properly, or even a bit of scoliosis in the spine. Our bodies cope with such things but often incur injury elsewhere as a result. As for a stable platform, the traditional response to any injuries has been aggressive orthotic correction. These days, that's being rethought and more athletes are benefiting from adapting to a platform that's flat and uncorrected and wider. Part of the reasoning was that it originally was felt that you needed a brace for the rest of your life; now it's recognized that your foot and calf can develop greater strength and self-correct any postural issues, often better than an orthotic can induce. Simply learning to rotate your knee slightly and building the strength to support it can correct arch problems which can in turn correct the tracking in your ankle. I'd suggest you at least include this as an option to consider. And understand that any alternative approach to surgery is something that can still take 2-3 years to manifest itself as improvements. You can start to reduce pain if you can correct postural and tracking faults, but don't expect to resolve your issue completely in, say, 3-6 months. Many people move on to surgery because they don't get fast recovery, when such recovery is simply unrealistic. It's just what you're dealing with. Hope that helps. If you supply more specific info on your injury and pain there's probably more to be said, but this is just a general response to an injury we've seen a fair bit of before.

[dgauthier]

(..) 2. There are new immune therapies using T-cells and other stem cell therapy that are in trials, but it isn't clear whether they can restore an athletic joint. That's a very different target than simply reducing pain and making a walkable joint. There's nothing that suggests that these therapies will regrow a joint for extensive physical activity if you don't start with that.
(...)

A family member (50-something, non-athletic female) had a stem cell injection procedure on her knee. It apparently did her a world of good, aleviated the pain, fixed the problem, etc.

11.4 says restoring an athletic joint is "a very different target than simply reducing pain and making a walkable joint", but you appear to be experiencing more pain walking than riding, so a walkable joint might be a ridable joint as well. You say you are looking for wisdom, and I'm afraid I am not wise in this area, but perhaps this form of therapy would be worth looking into.

[Ronsonic]

11.4, thanks for the comments, nice to hear an overview from another pro.

Especially interesting were your comments on alignment and use. The first thing I noticed back on the bike was that my knee and ankle no longer agreed about my previous cleat placement and position on the bike. Short rides with lots of tools followed. Pretty much dialed in now and can ride with comfort and minimal or no soreness afterward.

At this point my only problems and pain come from things that apply force in a toe-up position. I don't do hard calf stretches and avoid walking up hill flat footed. Running up hills and steps is fine.

At my age and considering the condition of my other limbs I'm pretty :banana:

[11.4]

11.4, thanks for the comments, nice to hear an overview from another pro.

Especially interesting were your comments on alignment and use. The first thing I noticed back on the bike was that my knee and ankle no longer agreed about my previous cleat placement and position on the bike. Short rides with lots of tools followed. Pretty much dialed in now and can ride with comfort and minimal or no soreness afterward.

At this point my only problems and pain come from things that apply force in a toe-up position. I don't do hard calf stretches and avoid walking up hill flat footed. Running up hills and steps is fine.

At my age and considering the condition of my other limbs I'm pretty :banana:

Are you sure that the pain isn't from a spur in the achilles tendon? Those can be surprisingly hard to identify in an x-ray when they are diffuse in a tendon -- you have to sight them along just the right axis or they just look like a slight cloud and are easily missed or minimized. If you've had the problem you describe, I'd almost predict an achilles spur as a side-effect and it can produce exactly the symptoms you describe. It's worth checking on. It's not easily to fix either, but is more amenable to stretching, heat, and so on.