Osteochondral Lesion of the Talus: fragment fixation or microfracture
Five-phase protocol after treatment of an osteochondral lesion of the talar dome, comparing fragment fixation with microfracture/nanofracture and managing loading in the joint that carries more weight per square centimetre than any other.
Non-weight bearing 6 weeks · Full weight bearing 8-10 weeks · Running 4-6 months · Sport 6-12 months
This protocol is part of the post-operative pathway and must be adapted to the surgeon’s instructions and to the individual clinical response.
These documents are protocol templates for information and education only: they do not replace the rehabilitation prescription for the individual case. Timing, loading and progressions must always be adapted to the patient, the lesion pattern, the surgical technique used and the clinical course, in collaboration between orthopaedic surgeon, physiotherapist and, where appropriate, physiatrist. Progression is driven by objective criteria, not by the calendar alone.
At a glance
- Offloading
- Complete non-weight bearing for 6 weeks after fragment fixation; 4-6 weeks after microfracture, according to lesion size and site.
- Brace
- Walker boot or cast for 2-4 weeks, then removable walker to allow out-of-boot mobilisation several times a day.
- Mobilisation
- Active unloaded mobilisation (ankle alphabet, dorsi/plantarflexion) from week 1 or as soon as the wound allows: the ankle must be moved early but not loaded.
- Load progression
- From week 6, increase by roughly 20-25 kg (or 25% body weight) per week on two crutches, reaching full weight bearing at 8-10 weeks.
- Dorsiflexion
- Target: <2 cm side-to-side difference on the weight-bearing lunge test by month 3.
- Running
- Not before month 4 (microfracture for a small lesion) or months 5-6 (fixation/large lesions), with a dry ankle and repeated single-leg calf raise.
- Return to sport
- Low-impact sport at 4-6 months; jumping, contact and cutting sports at 6-12 months with tests passed.
- Week 1Strict offloading, active motion in the air
- Weeks 2-6Full unloaded ROM, light bands
- Week 6Start of load progression
- Weeks 8-10Full weight bearing without crutches
- 3 monthsSymmetrical dorsiflexion, double-leg calf raise
- Months 4-6Progressive running
- Months 6-12Return to sport with tests passed
The talus sits wedged between tibia, fibula and calcaneus: it is almost entirely covered with cartilage and, having no muscle attachments, receives blood from very few vessels. This makes it particularly vulnerable: a severe sprain, an ankle fracture or osteochondritis dissecans can detach a fragment of its dome, typically at the medial corner (deeper, often cup-shaped) or lateral corner (shallower, usually post-traumatic).
What the surgery does
Loading timeline
Step by step
Each phase lists the goals, what to do and the exercises for that exact moment: do not anticipate them. Dosage is indicative and must be adapted by your physiotherapist.
Before surgery — Preparation for surgery (elective cases)
Short educational and functional phase in elective cases; not applicable to acute cases needing immediate treatment.
When it applies
- •Only in elective cases, typically chronic symptomatic lesions of the talar dome.
- •Aggressive ankle prehabilitation is not needed: the aim is to prepare off-loading, home management and allowed range of motion.
- •Fragment fixation, microfracture/marrow stimulation and other procedures have different restrictions, explained before surgery.
Goals before surgery
- •Crutch training with full or partial off-loading as directed.
- •Swelling and pain control.
- •Maintenance of allowed ankle and foot mobility.
- •Maintenance of hip, knee and contralateral limb strength.
Activities
- •Practical crutch trial with the planned off-loading, including stairs.
- •Education on brace/boot, off-loading duration and school organisation.
Preoperative exercises
Crutch and weight-bearing training
- •Try the crutches before surgery, with correct height and the weight-bearing status set by the surgeon.
- •Practise on level ground, stairs and the entrance to your home, with someone assisting.
- •Also practise sitting, standing and moving in the bathroom while respecting the planned loading restrictions.
Dosage: At least one training session before admission; repeat until the technique is safe.
Active ankle mobility
- •Seated or lying, move the ankle into flexion, extension and slow circles, within the pain-free range.
- •Keep the movement smooth, without forcing the painful end range.
Dosage: Indicative: 10-15 movements per direction, 2-3 times a day.
Readiness criteria for surgery
- ☐Safe crutch use with the planned weight bearing.
- ☐Swelling and pain controlled.
- ☐Allowed mobility maintained.
- ☐Family informed about procedure and restrictions.
When surgery must not be delayed
- •Acute, salvageable osteochondral fragment: fixation must not be delayed.
- •Joint locking or worsening mechanical symptoms.
What to prepare at home and school
- •Prepare clear pathways at home and a place to keep the leg elevated.
- •Check stairs, bathroom and school transport with the planned off-loading.
- •Inform the school: accessible desk, temporary PE exemption, backpack management.
Phase 1 — Offloading, protection and early motion
Indicative timing: Weeks 0-2
The time window is indicative: progression depends on the criteria listed below, not on the calendar.
Goals
- •Protect the repair with strict offloading
- •Control swelling and pain
- •Prevent stiffness and loss of muscle recruitment
What to do
- •Complete non-weight bearing with two crutches or a walker; in younger children consider a wheelchair or knee walker so that offloading is genuinely achieved
- •Walker boot or cast as prescribed; limb elevated above heart level for most of the day
- •Cryotherapy 15-20 minutes, 4-6 times daily (never ice directly on skin)
- •Unloaded active mobilisation as soon as allowed: ankle alphabet, slow dorsi/plantarflexion, circumduction, 5-10 minutes 3-4 times daily
- •Isometrics of calf, tibialis anterior and peroneals without resisted foot movement
- •Hip, knee and contralateral limb exercise, upper-body cardiovascular work
Restrictions and precautions
- •No foot contact at all, not even touch-down, when full offloading is prescribed
- •No resistance bands in this phase
- •Avoid prolonged dependent leg position
Exercises for this phase
1. Ankle alphabetFrom the first days, offloaded
- •Sitting or lying, leg elevated and foot free in the air.
- •Draw the letters of the alphabet with the big toe, moving only the ankle.
- •Slow, wide movements, within pain limits.
Dosage: Full alphabet, 3-4 times a day
2. Unloaded active ankle mobilityWeeks 0-6
- •Sitting with the leg on a chair, foot free beyond the edge.
- •Move the ankle up and down, then in and out, slowly and without forcing.
- •The foot must never touch the ground during the exercise.
Dosage: 3 sets of 15 per direction, 3-4 times a day
Ready for the next phase when
- ☐Pain controlled with simple analgesia
- ☐Decreasing swelling, dry wounds
- ☐Active unloaded ankle motion without sharp pain
- ☐Offloading performed correctly and safely, including stairs
Note for the physiotherapist
Check concretely how the patient moves at home and at school: practical difficulties (stairs, bathroom, schoolbag) are a frequent cause of offloading not being respected, more than lack of willingness. Planning the logistics is part of the protocol.
Phase 2 — Restoring full motion (still offloaded)
Indicative timing: Weeks 2-6
The time window is indicative: progression depends on the criteria listed below, not on the calendar.
Goals
- •Full symmetrical unloaded ROM
- •Maintain calf trophism
- •Prepare the ankle for loading
What to do
- •Active and active-assisted mobilisation in all planes, 4-5 times daily out of the removable boot
- •Low-resistance band work in plantarflexion, dorsiflexion, inversion and eversion (from week 3-4 as directed)
- •Scar and soft-tissue mobilisation and drainage techniques: only once the wound has fully healed and as directed by the physiotherapist
- •Hydrotherapy with the limb unloaded (floating) or stationary bike with heel support if authorised
- •Hip and core strengthening in offloading, so the whole chain is not deconditioned when loading starts
Restrictions and precautions
- •No loading before the prescribed time
- •No forced high-resistance inversion/eversion
- •No deep-water walking before partial weight bearing is authorised
Exercises for this phase
3. Load progression using scalesCrutch-weaning phase
- •Place the operated foot on bathroom scales while standing between crutches.
- •Learn what 20 kg, 40 kg and half your body weight feel like: memorise the sensation.
- •Increase one level per week, only if pain and swelling do not appear.
Dosage: 5 minutes of load training per day
4. Knee-to-wall (dorsiflexion)From the loading phase
- •Stand facing a wall, operated foot forward, heel firmly on the ground.
- •Push the knee forward towards the wall without lifting the heel.
- •Measure the toe-to-wall distance and compare with the healthy side: target difference <2 cm.
Dosage: 3 sets of 10 pushes, twice a day
5. Wall calf stretch (two positions)From full weight bearing
- •Hands on the wall, operated leg behind, heel firmly on the floor.
- •First with the knee straight (gastrocnemius), then with the knee bent (soleus).
- •The heel must never lift: if it does, move the foot closer to the wall.
Dosage: 3 x 30 seconds per position, twice a day
6. Four-direction band workFrom week 3-4
- •Sitting with the leg extended and a band around the forefoot.
- •Move in four directions: up, down, inwards, outwards.
- •Move slowly over 2 seconds, return under control over 3 seconds.
Dosage: 3 sets of 15 per direction, daily
7. Eversion band work (peroneals)From week 4
- •Band anchored on the inner side, wrapped around the forefoot.
- •Turn the foot outwards keeping the knee still: only the ankle moves.
- •Slow, controlled return without letting the band snap back.
Dosage: 3 sets of 15, daily
Ready for the next phase when
- ☐Symmetrical or near-symmetrical unloaded active dorsi/plantarflexion
- ☐No pain on passive mobilisation
- ☐Stable swelling, no night pain
- ☐Good voluntary activation of peroneals and tibialis posterior
Phase 3 — Progressive loading and gait re-education
Indicative timing: Weeks 6-12
The time window is indicative: progression depends on the criteria listed below, not on the calendar.
Goals
- •Reach full weight bearing without limp
- •Restore weight-bearing dorsiflexion
- •Reactivate the triceps surae
What to do
- •Clinical load progression on two crutches: increase weight bearing gradually, one level at a time, guided by pain, swelling and gait quality rather than by a figure in kilograms
- •Gait re-education in front of a mirror: heel-to-toe contact, symmetrical stance times, progressive crutch weaning
- •Weight-bearing dorsiflexion mobilisation (knee-to-wall) and calf stretching with knee extended and flexed
- •Assisted double-leg calf raise progressing towards single-leg; tibialis posterior and peroneal band strengthening
- •Double-leg proprioception on a stable surface, then single-leg as tolerated
- •Imaging review (MRI or CT) only where the surgeon considers it likely to change management, for example after fixation or in large lesions
Restrictions and precautions
- •No jumping, no running, no uneven surfaces
- •Pause load progression if recurrent evening swelling appears
Exercises for this phase
8. Calf raiseFrom full weight bearing
- •Standing with hands on a wall, rise onto the toes with both feet.
- •When easy, lower slowly on one leg only (3-second eccentric).
- •Final target: 25 full single-leg repetitions.
Dosage: 3 sets of 15, 4-5 times a week
9. Heel-to-toe gait re-educationFull weight-bearing phase
- •Walk slowly in front of a mirror, contacting heel first and then toes.
- •Count stance time mentally: it must be equal on both feet.
- •Short symmetrical steps are better than long steps with a limp.
Dosage: 5-10 minutes, twice a day
10. Balance on a soft surfaceFrom month 3
- •Stand on a cushion or soft mat on one leg.
- •Progress: eyes open → eyes closed → while throwing and catching a ball.
- •If you lose balance more than twice in 30 seconds, step back one level.
Dosage: 3 x 30 seconds, daily
11. Uphill and incline walkingPre-running phase
- •Treadmill at 5-8% incline or a gentle outdoor hill.
- •The heel must contact fully with every step.
- •This prepares the ankle for cyclic loading before running is introduced.
Dosage: 10-20 minutes, 3 times a week
Ready for the next phase when
- ☐Full weight bearing without crutches and without limp
- ☐Weight-bearing lunge test within 3 cm of the healthy side
- ☐Full pain-free double-leg calf raise
- ☐No persistent swelling after 30 minutes of walking
Note for the physiotherapist
Residual limp after crutch weaning nearly always comes from insufficient dorsiflexion or a weak triceps surae: measure both before attributing the problem to pain.
Phase 4 — Strength, proprioception and first impact
Indicative timing: Months 3-6
The time window is indicative: progression depends on the criteria listed below, not on the calendar.
Goals
- •Symmetrical calf strength
- •Single-leg control on unstable surfaces
- •Graded introduction of impact
What to do
- •Progressive single-leg calf raise (target 25 full repetitions), eccentric work on a step
- •Global limb strengthening: squats, lunges, step-ups and step-downs, posterior chain
- •Advanced proprioception: wobble board, cushion, unstable surfaces, eyes closed, dual task, external perturbations
- •Y-balance / Star Excursion as both exercise and measure
- •Interval return to running on even ground once criteria are met; first running in water or on an anti-gravity treadmill if available
Restrictions and precautions
- •No plyometrics or cutting before symmetrical single-leg calf raise
- •Avoid uneven ground and unplanned spontaneous sport
Exercises for this phase
12. Progressive plyometricsImpact phase
- •Start with two-foot hops on the spot, landing softly with bent knees.
- •Progress to front-back and lateral hops, then single-leg.
- •Landings must be silent: noise means insufficient shock absorption.
Dosage: 2-3 sets of 10-20 contacts, 2-3 times a week
Ready for the next phase when
- ☐Single-leg calf raise ≥20-25 repetitions, LSI ≥90%
- ☐Star Excursion Balance Test asymmetry <4 cm
- ☐10-15 minutes of light running without pain or next-day swelling
- ☐No deep pain during or after prolonged loading
Phase 5 — Return to sport and recurrence prevention
Indicative timing: Months 6-12
The time window is indicative: progression depends on the criteria listed below, not on the calendar.
Goals
- •Full sporting skills without symptoms
- •Prevention of chronic ankle instability
- •Long-term cartilage protection
What to do
- •Progressive plyometrics: double-leg → single-leg → jumps with rotation → unanticipated landings
- •Agility: shuttles, figure-of-8, decelerations, sharp cutting, sport-specific skills
- •Graded reintegration: partial training → full training → competition
- •Ongoing preventive neuromuscular programme (single-leg balance and peroneal strengthening at least three times weekly)
- •Consider taping or a semi-rigid brace in high-risk sports for the first 6-12 months
No new exercises are introduced in this phase: continue with the exercises of the previous phase, progressing load and difficulty as tolerated and as indicated by the physiotherapist.
Ready for the next phase when
- ☐Hop tests (single-leg hop, figure-of-8, side hop) with LSI ≥90%
- ☐Daily and sporting activities resumed without reported pain or limitation
- ☐No reported functional instability (no giving way)
- ☐No effusion or deep pain in the preceding 4 weeks
- ☐Surgeon clearance with consistent imaging in large lesions
If symptoms appear after a progression
If persistent pain, effusion or swelling, or loss of movement appears after moving to a new phase or increasing load, temporarily reduce load and volume and have the situation reassessed by the surgeon or physiotherapist before progressing again. This document is informative for families and physiotherapists and does not replace individual clinical assessment.
Return to sport / full activity
Low-impact sport (swimming, cycling) at 3-4 months; running at 4-6 months; jumping, contact and cutting sports at 6-12 months. Large lesions, deep medial lesions and grafted fixations take the longest.
- ☐Single-leg calf raise ≥25 repetitions with LSI ≥90%
- ☐Hop tests (single-leg hop, side hop, figure-of-8) with LSI ≥90%
- ☐Weight-bearing lunge test within 2 cm
- ☐Daily and sporting activities without pain or reported functional instability
- ☐No deep pain or swelling 48 hours after the hardest training session
Post-activity swelling is a sign of joint reactivity useful for regulating weekly loading, not a direct measure of cartilage status. In higher-risk individuals and sports it is useful to maintain some proprioceptive work in the long term, without this being mandatory for everyone. The Limb Symmetry Index has known limitations: on its own it is not sufficient, because the uninjured side may also be deconditioned; it should be combined with absolute strength values, movement quality and sport-specific demands.
Red flags: stop and contact us
- •Deep pain that increases with each loading progression or appears at night
- •Locking, painful catching or the sensation of a loose body in the ankle
- •Swelling that systematically returns after every session
- •Inability to restore dorsiflexion despite 6-8 weeks of specific work
- •Redness, warmth, fever or wound discharge (suspected infection)
- •Calf pain with swelling, breathlessness or chest pain (suspected deep vein thrombosis)
Written and reviewed by Dott. Daniele Priano, Paediatric Orthopaedics. Last review: August 2026.
Timings are indicative: progression depends on clinical and functional criteria and on the surgeon’s indications.
Frequent questions
Why must offloading be total rather than "light contact"?
Because the ankle contact surface is very small: even partial contact generates high pressure exactly on the treated talar dome. Where touch-down is tolerated in the knee, complete offloading is often preferred here.
I still have deep pain at 4 months: is that normal?
Discomfort after prolonged loading can persist for months. Deep pain that increases with every progression, or comes with recurrent swelling, is not normal: it signals overload and requires clinical review and possibly MRI.
Are insoles or braces needed after surgery?
Not always. They can help when hindfoot malalignment concentrates load on the side of the lesion, or a semi-rigid brace in high-risk sports during the first year. This is assessed clinically, case by case.
Can I cycle during the offloading period?
Only if authorised: a stationary bike with heel support and minimal resistance is often allowed after the first weeks, because loads are far lower than walking. Pushing through the forefoot should be avoided.
In-depth content (full introduction, technique comparison, FAQ, references) at ortopediaevolutiva.com/en/rehabilitation/talus-osteochondral-lesion
Osteochondral Lesion of the Talus: fragment fixation or microfracture — Dott. Daniele Priano, Pediatric Orthopaedics · Information document: it does not replace an in-person assessment.
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Email: daniele.priano@ortopediaevolutiva.com