Nonoperative treatment includes ankle bracing if instability is present. The subtle cavus foot may be treated with a foot orthotic: plantarflexed first ray recessed below the plane of the lateral rays and the arch kept lower than that of the patient.5
Intensive exercise programs may worsen symptoms.
If the medial impingement lesion is sufficiently symptomatic, open or arthroscopic surgery may be indicated.7,15,16
This lesion can be approached through a longitudinal medial incision over the medial gutter of the ankle joint. The talar lesion may present as a marginal osteophyte or a “sharp edge” of the most distal edge of the medial facet, varying in size, from small to very large in chronic phases. A deposition of immature bone may be present (grey to reddish in color), covering the leading edge of the facet ( and ). A pedunculated lesion may also occur at the edge or just distal to the facet ().
A, medial impingement spurs on the distal tibia and medial facet of the talus—talar spur (solid arrow) and tibial spur (broken arrow); B, a talar spur at the leading edge of the medial facet of the talus (solid arrow).
A pedunculated lesion in a teenage female gymnast (solid arrow).
When the ankle is dorsiflexed, the talar lesion will usually abut against the tibial lesion, which is an accumulation of new bone at the anterior portion of the medial malleolus-tibial plafond junction.14-16,18 The osteophyte does not arise from the edge of the mortise corner but lies just anterior to the edge, hanging downward like an awning over the corner of the mortise ( and ). Care must be taken to recognize and remove this lesion.
Figure 6. A, semicoronal computed tomography section through the anterior ankle joint in a male basketball player. The medial ankle mortise contour is normal in this section. B, computed tomography section anterior to the section in A, through the tibial impingement (more ...)
Figure 7. A, 3-dimensional reconstructive CT scan of medial impingement osteophytes in a male teenage soccer player. The prominent spur on the leading edge of the medial talar facet (solid arrow) and the “kissing” lesion spur on the tibial side (more ...)
Both the talar and tibial lesions are generally removed with small osteotomes, rongeurs, and files. When the talar spur is being removed, care should be taken not to notch the neck of the talus, to avoid creating a stress riser and a resultant pathologic fracture. The entire leading edge of the medial facet of the talus should be visualized because the osteophyte may extend inferiorly and cause synovitis between the spur and the deltoid ligament (). Frequently, there are loose bodies in the gutter that must be removed13,17
A bulky compression dressing is used to minimize swelling and ankle effusion. Motion and weightbearing are gradually begun when the wound is healed. Jumping activities are not advised for 6 to 8 weeks, if there was significant bone removal and exposed cancellous bone.