A clinical synthesis based on the EFORT 2022 algorithm (Herrera-Pérez), the TARVA 2022 trial, the Al-Mahrouqi 2018 meta-analysis and the PAASS framework for return to sport (Smith 2021).

How is this condition defined, who is affected and what are the risk factors?

Talocrural osteoarthritis, commonly called ankle osteoarthritis, is a degenerative joint condition characterised by the progressive degradation of the cartilage that covers the dome of the talus and the tibiofibular mortise.¹ Its prevalence in the general adult population is around 1 %, clearly less than osteoarthritis of the major weight-bearing joints such as the knee or the hip.²

Its most distinctive feature lies in its aetiology: unlike other primary osteoarthritis (age-related), ankle osteoarthritis is mostly post-traumatic, in 70 to 80 % of cases.¹﹐² In Valderrabano's prospective series (n=390 ankles with end-stage osteoarthritis), 78 % were post-traumatic, 13 % secondary (rheumatic, haemochromatosis, and so on) and only 9 % of primary origin.¹ Saltzman's series of 639 patients confirms this distribution (70 % post-traumatic, 12 % rheumatoid, 7 % primary).²

This traumatic origin explains why the affected population is significantly younger, with a mean age at diagnosis between 40 and 50 years, one to two decades earlier than for knee or hip osteoarthritis.³ In a community population over 50, the prevalence of symptomatic radiographic talocrural osteoarthritis is 3.4 % (Murray 2018, cross-sectional study of 5,109 respondents in North Staffordshire).⁴

📝 The risk factors are therefore mainly linked to a history of injury:

• Ankle fractures : the commonest cause of post-traumatic osteoarthritis. Tibial pilon fractures and bimalleolar or trimalleolar fractures are particularly at risk. At 12-22 years of follow-up in a surgically treated cohort (Lübbeke 2012, n=180 malleolar fractures), 36 % of patients had advanced radiographic osteoarthritis, with independent predictive factors being a medial malleolar fracture, fracture-dislocation, advanced age and a high BMI.⁵
• Chronic ankle instability (CAI) : repeated sprains and sustained microtrauma. The Doherty 2014 meta-analysis shows that indoor sports expose players to 7 sprains per 1,000 athlete exposures.⁶ About 40 % of sprains progress to CAI, which in turn increases the risk of talocrural osteoarthritis.⁷
• Osteochondral lesions of the talus (OLT) : a direct trauma can damage the subchondral bone and the cartilage at the same time, creating a lesion that can progress to global osteoarthritis.⁸
• Hindfoot malalignment : varus or valgus changes load distribution. Tibiotalar geometry and talar orientation in the axial plane are factors identified on weight-bearing CT (WBCT).⁹
• High BMI : a recognised aggravating factor, particularly in patients after a fracture.⁵

What happens in the body and how does talocrural osteoarthritis progress naturally?

In pathophysiological terms, the initial trauma disturbs the normal biomechanics of the tibiotalar complex. That change, even a minimal one (residual instability, an articular step after a fracture, malalignment), creates zones of abnormal mechanical stress on talocrural cartilage that is particularly vulnerable (thin cartilage of only 1 to 2 mm, against 4 to 6 mm at the knee).¹⁰

In response to this stress, the chondrocytes initiate an inflammatory cascade with the release of pro-inflammatory cytokines (IL-1β, TNF-α) and metalloproteases that degrade the extracellular matrix (collagen II, proteoglycans).¹¹ This degradation is faster at the ankle than in the other weight-bearing joints, probably because of the thinner cartilage and the high density of stress per unit area.¹⁰

📉 Structurally, this progressively produces:

• There is a narrowing of the joint space under load, the first radiographic sign of cartilage loss.
• There is a sclerosis of the subchondral bone, a marker of remodelling in response to increased stress.
• The formation of osteophytes, particularly anterior ones (limiting dorsiflexion) and posterior ones.¹
• There is a progressive axial deformity, most often in varus in lateral post-traumatic osteoarthritis (the sequel of repeated severe sprains).⁹

The natural history is marked by a slow but inexorable course in the majority of post-traumatic patients. Lübbeke's cohort with 18 years of follow-up shows that symptoms progress in flares interspersed with quieter periods, but that radiological degradation is continuous.⁵ A significant share of patients progresses to an end stage requiring surgery within 10 to 20 years of the initial trauma.¹

Which questions should you ask to understand the patient and their history?

The history is the cornerstone of the diagnosis. It aims to reconstruct the traumatic story and to quantify the functional impact. A structured approach is essential.¹﹐²

• Traumatic history : actively look for one or more previous injuries, even old ones (fracture, severe sprain, repeated microtrauma). Specify the nature of the event (Weber A/B/C, pilon, OLT), the initial treatment (conservative or surgical) and the quality of the recovery.³
• Characteristics of the pain : pain that is typically mechanical and worsened by weight-bearing, walking on uneven ground and going down stairs. Anterior (osteophytes) or diffuse in location. VAS scale. Brief morning stiffness (generally < 30 min); beyond that, suspect an inflammatory component (rheumatic disease, flare).
• Associated symptoms : intermittent swelling, a sense of cracking or locking, instability (subjective or with giving-way episodes). Subjective instability combined with mechanical pain suggests CAI progressing to post-traumatic osteoarthritis.⁴
• Functional impact and quality of life : use validated PROMs. The FAAM (Foot and Ankle Ability Measure) (Martin 2005), with its ADL (21 items) and Sport (8 items) subscales, is the reference tool, with high test-retest reliability (ICC 0.89 and 0.87 respectively).⁵ The AOS (Ankle Osteoarthritis Scale) (Domsic & Saltzman 1998) is the ankle-specific tool most used in trials.⁶

Which clinical tests should be done and which other conditions must be ruled out?

The clinical examination must corroborate the history and rule out the differential diagnoses. The Al-Mahrouqi 2018 meta-analysis (8 pooled studies, 563 participants) identified the most constant physical deficits in adults with talocrural osteoarthritis:⁷

• A large deficit in dorsiflexion range (a clinically large difference from the healthy side);
• A large strength deficit in dorsiflexion and plantarflexion;
• Significant (but heterogeneous) deficits in frontal-plane range and strength;
• Balance impairment (postural and dynamic);
• Electromyographic abnormalities and fatty infiltration of the calf muscle compartments.

The key clinical tests to include in the assessment are:

• Weight-Bearing Lunge Test (WBLT) : a reliable functional measure of weight-bearing dorsiflexion (Bennell 1998: intra-rater ICC 0.97-0.98, inter-rater 0.97-0.99).⁸ Norms: great toe to wall distance > 9-10 cm or tibial inclination > 35-38° in the absence of pathology.
• Non-weight-bearing goniometric measurement of dorsiflexion and plantarflexion, compared side to side.
• Balance tests : single-leg stance on a stable then an unstable surface, Star Excursion Balance Test (SEBT) (Gribble 2012, established predictive validity).⁹
• Isometric strength tests of the evertors, invertors, dorsiflexors and plantarflexors.
• Gait analysis : antalgic limp, shortened stance phase on the affected side, reduced terminal propulsion (limited by the loss of dorsiflexion).

The differential diagnosis must systematically rule out:

• Anterior or posterior ankle impingement (impingement): localised pain, with no diffuse joint space narrowing.¹⁰
• CAI without osteoarthritis : positive laxity tests (anterior drawer, talar tilt), instability dominating over pain.⁴
• Tendinopathies : peroneal, tibialis posterior (retromalleolar medial), tibialis anterior, distal Achilles.
• Osteochondral lesion of the talus (OLT) in isolation: localised pain, MRI diagnostic.¹¹
• Sinus tarsi syndrome : anterolateral pain, relieved by a test injection.
• Inflammatory arthritis (RA, spondyloarthritis): prolonged morning stiffness, symmetrical or polyarticular involvement, blood markers.
• Charcot foot (in a person with diabetes): rapid deformity, warm skin, little pain, a diagnostic emergency.

The definitive diagnosis rests on standard weight-bearing radiography (AP and lateral), the first-line investigation. Weight-bearing is essential : it alone allows reliable assessment of joint space narrowing, invisible on a non-weight-bearing film.¹⁰ The classic radiographic signs are:

• Narrowing of the tibiotalar joint space (an early sign);
• Subchondral sclerosis, cysts;
• Osteophytes (anterior, posterior, mediolateral);
• Axial malalignment (varus or valgus).

Weight-bearing CT imaging (WBCT) is emerging as a promising tool, allowing a 3D assessment of alignment and tibiotalar narrowing under physiological conditions.¹² MRI remains reserved for diagnosing OLT, subchondral bone stress or in the case of a radiological-clinical mismatch.

Should patients with talocrural osteoarthritis be classified, and for what benefit?

Radiological classification offers several theoretical benefits: standardising communication, guiding treatment decisions, establishing a prognosis. 🎯

The Kellgren-Lawrence classification (KL), developed for the knee, is the most used by default. Its application to the ankle is problematic, however: inter-observer agreement remains moderate (k=0.40-0.60 across studies) and above all it correlates poorly with symptoms and function.

The COFAS (Canadian Orthopaedic Foot and Ankle Society) classification distinguishes 4 types by alignment and involvement of the adjacent joints: type 1 (no deformity), type 2 (intra-articular deformity), type 3 (extra-articular deformity or laxity), type 4 (osteoarthritis of the adjacent joints, subtalar, transverse tarsal).¹³ Its inter-observer reliability is higher than KL (k=0.68) and it has shown a correlation with pre- and post-operative PROM scores (PROMIS, MOXFQ).¹⁴

The EFORT 2022 algorithm (Herrera-Pérez) builds this classification into its decision tree: the treatment strategy varies by stage and COFAS type.³

Criticism and controversy: the tyranny of the radiological image

The main point of controversy in diagnosing talocrural osteoarthritis is the radiological-clinical mismatch. The 2023 Dutch prospective study (Sezgin et al., n=171 chronically painful ankles) shows that the presence of radiographic osteoarthritis is not associated with pain severity or with disability in patients referred for radiography of a chronic ankle. A patient can have KL 4 osteoarthritis and few symptoms, and the reverse.

This mismatch demands a biopsychosocial view of the diagnosis: integrating the structure visible on imaging, the deficits documented on clinical examination, the PROMs and the contextual factors (beliefs, expectations, occupational context). The image is only one element among others. The classic error of « treating an image » is the one to abandon.

Where do you start? What is the hierarchy of interventions?

The management of talocrural osteoarthritis follows a tiered, progressive approach, based on the treatment algorithm proposed by the EFORT 2022 review (Herrera-Pérez), the most recent reference synthesis: whatever the radiological stage, conservative treatment must be tried for at least 6 months before elective surgery is considered.¹

• 1st line, the cornerstone : therapeutic education, activity modification, a structured exercise programme, weight control.²
• 1st line, mechanical adjuncts : an ankle-foot orthosis (AFO, rigid, semi-rigid or an Arizona brace), a rocker sole that reduces tibiotalar load during the propulsion phase.¹﹐³
• 2nd line : drugs (intermittent NSAIDs during flares), intra-articular injections. Corticosteroids give short-term relief (limited evidence, Jones 2025 SR).⁴ Hyaluronic acid is not recommended routinely (Cochrane review Witteveen 2015: very low evidence).⁵ PRP gives mixed results, possibly more promising on talar cartilage lesions (Liu 2024 SR/MA).⁶
• 3rd line, surgery : depending on the stage and the COFAS type, the options are debridement arthroscopy, realignment osteotomies, joint distraction (in a young patient), arthrodesis and total arthroplasty.¹

What is the place of exercise, and is there a superior approach?

Therapeutic exercise is a central, non-negotiable component of conservative treatment. The Al-Mahrouqi 2018 meta-analysis documents these patients' physical deficits, with loss of dorsiflexion and loss of strength leading: it justifies the targets of exercise, it does not measure its effect.² The effectiveness of exercise in talocrural osteoarthritis remains extrapolated from the knee and the hip. No single approach is shown to be superior; the consensus is that a combined and personalised programme gives the best results.

• Muscle strengthening : target the evertors (peroneals), invertors (tibialis posterior), plantarflexors (triceps surae) and dorsiflexors (tibialis anterior). Progress from isometric to isotonic, then to functional loading.
• Neuromuscular and proprioceptive training : balance exercises on stable → unstable → dynamic surfaces. The Arnold 2009 meta-analysis confirms the association between CAI and balance deficits (gold standard).⁸ The 2024 meta-analysis on balance training dose (Tang) shows that at least 4 weeks at 3 sessions a week are needed for clinically significant gains.⁹
• Joint mobility : self-mobilisation exercises for dorsiflexion (anteroposterior talocrural mobilisation), gastrocnemius and soleus stretches.
• Low-impact aerobic work : cycling, elliptical trainer, swimming, water walking. Prevents deconditioning without overloading the talocrural joint.

A structured programme of at least 6 to 12 weeks is generally required to see significant and durable benefits.⁷ Supervised exercise programmes (in the clinic, 1-2 sessions a week) combined with home exercise (3-5 sessions a week) optimise adherence.

Manual therapies, technologies, injections: what is their real effectiveness?

Passive therapies should be regarded as adjuncts to an active programme, never as the main treatment.

• Manual therapy : joint mobilisations (Maitland anteroposterior, distraction, talar glide) can improve dorsiflexion and reduce pain in the short term. Long-term evidence remains limited. Level of evidence: moderate in the short term, low in the long term.¹⁰
• Low-level laser therapy (LLLT) and ultrasound : no convincing evidence specific to talocrural osteoarthritis. Their routine use is not recommended : there is no clinical practice guideline specific to talocrural osteoarthritis, and the EFORT 2022 synthesis does not retain these modalities.¹
• Shockwave therapy (ESWT) : emerging but heterogeneous evidence; no strong recommendation specific to talocrural osteoarthritis.¹
• Corticosteroid injection : 2025 systematic review (Jones et al.), 2 pooled RCTs on 57 participants. No difference at 8 weeks against prolotherapy for MTP1. Significant improvement when corticosteroids are combined with HA for post-traumatic subtalar osteoarthritis. Evidence overall insufficient to guide routine use at the ankle.⁴
• Hyaluronic acid (HA) : Witteveen 2015 Cochrane, inconclusive data; not recommended routinely.⁵
• PRP (platelet-rich plasma) : Liu 2024 meta-analysis (5 pooled RCTs), no significant difference for the overall AOFAS; a more marked effect in selected talar cartilage lesions. An uncertain effect, to be confirmed.⁶

Beyond the physical: how do you educate the patient and address psychological factors?

The impact of ankle osteoarthritis goes beyond pain and stiffness. The psychological factors play a major role in disability and must be systematically assessed and addressed.¹¹

Therapeutic patient education (TPE) is an active intervention that aims to:

• Improve understanding of the condition (dismantling the myth that « wear is inevitable »);
• Promote self-management (load management, activity modulation, warning signs);
• Reframe pain as a modulable signal, not merely a witness to damage;
• Set SMART objectives (Specific, Measurable, Achievable, Realistic, Time-bound).

Both kinesiophobia (fear of movement) and fear-avoidance beliefs are powerful predictors of a poor functional course, independently of radiological severity.¹¹﹐¹² Useful screening tools:

• Tampa Scale for Kinesiophobia (TSK-11) : a threshold of ≥ 17 / 44 is often used to identify clinically significant kinesiophobia.
• Pain Catastrophizing Scale (PCS) : screens for the catastrophising associated with a poor chronic prognosis.
• Örebro Musculoskeletal Pain Screening Questionnaire : multifactorial screening for psychosocial barriers (Linton et al. evidence, adapted to many musculoskeletal conditions).

Graded exposure to feared movements, work on confidence and, if needed, collaboration with a psychologist (CBT, ACT) are essential complements.¹¹

Criticism and controversy

Three zones of uncertainty persist in treatment:

First, most randomised trials on exercise at the ankle extrapolate protocols from the knee or the hip. The unique tibiotalar biomechanics and the mostly post-traumatic origin of ankle osteoarthritis should nonetheless inspire specific protocols. The optimal FITT parameters (Frequency, Intensity, Type, Time) remain imprecise.⁷

Second, the routine use of passive modalities with no or very low evidence (laser, ultrasound, sometimes TENS) remains very widespread in practice. This inertia between evidence and everyday practice is an economic and ethical issue: it can delay engagement in more effective active therapies.¹

Third, the TARVA 2022 trial demonstrated equivalence at 1 year between TAR and arthrodesis on the MOXFQ score (Manchester-Oxford Foot Questionnaire walking/standing) with comparable rates of adverse events.¹³ Yet the older observational literature suggested an advantage of TAR on quality of life at the cost of a higher revision rate. The decision remains highly personalised and sensitive to age, activity and the state of the adjacent joints (subtalar, Chopart).¹

What is the prevalence of CAI and how does it lead to osteoarthritis?

Lateral ankle sprain is the commonest sports injury. The Doherty 2014 meta-analysis (prospective pooling) puts the incidence at 7 sprains per 1,000 athlete exposures in indoor sports (basketball, volleyball), with a point prevalence of 12.2 % among participants.¹

The central problem is chronicity : about 40 % of sprains progress to chronic ankle instability (CAI, Chronic Ankle Instability), defined by symptoms persisting > 1 year (a sense of giving way, episodes of instability, residual pain, activity restriction).² A 2021 systematic review (Lin et al.) confirms a high prevalence of CAI in sporting populations, particularly among adolescents and women.³

The updated model of CAI (Hertel & Corbett 2019) includes:⁴

• Primary mechanical contributors: pathological ligament laxity (often the anterior talofibular ligament), arthrokinematic restrictions (a posterosuperior talar positional fault), degenerative changes (cartilage, synovium).
• Primary neuromuscular contributors: impaired proprioception, altered muscle timing (slow peroneals), postural control problems, gait and running abnormalities.
• Primary sensory-perceptual contributors: chronic pain, altered perception of instability, kinesiophobia.
• Personal modulators (sex, BMI, activity level, history) and environmental ones (playing surfaces, footwear, training load).

The osteoarthritic cascade after CAI results from several intertwined mechanisms:⁵

• Repeated microtrauma : subclinical instability episodes accumulated over years progressively degrade the cartilage of the talar dome (the anterolateral zone in particular).
• Arthrokinematic changes : a talar positional fault reduces dorsiflexion, creating zones of overload at propulsion.
• Neuromuscular inhibition and deconditioning : persistent weakness of the stabilisers (peroneals), altered gait pattern.
• Induced sedentary behaviour : Hubbard-Turner & Turner showed that patients with CAI walk ~2,100 steps a day less than healthy controls, accelerating overall deconditioning and favouring comorbidities (excess weight, osteopenia).⁶

Which neuromuscular exercises are proven effective?

The APTA 2021 Clinical Practice Guideline (Martin RL et al., JOSPT) updates the recommendations for lateral ankle sprains and CAI from an exhaustive review of the literature.⁷ The key elements for preventing the osteoarthritic cascade:

• Balance and proprioception exercises (recommendation A): significant improvement in postural control, reduced risk of recurrent sprain. Tang's 2024 meta-analysis confirms a minimum effective dose: 3 sessions a week for ≥ 4 weeks, 20-30 min per session.⁸ The PEP/HOPS programme and SEBT-based protocols have shown their effectiveness.
• Strengthening the lateral stabilisers (recommendation B): peroneals in eversion against progressive resistance, integrated in closed chain.
• Adjunct manual therapy (anteroposterior talocrural mobilisations) when an arthrokinematic restriction is documented: a moderate recommendation in the short term.⁷
• Multimodal programmes (Martin 2021): the combination of balance + strength + mobility + education is superior to any isolated modality.
• The PAASS framework for return to sport (Smith 2021): objective decision criteria (strength, balance, hop tests, psychological readiness), see chapter 5.⁹

The Vuurberg 2018 (Br J Sports Med) guideline and the International Ankle Consortium also recommend:¹⁰

• Early mobilisation (vs prolonged immobilisation) after the acute sprain;
• Structured functional exercise (vs simple rest) to prevent chronicity;
• Bracing (a semi-rigid orthosis) as secondary prevention in athletes at high risk.

How is the patient made an active participant in their own recovery through self-management?

Self-management (self-management) is the cornerstone of durable results. It aims to transfer responsibility for daily treatment from the therapist to the patient. A 2020 randomised pilot study (Bennell et al.) compared an exercise plus self-management programme supervised by a physiotherapist with a simple self-management booklet in patients with ankle osteoarthritis; the results favoured supervision for adherence and for the perception of progress.¹

The components of an effective self-management programme:

• Structured therapeutic education : the nature of osteoarthritis (continuous remodelling, not simple wear), the distinction pain ≠ damage, the essential role of movement for joint health.
• A home exercise programme that is targeted and progressive: combining strengthening (peroneals, triceps surae, tibialis posterior), mobility (talocrural self-mobilisation, gastrocnemius and soleus stretches) and neuromuscular training (balance, motor control under load).²
• Pacing : modulating activity according to pain signals. Learning a flare-up plan : what to do during a flare (load, icing, short-term NSAIDs, footwear adjustment, contacting the therapist).
• Shared SMART objectives : for example « walk 25 min without stopping, 3 times a week, within 6 weeks » rather than « walk more ».
• Weight management : every kilogram lost significantly reduces joint stress on the loaded ankle.³
• Long-term adherence : telephone follow-up, an exercise diary, mobile apps and refresher sessions at 3 and 6 months significantly increase the persistence of the benefits.⁴

When and how should a safe return to sport and activities be planned?

Return to sport or to demanding activities must never be based on elapsed time or on the mere absence of pain at rest. An approach based on objective criteria is essential to minimise the risk of a recurrent sprain or of osteoarthritic progression.⁵

The PAASS framework (Postural-control / Ankle range and Strength / Athlete perception / Sport activities) proposed by Smith et al. (2021) for lateral sprains also applies very well after osteoarthritic decompensation or ankle surgery:⁵

• P, postural control : single-leg and dynamic postural control, assessed by the Star Excursion Balance Test (SEBT) or the Y-Balance Test, with a deficit < 10 % against the healthy side.⁶
• A, ankle range and strength : ranges (dorsiflexion in particular, by WBLT, Bennell 1998), isometric strength in eversion, inversion, dorsiflexion and plantarflexion. Symmetry difference < 10-15 %.⁷
• A, athlete perception : psychological readiness assessed by the ALR-RSI (Ankle Ligament Reconstruction-Return to Sport after Injury, Sigonney 2020) scale, a score > 56 / 100 often used.⁸
• S, sport activities : functional capacity assessed by a battery of hop tests (single hop, triple hop, crossover hop, 6-meter timed hop) with a Limb Symmetry Index (LSI) > 90 %.⁹
• S, symptoms : no pain or tolerable pain (NPRS < 3/10) during and after exertion, with no flare at 24 h.

Progression should follow a gradual, sport-specific reintroduction : general exercises → sport-specific movements without opposition → with opposition → full training → competition. A 2021 systematic review stresses that fewer than 20 % of studies on ankle conditions use objective functional criteria to validate return to play, a major methodological quality problem.⁵

Criticism and controversy

Three grey areas deserve light in planning return to activity after post-traumatic talocrural osteoarthritis:

First, the PAASS criteria were developed for lateral sprains (Smith 2021) and their extrapolation to established talocrural osteoarthritis is not formally validated by trial. The biomechanical analogy (balance deficit, strength deficit, kinesiophobia) nonetheless makes their use reasonable while specific studies are awaited.

Second, the definition of a « successful return » remains imprecise. Is it resuming the activity, or regaining the previous level without accelerating long-term cartilage degradation? The predictive value at 5-10 years of current functional tests for osteoarthritic progression remains to be demonstrated.⁵

Third, the debate on high-impact sports (running, pivoting sports) in the osteoarthritic patient remains open. The current approach favours shared decision-making : weigh the individual benefit and risk, adjust volumes and intensities, rather than banning systematically. A patient who is well prepared physically and psychologically, with stabilised moderate osteoarthritis, can often resume a reasonable activity.

Analysis of a classic case: from the trauma to the surgical decision.

The typical path of a patient with advanced post-traumatic talocrural osteoarthritis illustrates the continuum to know. The prospective cohort TARVA 2022 (Goldberg AJ et al., Annals of Internal Medicine, n=303 patients aged 50 to 85, 17 British centres) offers a robust reference on the move to elective surgery.¹

The typical profile represented in TARVA: a patient who has had an ankle fracture or chronic instability after sprains over several years, becoming progressively symptomatic with disabling mechanical pain, loss of dorsiflexion, and a marked impact on walking and on work or leisure activities. Conservative treatment has failed (analgesics, NSAIDs, supervised physiotherapy > 6 months, orthoses, rocker soles, injections).

The TARVA trial showed that at 1 year:¹

• Both interventions (total arthroplasty TAR vs arthrodesis AA) improved the MOXFQ walking/standing score significantly and in a clinically relevant way;
• The difference between the two groups was not clinically significant (MOXFQ-W/S mean improvement +33.6 points TAR against +33.3 points AA);
• The adverse events overall were similar between the groups;
• Cost-utility analysis published in 2024 finds comparable effectiveness, with a slight trend in favour of TAR on quality of life (PharmacoEconomics-Open 2024).²

Clinical conclusion: for patients aged 50-85 with end-stage osteoarthritis, the decision between arthroplasty and arthrodesis must be individualised by age, activity level, the state of the adjacent joints (subtalar, transverse tarsal), the surgeon's experience and the patient's informed preferences.

The largest comparative meta-analysis (Fanelli 2021, 21 comparative studies, 18,448 patients) finds better post-operative range of motion and better quality of life (SF-36) after arthroplasty, with no difference on most other patient-reported scores, and complication and revision rates comparable to arthrodesis (revisions: OR 1.72; 95 % CI 0.89 to 3.32, not significant). The choice therefore rests on the patient's profile, not on a supposedly different revision risk.³

The diagnostic challenge: when talocrural osteoarthritis mimics another condition.

Some clinical cases highlight the common diagnostic traps.

Chronic ankle pain with a sense of instability can wrongly point to ligamentous CAI, when it may hide:

• An early osteoarthritis (discreet radiographic signs on a non-weight-bearing film);
• An anterolateral impingement from fibrous tissue or an osteophyte;
• An osteochondral lesion of the talus (OLT) in isolation.

The anterolateral impingement syndrome (anterior impingement) is a classic cause of persistent anterolateral pain after repeated sprains. Arthroscopy can reveal fibrous synovial hypertrophy (meniscoid lesion) rather than pure ligament laxity. The diagnosis is made on MR arthrography or arthroscopy; surgical resection of the fibrous tissue gives excellent functional results in well-selected patients.

The other differential diagnoses always to consider:

• Tibialis posterior tendinopathy (medial retromalleolar pain, valgus deformity, single-leg heel raise test);
• Sinus tarsi syndrome (anterolateral pain, relieved by a test injection);
• Osteochondral lesion of the talus (localised pain, locking, effusion, MRI diagnostic);
• CRPS type I after a fracture (disproportionate pain, vasomotor disturbance, hyperaesthesia).

The rigorous differential diagnosis remains the clinical art. Standard imaging (weight-bearing radiography) is the first-line investigation, but MRI or CT arthrography may be needed to distinguish early cartilage damage from other periarticular conditions.⁴

Study of a complex case: joint distraction and structural grafts.

For young patients (often < 50 years, post-traumatic) in whom arthrodesis and arthroplasty are premature or contraindicated, biological alternatives exist.

• Joint distraction (arthrodiastasis) : a technique that offloads the joint for 8 to 12 weeks with an external fixator (often of the Ilizarov type). A 2023 survival review confirms a survival rate without conversion to surgery of about 75 % at 5 years and 60 % at 10 years, with improved AOFAS and SF-36 scores in responders.⁵ Preferred indications: a young, post-traumatic patient, with no major deformity or bone loss, motivated to follow a long rehabilitation. Limits: a high failure rate in obesity, severe deformity and inflammatory osteoarthritis.
• Structural bone grafts (femoral head allograft, fresh talar allograft): used in cases of massive bone loss (talar osteonecrosis, tibial pilon sequel, failed prosthesis). Combined with a tibiotalocalcaneal (TTC) arthrodesis, they restore a stable weight-bearing platform for walking. The 2025 review of fresh talar grafts shows a higher fusion rate than traditional femoral head grafts.
• Cartilage reconstruction : for focal OLTs of the talar dome in a young patient, bone marrow stimulation (microfracture), autologous osteochondral graft (OATS, mosaicplasty), synthetic implants. The Toale 2019 meta-analysis shows a mean post-operative AOFAS score of 89.9 at 71.9 months of follow-up, a complication rate of 3.4 % and a revision rate of 6.0 %.⁶

Criticism and controversy

While individual clinical cases and case series have great educational value, they remain at the bottom of the evidence pyramid. Three cautions:

The publication bias : cases with positive results or novel techniques are published more than failures or conventional approaches. The clinician must keep a critical eye on anecdotal reports.

The debate on TAR vs arthrodesis remains active. Arthrodesis is durable and abolishes pain, but it sacrifices tibiotalar mobility and increases stress on the adjacent joints (subtalar, Chopart), which can lead to secondary osteoarthritis at 10-15 years. TAR preserves mobility but has a limited lifespan and a risk of mechanical complications (loosening, polyethylene wear). The TARVA 2022 trial concludes there is equivalence at 1 year; the debate remains open for results at 10-20 years.¹﹐³

Finally, the role of PRP and stem cell injections remains controversial. Several case studies and low-level series report promising results, but the high-quality systematic reviews (Liu 2024, Boffa 2021) conclude that there is an absence of solid evidence for a routine recommendation in talocrural osteoarthritis.⁷﹐⁸

When and to which other health professionals should the patient be referred?

Referral is a key skill for the physiotherapist. Recognising what lies beyond one's scope of practice is not a weakness but a marker of professionalism and of safety for the patient.

The IFOMPT 2020 international framework (Finucane et al.) for red flags, although developed for spinal conditions, provides a model transposable to peripheral conditions. It distinguishes 3 levels of alert:¹

• Level 1 is an isolated non-specific signal, vigilance;
• Level 2 is a combination of several signals or a moderately specific signal, further investigation;
• Level 3 is a set of signals highly specific for a serious condition, urgent referral.

At the ankle, the main red flags to refer to a doctor without delay:

• Non-mechanical night pain not relieved by rest, unexplained weight loss, prolonged fever → rule out a bone tumour or infection;
• Inflammatory swelling with fever, leucocytosis, raised markers (CRP, ESR) → septic arthritis: a hospital emergency;
• Change in skin colour, disproportionate hyperaesthesia, vasomotor disturbance → CRPS;
• Rapid painless deformity in a patient with diabetes → Charcot: a diagnostic emergency;
• Absent posterior tibial and dorsalis pedis pulses with claudication or rest pain → arterial disease: vascular referral;
• New neurological symptoms (stocking paraesthesia, motor deficit) → rule out a neuropathy (diabetic or other) or tarsal compression.

Identifying the yellow flags (psychosocial factors) justifies interprofessional collaboration:²

• Catastrophising (PCS > 30/52);
• Marked kinesiophobia (TSK-11 > 17/44);
• Anxiety or depression suggested by questionnaire (HADS, PHQ-9);
• An unresolved insurance dispute or workplace conflict;
• Low self-efficacy (Self-Efficacy Scale).

An open, structured discussion with the general practitioner, the sports physician, the orthopaedic surgeon or, when yellow flags dominate, the psychologist or pain physician allows the treatment plan to be readjusted. Collaboration within multidisciplinary teams improves clinical results and patient satisfaction.²

How do you measure outcomes and overcome the barriers to implementation?

« You can only improve what you measure ». The systematic use of PROMs has become the gold standard for tracking the effectiveness of interventions and adapting management.³

No set of instruments is recommended by any body in talocrural osteoarthritis. The minimum assessment proposed below brings together the validated and most-used tools in this condition:

• FAAM (Foot and Ankle Ability Measure) (ADL subscale, 21 items, and Sport, 8 items), validated (Martin 2005, ICC 0.89-0.87).⁴
• AOS (Ankle Osteoarthritis Scale) (Domsic & Saltzman 1998), the tool most used in trials specific to talocrural osteoarthritis.⁵
• NPRS / VAS for pain intensity at rest, on exertion, and the impact on night-time quality of life.
• MOXFQ (Manchester-Oxford Foot Questionnaire) used in TARVA 2022, sensitive to change after surgery.⁶
• EQ-5D-5L for health utility in cost-effectiveness studies.
• Direct functional measures: WBLT, isometric strength, SEBT, hop tests (see chapter 5).

The obstacles to implementing EBP in the everyday practice of the French physiotherapist include:⁷

• A lack of time for continuing education and critical appraisal;
• A lack of access to quality scientific databases;
• Variable skills in critically appraising papers;
• Long-standing habits (passive modalities) that are hard to abandon;
• Limited organisational support (isolated practices, no practice reviews).

Practical strategies for integrating evidence into daily work: ✨

• Targeted continuing education (evidence-based seminars, critical appraisal workshops).
• Building PROMs into the patient record (on paper or electronically) with scoring at T0, T+6 weeks, T+3 months, T+6 months.
• Reflective practice : team case reviews, analysis of early treatment drop-outs.
• Professional network : taking part in a peer group, clinical mentoring, local conferences.
• Follow reliable sources (PubMed, PEDro, Cochrane, JOSPT, BJSM, EFORT Open Reviews, JAAOS).

Criticism and controversy

Three structural tensions deserve recognition in applying the recommendations:

First, the paradox of standardisation versus personalisation. Core Outcome Sets and guidelines aim to make quality uniform, but physiotherapy is also an art of individualisation. The risk is to reduce the clinician to an applier of protocols. Expert practice consists of using the standardised tools in the service of tailored therapy, not as a substitute for it.⁸

Second, the unfair transfer of responsibility. Blaming the individual clinician for a lack of time or of EBP skills hides the systemic failures : economic models that pay for volume rather than quality, crushing administrative loads, variable initial training. Improving EBP implementation requires organisational and political change, not only individual change.⁷

Third, the relevance gap between research evidence and the real patient. Randomised trials are run on selected populations that often do not resemble the real patient (comorbidities, social context, variable adherence). The clinician is therefore permanently at work translating and adapting , which is exactly what Sackett's EBP model recognises (evidence + expertise + patient values).⁸