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Firstly forgive me for the lack of clinical investigations on the below patient, but the family member in question lives interstate and the consultations have all taken place over the phone

57 year old female - very active at work (newsagency = very long hours)

Hx of pain in L/sinus tarsi area and rediating around to talo-nav area.
Pain has been present for a long period of time (up to a year or more), but has recently (last month) got to the stage of being incredibly painful (esp at night) and pt at times is unable to weightbare.

At the first sign of pain a year ago pt changed shoes and accquired some rigid 10 degree wedge posted orthoses and this worked with some success.

Recently due to increasing pain had x-ray and CT

X-ray report stated:

There appears to be a small subchondral lucency seen in relation to the medial talar dome ?degenerateve varsus post traumatic in nature.

CT report states:
There is a focal well demined 6mm area of lucency with a thin sclerotic rim seen alog the postero-medial aspect of the talar dome, presumably corresponding to the plain film abnormality. It's appearances are non-agressive, most likely degenerative in nature, representing a subchondral cyst/geode.

My question is what are the treatment options from here?

From what i have read a period of immobilisation should be tried and if this is not successful in reducing pain then a surgical review is warrented.

Do people agree with this treatment regime?

Any help appreciated
Cheers Sooze

 

Hi Sooze:

Well first you need to actually examine the patient in order to correlate CT findings with physical symptoms.

Let's assume this patient's pain is in fact from the OCD seen on CT.
You will need to access ROM of the ankle, area of tenderness, presence or absence of crepitus.

At age 57 and after 12 months it is unlikely to resolve on its own, as it does in children at times.

As you know there are several types of OCD (vs subchondral cysts) depending on the action of the fracture fragment (attached, loose, shifted, relocated). An intraarticular cortisone injection is always worth a try.

These can be repaired "fairly" easily via arthroscopy using a triangulator which allows debridement and drilling of the defect. I have done several of these and they heal very well.

Good luck

Steve