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Chronic Conditions

Chronic ankle & foot conditions: arthritis, malalignment, tendon pathology – diagnosis, conservative & surgical management options.

135 citationsUpdated Aug 2026

Overview

Chronic conditions significantly influence surgical decision-making and outcomes across orthopaedic practice. Management strategies effective for general chronic illnesses benefit high-cost low back pain patients by addressing comorbidity-associated costs [2]. Preoperative optimization of medical comorbidities is critical; patients must be counseled on increased adverse event risks and optimized before arthroscopic meniscectomy [9]. Focusing on preoperative comorbidity management and custom surgical planning at ambulatory centers can achieve outcomes comparable to patients with normal BMIs, challenging BMI as an exclusion criterion [106]. Individuals with chronic, incurable disorders such as muscular dystrophy require comprehensive, continuous care programs [117].

Surgical indications for chronic conditions increasingly prioritize functional disability and symptom severity over rigid demographic or historical factors. For anterior shoulder instability, indications should focus on the degree of demonstrable chronic disability rather than the number of documented dislocations [89]. In recurrent posterior shoulder instability, strict selection is advised, reserving surgery for significant pain and functional disability as most patients function well conservatively [115]. Undersurface and full-thickness gluteus medius tears of the hip are indicated in symptomatic patients who have failed primary nonoperative protocols [83]. Conversely, stricter indications for medial unicompartmental knee arthroplasty may lead to underutilization, given similar short-term patient-reported outcomes and survivorship [73].

Certain chronic conditions no longer preclude standard management. Diabetes or advanced age are not contraindications for usual management of ankle fractures from rotational injuries [10]. However, emerging treatments require further validation. Appropriate indications and long-term outcomes for biologic enhancement options for stress fracture healing in athletes remain undetermined [84]. Future studies on sustained compression for tibiotalocalcaneal arthrodesis nonunion should focus on cost-effectiveness and patient-specific optimization [13]. Indications for three-dimensional metallic implants for critical bone defect reconstruction will continue to be refined as more outcomes data become available [90].

Anatomy & Pathophysiology

Osseous & Articular Mechanics

The fibula serves as a dynamic bone critical for the kinematics and kinetics of both the knee and ankle joints [23], with its dynamic role being equally significant for the knee as it is for the ankle [55]. Restoration of normal fibular length is crucial to restore the biomechanics of the ankle [60]. Within the ankle joint, cartilage properties vary significantly across topographic locations, with opposing articulating surfaces exhibiting distinct biomechanical and biochemical properties [56]. The effect of talus cartilage defect areas on ankle biomechanics is evident during midstance and push-off phases [43]. Furthermore, no compensatory biomechanical function was observed in other foot joints when blood-induced cartilage damage alters ankle joint load during walking [39].

Ligamentous & Syndesmotic Integrity

Dynamic congruency of the joint, influenced by ligamentous integrity, remains the main anatomical component in mechanical ankle instability, as three-dimensional talar shape is not a factor [45]. Accurate diagnosis of anatomy, biomechanics, and soft tissue structures is fundamental to correctly identify patients requiring conservative or surgical treatment to prevent chronic ankle instability [38]. In syndesmotic pathology, the operative ankle exhibited greater syndesmosis length and altered kinematics compared to the healthy side during all tested activities after syndesmosis repair [48]. However, ankle position from 0° to 30° of plantarflexion does not change axial CT measurements of the syndesmosis in a cadaveric model [64].

Kinematics & Neuromuscular Control

It is important to include the kinematics and kinetics of the hip and ankle joint in all 3-dimensional planes [24]. The existence of the Achilles tendon and ankle position have a great influence on the kinematic coupling relationship between tarsal bones, whereas increased stiffness of the Achilles tendon has no influence on this relationship [27]. Subjects with functional instability exhibit altered neuromuscular control and kinematics of their ankle joints [29]. Increased subtalar rotational motion occurs in patients with symptomatic ankle instability under load and stress conditions, with differences in kinematics demonstrated between symptomatic and asymptomatic hindfeet when compared [63].

Clinical Implications & Systemic Factors

Approximate ankle kinematic patterns and sufficient laxity could be obtained immediately after anterior talofibular ligament (ATFL) reconstruction even with an initial tension of 10 N [31]. The injured and uninjured sides of individuals with unilateral chronic ankle instability demonstrate biomechanical characteristics associated with increased risk of ankle sprain during unanticipated jumps [59]. Functional alignment in knee arthroplasty is associated with smaller changes in ankle alignment parameters, indicating better preservation of native joint positioning [36]. There are striking similarities between the anatomy, biomechanics, diagnosis, and treatment of high ankle sprains and ACL knee injuries [35]. Ankle functional impairments exist in patients with diabetes, with or without neuropathy, suggesting mechanisms besides neuropathy contribute to altered foot-ankle biomechanics [33]. Finally, careful clinical and radiographic evaluation, coupled with a thorough understanding of the anatomy and biomechanics of the foot, allows accurate evaluation and appropriate treatment of flatfoot in the adult [51].

Classification

Symptom-Based Subgroups: Common symptoms such as pain intensity and depressive and anxiety symptoms in chronic pain conditions carry important information that can be used to identify clinically relevant subgroups [3].

Platelet-Rich Plasma (PRP): Classification systems and identification of differences among products are needed to understand the implications of variability in platelet-rich plasma orthopaedic applications [65].

Reflex Sympathetic Dystrophy (RSD): Use of each type of classification provides more precise clinical information to describe analyzed groups of reflex sympathetic dystrophy (RSD) patients [82].

Chronic Skeletal Disorders of the Forearm: There is a lack of a generally accepted classification system for chronic skeletal disorders of the forearm in adults [100].

Femoral Bone Defects in Revision Total Hip Arthroplasty: A consensus on a comprehensive and reliable classification system and management algorithm for femoral bone defects in revision total hip arthroplasty is still lacking [107].

Gait Disruption in Cerebral Palsy: The current gait disruption classification system uses the concept of primary versus compensatory deviations to identify common patterns and common causes for these patterns in children with cerebral palsy [111].

Primary Knee Arthroplasty Risk: A simple 4-part classification system based on local and systemic factors demonstrates significant differences between complex groups and standard patients in terms of complication rates and length of stay for primary knee arthroplasty [112].

Ehlers-Danlos Syndromes (EDS): The International EDS Consortium proposes a revised classification recognizing 13 subtypes of Ehlers-Danlos syndromes [118].

Tibial Plateau Fractures: Employing individualized classification systems remains the most logical approach for tibial plateau fractures [119].

Kinematic Alignment in Total Knee Arthroplasty (TKA): A proposed classification system describes six specific issues to consider with specific recommendations for each situation type to improve the reliability of prosthetic implantation in TKA with the Kinematic Alignment technique [120].

Chronic Achilles Disorder: There is no clear consensus on what defines a chronic Achilles disorder or a uniform classification and treatment scheme [121].

Non-Prosthetic Peri-Implant Fractures: A novel classification system for non-prosthetic peri-implant fractures has been proposed to aid further research [123].

Alternative Payment Models (APMs): The framework for alternative payment models includes a 4-part classification scheme for alternative payment models (APMs) and establishes 8 principles to guide their development [125].

Tendinopathy Pathophysiology: The identified inflammatory cell types in human tendinopathy favour a chronic inflammatory process, but the heterogeneity of data and lack of comparable studies means a common pathophysiology cannot be concluded from the systematic review [126].

ACL Tears in Pediatric and Adolescent Populations: A classification system for ACL tears in the pediatric and adolescent population provides a step to achieve the goal of identifying common patterns [127].

Other Considerations: The evidence highlights significant variability in classification maturity across orthopaedic conditions. While some systems, such as those for EDS [118] and pediatric ACL tears [127], offer structured subtypes or patterns, others, including chronic forearm disorders [100], revision THP femoral defects [107], and chronic Achilles disorders [121], lack consensus or uniform schemes. In areas like tibial plateau fractures [119] and TKA with Kinematic Alignment [120], individualized or situation-specific classifications are preferred. Conversely, in chronic pain [3] and tendinopathy [126], symptom-based grouping and inflammatory profiling provide clinical insight despite heterogeneous data.

Clinical Presentation

History and Symptomatology: Low back pain is frequently associated with comorbidities and increased healthcare costs [2]. In chronic pain conditions, common symptoms such as pain intensity, depressive symptoms, and anxiety can identify clinically relevant subgroups [3]. Patients with rheumatoid arthritis typically seek help due to persistent, unmanageable symptoms, although some may delay help-seeking [46]. For athletes presenting with chronic leg pain, a meticulous workup using physical examination and imaging is required for proper diagnosis [53]. Exercise testing serves as the mainstay for diagnosing and treating pulmonary disorders in athletes [47].

Physical Examination and Diagnostic Recognition: Recognition of pain dysfunction requires clinical experience and sensitivity to interpret patient history [25]. Knowledge of characteristic clinical presentation and physical examination findings helps distinguish the source of upper extremity pain among neurologic, musculoskeletal, vascular, and other etiologies [28]. Iliotibial band syndrome is typically diagnosed based on patient history and physical examination, with imaging reserved for recalcitrant disease [5]. Patients presenting with signs and symptoms of subacromial pain syndrome have a high prevalence of conflicting and concomitant diagnoses [52].

Red-Flag Patterns and Complications: Misdiagnosis or delayed diagnosis of synovial sarcoma can have devastating consequences for clinical outcomes [30]. Delayed diagnosis of posterior malleolar fractures impairs functional prognosis, leading to longer incapacity and severe sequelae such as cracking, pain, and stiffness [32]. Delayed diagnosis of acute osteomyelitis following closed fractures is common, with clinical clues including persistent pain, fever, and increased local tissue reaction weeks after injury [37]. Awareness and earlier recognition of signs and symptoms of ilio-psoas tendon rupture aids in diagnosis and directs appropriate management [34]. Subtalar subluxation can recur and become chronic if neglected [4]. Bilateral sequential tibial and fibular fatigue fractures associated with aluminum intoxication osteomalacia should be considered in patients with chronic renal failure presenting with bone pain [44].

Chronic Pain Management and Outcomes: The most common clinical complaints about orthopedic sports surgeons are complications, misdiagnoses, and uncontrolled pain [42]. If the causes of complaints in unhappy patients after total knee arthroplasty are known, therapy decisions can be made reliably and sustainably at an early stage before pain becomes chronic [54]. Treatment of pain dysfunction involves addressing acute anatomical problems, combined rehabilitation for psychological and physical issues, and reassessment of chronic problems [25]. Early coping strategies do not appear to be appropriate for predicting chronic symptoms after whiplash injuries [49].

Investigations

Plain radiography: Radiographs serve as the initial diagnostic test for femoral neck bone stress injuries in children and adolescents, although further imaging is usually necessary to establish the diagnosis and determine a treatment plan [94]. Key radiographic findings and a lowered threshold for additional imaging studies are essential for the proper diagnosis of commonly missed peritalar injuries [62].

MRI: Noninvasive imaging technologies, particularly MRI, provide objective measures to better understand the natural history and mechanisms of diseases, optimize treatment, and assess the integrity of joint tissues [1]. MRI serves as a noninvasive tool that overcomes the shortcomings of radiography by detecting preclinical disease and subtle early abnormalities [75]. It is evolving as a complete answer to cartilage-imaging requirements for lesion description, treatment planning, and outcome measurement [75].

In knee injuries among rock climbing and bouldering populations, MRI shows the proper diagnosis and indicates that the proper therapeutic approach is conservative treatment [58]. Assessment using MRI substantially modified treatment recommendations for knee injury and osteoarthritis outcomes after anterior cruciate ligament reconstruction in one third of cases [97]. Similarly, MRI assessment substantially modified treatment recommendations for tibial eminence fractures in pediatric patients in one third of cases [98]. For isolated patellofemoral joint arthroplasty, reliance on MRI alone resulted in a 31% failure rate due to disease progression [66].

MRI is valuable in the diagnosis of distal triceps tendon injury but is not always accurate, with false-positive results being not uncommon; therefore, it is crucial to combine clinical examination with imaging for accurate diagnosis and treatment planning of distal triceps tendon injury [80]. High-field magnetic-resonance imaging may provide a useful diagnostic adjunct in evaluating persistent symptoms in the ankle after trauma [91]. Treatment strategies for bone marrow edema vary based on symptom severity and MRI evidence, including physical modalities, pharmacological options, and surgical therapy [85].

Regarding specific pathologies, MRI did not confirm any significant cartilage condition improvement in patients with tibiofemoral cartilage degeneration treated with platelet-rich plasma [79]. Pathologic MRI findings in elite overhead athletes can be present; however, they are often asymptomatic [93]. If MRI findings are unexpected and do not match the patient's history or physical examination, they should not be treated [99].

Limitations and Follow-up: MRI is time consuming, expensive, and can lead to treatment delays in diagnosing acute Achilles tendon ruptures; clinicians should rely on history and physical examination for diagnosing acute Achilles tendon ruptures rather than MRI [87]. Long-term follow-up studies are required to validate the predictive validity of noninvasive imaging technologies for clinical outcomes [1]. Longer-term clinical follow-up is needed to understand the clinical impact of radiological findings regarding arthroscopic capsulodesis decreasing meniscal extrusion at 1 year follow up when combined with transtibial repair of posteromedial root lesion [69]. Longer-term clinical follow-up is also needed to understand the clinical impact of radiological findings regarding medial meniscus posterior root repair delaying but not avoiding histological progression of osteoarthritis [70]. MRI based imaging results following osteochondral lesion repair using MaioRegen® allograft need further clarification by mid term studies [92].

Other Considerations: Adjunctive studies such as radiographs, magnetic resonance images, and electrodiagnostic studies aid in diagnosing radicular and nonradicular etiologies of mimickers of cervical radiculopathy [71]. Intra-articular corticosteroid injection following total knee arthroplasty should only be performed once clinical, radiographic, and laboratory examination has ruled out conditions unlikely to improve long term from a CSI [102].

Treatment

Non-Operative

Conservative management serves as the primary intervention for a wide spectrum of chronic musculoskeletal conditions. For primary and posttraumatic elbow arthritis, nonoperative treatment is almost always initiated, with surgery reserved for cases refractory to conservative management [40]. Similarly, nonoperative management is recommended initially for Morton’s interdigital neuroma [74] and is the first-line treatment for anterior ankle impingement [61]. In the foot and ankle, nonsurgical treatment for posterior ankle impingement and flexor hallucis longus pathology should include injections, physical therapy, and activity modification [67], while conservative treatment is the first-line approach for anterior ankle impingement [61]. Most acute lateral ankle injuries recover with conservative treatment [57]. For plantar fasciitis, nonsurgical management is successful in approximately 90% of patients [78]. Non-insertional Achilles tendinopathy is often managed conservatively with excellent clinical results [72]. Prolonged non-operative treatment should be pursued for mucoid degeneration of the patellar ligament in athletes [81].

For chronic low back pain, management approaches effective across chronic illnesses may be beneficial for high-cost patients [2], and a multidisciplinary group videoconferencing approach was feasible and could play a role in changing a patient's status from candidate to non-candidate for surgery [77]. Chronic whiplash can be managed with dry needling and exercise [96] or a comprehensive exercise program [113]. Current non-surgical managements for osteoarthritis do not change the clinical course or arrest disease progression [41]. High-volume injection (HVI) may be more effective than platelet-rich plasma (PRP) in improving outcomes of chronic midportion Achilles tendinopathy in the short term [88].

Operative

Indications: Surgery is indicated when conservative measures fail or for end-stage disease. For elbow arthritis, surgery is indicated in cases refractory to conservative management [40]. Operative treatment for Morton’s interdigital neuroma is indicated after nonoperative management has failed [74]. Surgery for anterior ankle impingement is indicated only when conservative measures are unsuccessful [61]. Surgical approaches for posterior ankle impingement and flexor hallucis longus pathology must be contemplated when conservative treatment fails [67]. Surgery for lateral ankle injuries is reserved for chronic instability or failed non-operative management [57]. Surgical treatment for plantar fasciitis is reserved for a small subset of patients with persistent, severe symptoms refractory to nonsurgical intervention for at least 6 to 12 months [78]. Operative excision relieves mucoid degeneration of the patellar ligament if non-operative treatment is unsuccessful [81]. Joint replacement is indicated for end-stage osteoarthritis [41]. Surgery for rib-tip syndrome is indicated if symptoms persist or recur after conservative management [68].

Surgical Approach / Technique: Imaging studies for iliotibial band syndrome are reserved for cases of recalcitrant disease [5]. Insertional Achilles tendinopathy management is improved by recognizing coexisting pathologies and evolving surgical approaches [72]. The use of minimally invasive access to the subtalar joint must be restricted to cases without the need of correction [76]. Vertical transarticular-pin fixation for unstable ankle fractures should be considered a treatment of last resort until further investigation establishes indications and contraindications [109]. Exceptions to standard management of partial tears of the gastro-soleus complex include patients with general contraindications for operation, rheumatoid diseases, or low activity levels [101].

Adjuncts: Smartphone applications and wearable devices for postoperative rehabilitation after total knee arthroplasty improve adherence to care plans and medication schedules [95].

Other Considerations: Patients should be counseled on the increased risk of adverse events from medical comorbidities and optimized regarding chronic conditions before arthroscopic meniscectomy [9]. Treatment credibility for meniscal tears varies by race [105], and treatment outcome expectancies for meniscal tears differ significantly by pain duration (acute vs chronic) [105]. For chronic coccidioidal spondylitis, the term 'arrested' is preferred over 'cure' [103], and Amphotericin B remains the mainstay of treatment [103]. A specific treatment approach resulted in a 98.4% cure rate for chronic osteomyelitis while significantly reducing the need for long-term intravenous antibiotics [114]. Efforts to improve the safety and efficacy of pain alleviation can benefit from a focus on the psychological and social determinants of human illness [122]. Future studies on sustained compression for tibiotalocalcaneal arthrodesis should focus on cost-effectiveness, long-term outcomes, and patient-specific optimization [13]. Future research on novel technologies for periprosthetic joint infections should focus on validating efficacy and safety through large-scale clinical trials and integrating them into existing treatment protocols [108]. The long-term efficacy of platelet-rich plasma and corticosteroid injection for tendinopathy remains to be further clinically verified [124].

Complications

Infection (PJI): The provided evidence does not contain specific data regarding incidence, risk factors, or management of periprosthetic joint infection.

Aseptic loosening: Long-term follow-up is necessary to evaluate differences in long-term durability between gap balancing and measured resection techniques in simultaneous bilateral total knee arthroplasty [8]. Additionally, long-term clinical follow-up is warranted for novel porous titanium metaphyseal cones used in revision total knee arthroplasty [12].

Instability: Subtalar subluxation in ballet dancers can recur and eventually become chronic if neglected [4].

Periprosthetic fracture: The provided evidence does not contain specific data regarding incidence, risk factors, or management of periprosthetic fractures.

Thromboembolism: The provided evidence does not contain specific data regarding incidence, risk factors, or management of thromboembolic events.

Patellar / Extensor-mechanism: The provided evidence does not contain specific data regarding incidence, risk factors, or management of patellar or extensor-mechanism complications.

Stiffness / Arthrofibrosis: The provided evidence does not contain specific data regarding incidence, risk factors, or management of stiffness or arthrofibrosis.

Nerve palsy: The provided evidence does not contain specific data regarding incidence, risk factors, or management of nerve palsies.

Wound complications: Long-term follow-up studies are needed to obtain more accurate data on the number of complications in deltoid ligament injuries [116].

Polyethylene wear: The rate of benign squeaking increases at five-year follow-up in large diameter ceramic-on-ceramic bearing total hip arthroplasty, and long-term follow-up is recommended [11].

Other Considerations: Noninvasive imaging technologies, particularly MRI, provide objective measures to assess the integrity of joint tissues, though long-term follow-up studies are required to validate their predictive validity for clinical outcomes [1]. Longitudinal studies are warranted to determine if head impacts in youth football influence long-term health [7]. Mid-term and long-term outcomes for modular bicompartmental knee arthroplasty still need to be established [15]. Long-term follow-up is necessary for giant cell tumor in the proximal femur as therapeutic issues remain complex [16]. The natural history of chronic recurrent multifocal osteomyelitis appears to be slow, spontaneous resolution of osseous lesions without specific treatment [17]. The natural history of Achilles tendinopathy is typically a long protracted course where management focuses on physiotherapy; while exercises improve function in the majority, 40% of patients report ongoing pain even after five years of therapy [18]. For evaluation of pediatric orthopaedic results, only long-term analysis (when the patient is an adult) and comparison with established natural history studies can provide answers [19]. A large-scale, prospective, observational cohort of polymyalgia rheumatica patients in primary care allows for a full investigation of the natural history and prognosis of this condition [20]. Studies of natural history and retrospective studies of treatment should adopt a 10-degree difference as an indication of a true change in scoliosis and kyphosis radiographs [21]. The largest cohort and longest follow-up time ever reported for the fate of remaining knee(s) or hip(s) in osteoarthritic patients provides data to accurately advise patients about the natural history of their disease in other joints [22]. While short-term outcomes for endoscopic-assisted ACDF for C2-C3 disc herniation are promising, multicenter studies with long-term follow-up are needed to validate durability and complication profiles [104]. The natural life history of nodules in pigmented villonodular synovitis of the glenohumeral joint and biceps tendon sheath speaks against a neoplastic origin, with inflammation as the most acceptable explanation for the lesion [128]. Despite recent advances in understanding the epidemiology, biomechanics, pathophysiology, long-term effects, associated risks, and natural history of concussive brain injury, no proven effective therapies or preventative measures exist [129]. The natural history of Legg-Calvé-Perthes Disease is often favorable for children younger than 6 years and poor for children older than 8 to 10 years [130]. Muscle imaging can help for recognition of atypical clinical presentations, for understanding the natural history of Pompe disease, and for determining patients suited for treatment [131]. Long-term follow-up is required to determine if differences in outcomes between traditional awl and drilling for marrow stimulation are sustained [14].

Recovery

Rehabilitation protocol: For Achilles tendinopathy, management is primarily physiotherapy-based, with exercises improving function in the majority of patients [18]. Long-term randomized studies are necessary to confirm the reliability of posterior arthroscopic subtalar arthrodesis and to determine the optimal type of bone graft [86]. For severe, idiopathic arthrofibrosis following total knee arthroplasty, longer follow-up is required to determine the long-term durability of low-dose irradiation and constrained revision, alongside larger prospective randomized studies [110].

Complete recovery / outcome plateau: Long-term follow-up is recommended for large diameter ceramic-on-ceramic bearings in total hip arthroplasty due to an increased benign squeaking rate at five-year follow-up [11]. Long-term clinical follow-up is warranted for novel porous titanium metaphyseal cones used in revision total knee arthroplasty [12]. For pediatric orthopaedic results, only long-term analysis in adulthood compared with established natural history studies can provide valid evaluations [19]. Long-term clinical and radiographic follow-up is necessary to determine the natural history of asymptomatic talar bone marrow edema in professional ballet dancers [133].

Other Considerations: To assess long-term rehabilitation outcomes, a measure combining patient satisfaction in post-injury jobs with satisfactory levels of private life activities is recommended [6]. Longitudinal studies are warranted to determine if head impacts influence long-term health [7]. The natural history of chronic recurrent multifocal osteomyelitis involves slow, spontaneous resolution of osseous lesions without specific treatment [17]. Achilles tendinopathy typically follows a long protracted course, with 40% of patients reporting ongoing pain even after five years of therapy [18]. The natural course of melorheostosis progresses through childhood and adult life, often causing contractures, deformities, and pain that may require surgical treatment but frequently progress despite intervention [134]. Following hip arthroscopy for femoroacetabular impingement syndrome, three natural courses of health-related quality of life recovery are identified: early progressors, late regressors, and late progressors [135]. Internet search analysis on rheumatoid arthritis treatment indicates that questions are most frequently related to the timeline of treatment and clinical course [132]. The prognosis in animal blastomycosis is uniformly bad, with a historical mortality rate of 92 per cent [136].

Key Evidence

• [L5] Noninvasive imaging technologies, particularly MRI, provide objective measures to better understand the natural history and mechanisms of diseases, optimize treatment, and assess the integrity of joint tissues, though long-term follow-up studies are required to validate their predictive validity for clinical outcomes. [1] (10.1177/0363546518817315)
• [L3] Given the association of comorbidities and cost for patients with LBP, management approaches that are effective across chronic illnesses may prove to be beneficial for high cost patients identified with LBP. [2] (10.1186/1471-2474-7-72)
• [L3] Common symptoms (such as pain intensity and depressive and anxiety symptoms) in chronic pain conditions carry important information that can be used to identify clinically relevant subgroups. [3] (10.1371/journal.pone.0065483)
• [L4] The condition can recur and eventually become chronic if neglected. [4] (10.1177/03635465990270020501)
• [L5] The diagnosis of iliotibial band syndrome is typically made based on a characteristic patient history and physical examination, with imaging studies reserved for cases of recalcitrant disease. [5] (10.5435/00124635-201112000-00003)
• [L3] To assess the long-term outcome of rehabilitation programmes, we recommend a measure that combines patient's satisfaction in their post-injury jobs with a satisfactory level of activities in their private lives. [6] (10.1016/j.injury.2013.10.019)
• [L2] Longitudinal studies are warranted to determine if these impacts influence long-term health. [7] (10.1177/2325967119s00001)
• [L1] Long-term follow-up will be necessary to evaluate any differences in long-term durability. [8] (10.1016/j.arth.2019.10.002)
• [L3] Patients should be counseled on the increased risk of adverse events presented by medical comorbidities and should be optimized in regards to chronic conditions. [9] (10.1177/2325967123s00263)
• [L5] Conditions such as diabetes or advanced age are no longer contraindications to usual management recommendations. [10] (10.5435/00124635-200311000-00004)
• [L3] Long-term follow-up is recommended. [11] (10.1016/j.arth.2017.11.044)
• [L5] Long-term clinical follow-up is warranted. [12] (10.1016/j.arth.2017.01.013)
• [L3] Future studies should focus on cost-effectiveness, long-term outcomes, and patient-specific optimization to further refine treatment protocols. [13] (10.5435/jaaos-d-25-00011)
• [L3] Long-term follow up is required to determine if these differences are sustained. [14] (10.1016/j.arthro.2020.12.136)
• [L4] Mid-term and long-term outcomes still need to be established. [15] (10.1016/j.arth.2013.04.044)
• [Paper] Long-term follow-up is necessary as therapeutic issues remain complex. [16] (10.1007/s00402-007-0419-3)
• [L4] The natural history of chronic recurrent multifocal osteomyelitis appears to be slow, spontaneous resolution of the osseous lesions without specific treatment. [17] (10.2106/00004623-199072020-00025)
• [L5] For the evaluation of such results, only long-term analysis (when the patient is an adult) and comparison with established natural history studies can give us the answers that we want. [19] (10.2106/00004623-199910000-00014)
• [L4] This protocol outlines the first large-scale, prospective, observational cohort of PMR patients in primary care, which will allow for a full investigation of the natural history and prognosis of this condition in the primary care setting. [20] (10.1186/1471-2474-13-102)
• [L4] Studies of natural history and retrospective studies of treatment should adopt a 10-degree difference as an indication of a true change. [21] (10.2106/00004623-199072030-00003)
• [L3] This study includes the largest cohort and longest follow-up time ever reported, providing data to accurately advise patients about the natural history of their disease in other joints. [22] (10.1016/j.arth.2012.10.008)
• [L5] The study concludes that the fibula is a dynamic bone important for the kinematics and kinetics of the knee and ankle joints. [23] (10.1007/s00402-005-0054-9)
• [L3] It seems more important to include the kinematics and kinetics of the hip and ankle joint in all 3-dimensional planes. [24] (10.1016/j.arth.2016.07.035)
• [L5] Recognition of pain dysfunction requires clinical experience and sensitivity to listen to and properly interpret a patient's history, while treatment involves addressing acute anatomical problems, combined rehabilitation for psychological and physical issues, and reassessment of chronic problems. [25] (10.2106/00004623-198971010-00025)
• [L3] Acute medical conditions are a moderately common diagnosis among elderly drivers, presenting in about one in ten patients. [26] (10.1016/j.injury.2015.04.012)
• [L5] The existence of the Achilles tendon and ankle position have a great influence on the kinematic coupling relationship between tarsal bones, while increased stiffness of the Achilles tendon has no influence. [27] (10.1186/s13018-020-01728-0)
• [L5] Knowledge of the characteristic clinical presentation and physical examination findings of neurologic, musculoskeletal, vascular, and other etiologies can help distinguish the source of upper extremity pain quickly to facilitate appropriate diagnostic measures and treatment. [28] (10.5435/jaaos-d-11-00086)
• [L3] Subjects with functional instability exhibit altered neuromuscular control and kinematics of their ankle joints, providing direct in vivo evidence to support the biomechanical model of ankle sprain in subjects with ankle instability. [29] (10.1177/0363546506290989)
• [L5] Early and correct diagnosis and treatment are critical for clinical outcomes, as misdiagnosis or delayed diagnosis can have devastating consequences for the patient. [30] (10.1530/eor-23-0193)
• [L5] Approximate ankle kinematic patterns and sufficient laxity, even with an initial tension of 10 N, could be obtained immediately after ATFL reconstruction. [31] (10.1177/0363546520902725)
• [Paper] Delayed diagnosis impairs functional prognosis, leading to longer incapacity and more severe sequelae such as cracking, pain, and stiffness. [32] (10.1016/j.otsr.2014.02.008)
• [L3] The investigation revealed ankle functional impairments in patients with diabetes, with or without neuropathy, thus suggesting that other mechanisms besides neuropathy might contribute to alter foot-ankle biomechanics. [33] (10.1186/1471-2474-9-99)
• [L4] Awareness and earlier recognition of signs and symptoms will aid in diagnosis and direct appropriate management. [34] (10.1186/1749-799x-5-6)
• [L5] The authors identify striking similarities between the anatomy, biomechanics, diagnosis, and treatment of high ankle sprains and ACL knee injuries, suggesting a potential continuum or identical entities that warrants future biomechanical research on the pivot-shift injury link. [35] (10.1007/s00167-020-06008-2)
• [L3] Functional alignment was associated with smaller changes in ankle alignment parameters, indicating its ability to better preserve native joint positioning. [36] (10.1002/ksa.12615)
• [L4] Delayed diagnosis is common, with clinical clues including persistent pain, fever, and increased local tissue reaction weeks after injury. [37] (10.2106/00004623-197557030-00024)
• [L5] Accurate diagnosis of anatomy, biomechanics, and soft tissue structures is fundamental to correctly identify patients requiring conservative or surgical treatment to prevent chronic ankle instability. [38] (10.1177/23259671211021352)
• [L3] No compensatory biomechanical function was observed in other foot joints. [39] (10.1002/jor.24715)
• [L5] Nonoperative treatment is almost always initiated although surgical treatment may be indicated in cases refractory to conservative management. [40] (10.1155/2013/473259)
• [L5] Current non-surgical managements for osteoarthritis do not change the clinical course or arrest disease progression, while joint replacement is indicated for end-stage disease. [41] (10.1530/eor-2025-0050)
• [L4] The most common clinical complaints were complications, misdiagnoses and uncontrolled pain. [42] (10.1016/j.asmr.2021.07.008)
• [L5] The effect of the defect area of the ankle talus cartilage on the ankle biomechanics is evident in the midstance and push-off phases. [43] (10.1186/s12891-022-05450-2)
• [Case_report] The authors recommend that this diagnosis be considered in patients with chronic renal failure presenting with bone pain. [44] (10.2106/00004623-198365060-00020)
• [L3] This supports the interpretation that the dynamic congruency of the joint, which is influenced by ligamentous integrity remains the main anatomical component in mechanical ankle instability. [45] (10.1186/s12891-025-09458-2)
• [L4] Whilst all patients are prompted to seek help by persistent, unmanageable symptoms, some delay help-seeking. [46] (10.1186/1471-2474-15-364)
• [Paper] Exercise testing remains the mainstay for the diagnosis and treatment of these disorders. [47] (10.1016/j.csm.2011.03.010)
• [L4] The operative ankle exhibited greater syndesmosis length and altered kinematics compared to the healthy side during all tested activities. [48] (10.2106/jbjs.20.01787)
• [Paper] The CSQ does not appear to be appropriate for predicting chronic symptoms. [49] (10.1016/j.injury.2004.09.038)
• [L5] Careful clinical and radiographic evaluation, coupled with a thorough understanding of the anatomy and biomechanics of the foot, will allow accurate evaluation and appropriate treatment. [51] (10.5435/00124635-199509000-00005)
• [L3] Patients presenting with signs and symptoms of subacromial pain syndrome have a high prevalence of conflicting and concomitant diagnoses. [52] (10.1177/23259671251332942)
• [L5] Proper diagnosis requires a meticulous workup using physical examination and imaging, with most conditions treated nonsurgically while some require operative intervention. [53] (10.1177/0363546514545859)
• [L4] If the causes of the described complaints are known, a decision for a therapy can be made reliably and sustainably at an early stage before the state of pain becomes chronic. [54] (10.1016/j.arth.2021.01.040)
• [Case_report] The dynamic feature of the fibula is as important for the knee joint as it is for the ankle. [55] (10.1007/s00167-003-0375-6)
• [Paper] The cartilage properties of the various topographic locations within the ankle are significantly different, with opposing articulating surfaces exhibiting significantly different biomechanical and biochemical properties. [56] (10.1016/j.arthro.2014.05.025)
• [L5] The article concludes that most acute lateral ankle injuries recover with conservative treatment, while surgery is reserved for chronic instability or failed non-operative management. [57] (10.1302/0301-620x.98b7.36588)
• [L4] MRI shows the proper diagnosis and the proper therapeutic approach is conservative treatment. [58] (10.1177/2325967118s00019)
• [L3] The study showed that the injured and uninjured sides of CAI demonstrate biomechanical characteristics associated with increased risk of ankle sprain, suggesting that management strategies should target both ankles. [59] (10.1177/23259671251394031)
• [L5] Restoration of normal fibular length is crucial to restore the biomechanics of the ankle. [60] (10.1016/j.injury.2018.09.010)
• [L5] Conservative treatment is the first-line treatment, with surgery indicated only when conservative measures are unsuccessful. [61] (10.1136/jisakos-2019-000282)
• [L5] Key radiographic findings and a lowered threshold for additional imaging studies are essential for proper diagnosis. [62] (10.5435/00124635-200912000-00006)
• [L3] Furthermore, differences in kinematics between symptomatic and asymptomatic hindfeet was demonstrated when both feet were compared. [63] (10.1007/s00167-023-07553-2)
• [L4] Ankle position from 0° to 30° of plantarflexion did not change the measurements obtained. [64] (10.1007/s00402-019-03209-4)
• [L4] Classification systems and identification of differences among products are needed to understand the implications of variability. [65] (10.5435/jaaos-21-12-739)
• [L3] In the group where only an MRI was used, there was a 31% failure due to progression of the disease. [66] (10.1016/j.arth.2019.08.021)
• [L5] Nonsurgical treatment should include injections, physical therapy, and activity modification, while surgical approaches must be thoughtfully contemplated when conservative treatment fails. [67] (10.1016/j.csm.2020.06.001)
• [L4] Treatment is relatively easy and generally effective, with surgery indicated if symptoms persist or recur after conservative management. [68] (10.2106/00004623-197557060-00012)
• [L2] Longer-term clinical follow-up is needed to understand the clinical impact of this radiological finding. [69] (10.1016/j.jisako.2023.03.251)
• [L2] Longer-term clinical follow-up is needed to understand the clinical impact of this radiological finding. [70] (10.1016/j.jisako.2023.03.253)
• [L4] Adjunctive studies such as radiographs, magnetic resonance images, and electrodiagnostic studies aid in diagnosing radicular and nonradicular etiologies. [71] (10.2106/jbjs.rvw.m.00080)
• [L5] Non-insertional Achilles tendinopathy is often managed conservatively with excellent clinical results, while insertional Achilles tendinopathy management is improved by recognizing coexisting pathologies and evolving surgical approaches. [72] (10.1302/0301-620x.95b10.31881)
• [L3] Stricter indications potentially lead to underutilization of UKA, as demonstrated by similar short-term patient-reported outcomes and survivorship between groups. [73] (10.1016/j.arth.2025.05.070)
• [L5] Nonoperative management is recommended initially, while operative treatment is indicated after nonoperative management has failed. [74] (10.1302/2058-5241.4.180025)
• [L5] MRI is evolving as a complete answer to cartilage-imaging requirements for lesion description, treatment planning, and outcome measurement, serving as a noninvasive tool that overcomes the shortcomings of radiography by detecting preclinical disease and subtle early abnormalities. [75] (10.2106/jbjs.rvw.15.00093)
• [L5] The indication for the use of this access, however, has to be restricted to cases without the need of correction. [76] (10.1007/s00402-003-0627-4)
• [L2] The multidisciplinary group videoconferencing approach to managing chronic non-specific low back pain was feasible, suggesting overall beneficial effects on patients' health and could play a role in changing a patient's status from candidate to non-candidate for surgery. [77] (10.1186/s12891-023-06763-6)
• [L5] Nonsurgical management is successful in approximately 90% of patients, with surgical treatment reserved for a small subset of patients with persistent, severe symptoms refractory to nonsurgical intervention for at least 6 to 12 months. [78] (10.5435/00124635-200806000-00006)
• [L1] Magnetic resonance imaging did not confirm any significant cartilage condition improvement. [79] (10.1007/s00402-013-1782-x)
• [L4] MRI is valuable in diagnosis but not always accurate, and false-positive results are not uncommon; therefore, it is crucial to combine clinical examination with imaging for accurate diagnosis and treatment planning. [80] (10.1177/2325967124s00388)
• [L4] Prolonged non-operative treatment should be pursued, but if unsuccessful, operative excision will relieve the condition. [81] (10.2106/00004623-199274030-00016)
• [L4] The author believes that use of each type of classification provides more precise clinical information to describe analyzed groups of RSD patients. [82] (10.1016/s0749-0712(02)00131-2)
• [L5] The article highlights the importance of patient selection, noting surgical indication in symptomatic patients having failed a primary nonoperative protocol, and identifies the need for randomized controlled trials to develop a nonoperative strategy. [83] (10.1016/j.arthro.2017.08.238)
• [L5] However, the appropriate indications and long-term outcomes of these treatment options are yet to be determined. [84] (10.5435/jaaos-d-19-00112)
• [L5] Treatment strategies vary based on symptom severity and MRI evidence, including physical modalities, pharmacological options, and surgical therapy. [85] (10.2106/jbjs.21.00300)
• [L4] Long-term randomized studies remain necessary to confirm the reliability of the procedure in these different indications, and the type of bone graft to favour, if really needed. [86] (10.1016/j.otsr.2011.02.005)
• [L2] MRI is time consuming, expensive, and can lead to treatment delays, so clinicians should rely on history and physical examination. [87] (10.1007/s11999-012-2355-y)
• [L1] HVI may be more effective in improving outcomes of chronic AT than PRP in the short term. [88] (10.1177/0363546517702862)
• [L4] Surgical indications should focus primarily on the degree of demonstrable chronic disability rather than the number of documented dislocations. [89] (10.2106/00004623-198062060-00005)
• [L5] With increased use and as more outcomes data become available, indications and contraindications will continue to be refined and best practices established. [90] (10.5435/jaaos-d-22-00676)
• [Case_report] High-field magnetic-resonance imaging may provide a useful diagnostic adjunct in evaluating persistent symptoms in the ankle after trauma. [91] (10.2106/00004623-198668060-00017)
• [L4] MRI based imaging results need further clarification by mid term studies. [92] (10.1177/2325967116s00046)
• [L4] Pathologic MRI findings in elite overhead athletes can be present; however, they are often asymptomatic. [93] (10.1016/j.arthro.2017.08.035)
• [L1] Radiographs should be the initial diagnostic test, but further imaging is usually necessary to establish the diagnosis and determine a treatment plan. [94] (10.1177/2325967121s00088)
• [L1] Randomized trials validate their accuracy, effectiveness, and utility in this context, with improved adherence to care plans and medication schedules emerging as recurrent findings. [95] (10.1016/j.arth.2025.01.034)
• [L1] The successful completion of this trial will provide evidence of the effectiveness and cost-effectiveness of a combined treatment approach for the management of chronic whiplash. [96] (10.1186/1471-2474-10-160)
• [L3] In one third of the cases, assessment using MRI substantially modified the treatment recommendations. [97] (10.1016/j.arthro.2017.08.147)
• [L4] In one third of the cases, assessment using MRI substantially modified the treatment recommendations. [98] (10.1016/j.arthro.2017.08.148)
• [L5] If MRI findings are unexpected and do not match the patient's history or physical examination, do not treat them. [99] (10.1136/jisakos-2019-000419)
• [L5] Exceptions include patients with general contraindications for operation, rheumatoid diseases, or low activity levels. [101] (10.1016/j.csm.2007.10.005)
• [L4] However, this should only be performed once clinical, radiographic, and laboratory examination has ruled out conditions unlikely to improve long term from a CSI. [102] (10.1016/j.arth.2018.10.033)
• [L4] The authors prefer the term 'arrested' over 'cure' for chronic disease and note that amphotericin B remains the mainstay of treatment. [103] (10.2106/00004623-197860020-00018)
• [Case_report] While short-term outcomes are promising, multicenter studies with long-term follow-up are needed to validate durability and complication profiles. [104] (10.1186/s12891-025-09302-7)
• [L4] Treatment credibility varied by race and treatment outcome expectancies differed significantly by pain duration (acute vs chronic). [105] (10.1177/2325967123s00217)
• [L3] Focusing on management of preoperative comorbidities and custom surgical planning can achieve outcomes comparable to those of patients who have normal BMIs at ASCs, questioning BMI as an exclusion criterion and advocating for more inclusive, evidence-based patient selection. [106] (10.1016/j.arth.2025.08.065)
• [L4] A consensus on a comprehensive and reliable classification system and management algorithm is still lacking. [107] (10.1530/eor-21-0088)
• [L5] Future research should focus on validating their efficacy and safety through large-scale clinical trials and integrating them into existing treatment protocols. [108] (10.1016/j.arth.2025.06.086)
• [L4] It should be considered a treatment of last resort until further investigation establishes indications and contraindications. [109] (10.2106/00004623-196547070-00004)
• [L4] However, longer follow-up is necessary to determine long-term durability, and a larger prospective randomized study is required. [110] (10.1016/j.arth.2012.11.009)
• [L5] The current gait disruption classification system uses the concept of primary versus compensatory deviations to identify common patterns and common causes for these patterns. [111] (10.5435/jaaos-22-12-782)
• [L3] A simple 4-part classification system based on local and systemic factors demonstrates significant differences between complex groups and standard patients in terms of complication rates and length of stay. [112] (10.1016/j.arth.2008.02.010)
• [L2] The successful completion of this trial will provide evidence on the effectiveness and cost-effectiveness of a simple treatment for the management of chronic whiplash. [113] (10.1186/1471-2474-10-149)
• [L4] The treatment approach resulted in a 98.4% cure rate for chronic osteomyelitis while significantly reducing the need for long-term intravenous antibiotics, offering benefits to patient care and society. [114] (10.1016/j.injury.2019.04.016)
• [L4] The authors advise strict patient selection for surgery, reserving it for those with significant pain and functional disability, as most patients function well with conservative management. [115] (10.2106/00004623-198466020-00002)
• [L4] Long-term follow-up studies are needed to obtain more accurate data on the number of complications. [116] (10.1002/ksa.12274)
• [L5] Individuals with chronic, incurable disorders require more than average support from their physician, and a comprehensive program of care stressing continuity is absolutely essential. [117] (10.2106/00004623-196749060-00022)
• [L5] The International EDS Consortium proposes a revised classification recognizing 13 subtypes. [118] (10.1002/ajmg.c.31552)
• [L2] Therefore, employing individualized classification systems remains the most logical approach at present. [119] (10.1530/eor-2024-0184)
• [L5] The proposed classification system describes six specific issues to consider, with specific recommendations for each situation type to improve the reliability of prosthetic implantation. [120] (10.1302/2058-5241.6.210042)
• [L5] There is no clear consensus on what defines a chronic Achilles disorder or a uniform classification and treatment scheme. [121] (10.5435/00124635-200901000-00002)
• [L5] Efforts to improve the safety and efficacy of the alleviation of pain can benefit not only from optimal pharmaceuticals but also from a focus on the psychological and social determinants of human illness. [122] (10.2106/jbjs.18.00960)
• [L4] The authors propose a novel classification system to aid further research. [123] (10.1007/s00402-018-2905-1)
• [L1] However, the long-term efficacy remains to be further clinically verified. [124] (10.1186/s12891-025-08566-3)
• [Paper] The framework includes a 4-part classification scheme for alternative payment models (APMs) and establishes 8 principles to guide their development. [125] (10.1001/jama.2017.20226)
• [L1] The identified inflammatory cell types favour a chronic inflammatory process, but the heterogeneity of data and lack of comparable studies means we cannot conclude a common pathophysiology from this systematic review. [126] (10.1186/s12891-020-3094-y)
• [L4] Our classification system provides a step to achieve this goal. [127] (10.1177/2325967120s00255)
• [L5] Despite recent advances in understanding the epidemiology, biomechanics, pathophysiology, long-term effects, associated risks, and natural history of concussive brain injury, no proven effective therapies or preventative measures exist. [129] (10.1016/j.csm.2010.09.008)
• [L4] The natural history is often favorable for children younger than 6 years and poor for children older than 8 to 10 years. [130] (10.5435/jaaos-d-24-01469)
• [L5] Muscle imaging can help for recognition of atypical clinical presentations, for understanding the natural history of the disease, and for determining patients suited for treatment. [131] (10.1186/1471-2474-14-s2-o2)
• [L4] The questions were most frequently related to the timeline of treatment and clinical course. [132] (10.1371/journal.pone.0285869)
• [L4] Long-term clinical and radiographic follow-up is necessary to determine the natural history of these lesions. [133] (10.1177/23259671231159910)
• [L3] Three natural courses of health-related quality of life recovery were identified: early progressors, late regressors, and late progressors. [135] (10.1177/2325967121s00562)

See Also

• Arthritis

References

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[90] Orthopaedic Advances: Use of Three-Dimensional Metallic Implants for Reconstruction of Critical Bone Defects After Trauma. Journal of the American Academy of Orthopaedic Surgeons. 2023. DOI: 10.5435/jaaos-d-22-00676

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[122] Safe and Effective Alleviation of Pain. Journal of Bone and Joint Surgery. 2018. DOI: 10.2106/jbjs.18.00960

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[126] A systematic review of inflammatory cells and markers in human tendinopathy. BMC Musculoskeletal Disorders. 2020. DOI: 10.1186/s12891-020-3094-y

[127] CLASSIFICATION OF ACL TEARS IN THE PEDIATRIC AND ADOLESCENT POPULATION. Orthopaedic Journal of Sports Medicine. 2020. DOI: 10.1177/2325967120s00255

[128] Pigmented Villonodular Synovitis of the Glenohumeral Joint and Biceps Tendon Sheath. 2021.

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[130] Legg-Calvé-Perthes Disease. Journal of the American Academy of Orthopaedic Surgeons. 2025. DOI: 10.5435/jaaos-d-24-01469

[131] Advances in imaging for the diagnosis and disease monitoring of Pompe disease. BMC Musculoskeletal Disorders. 2013. DOI: 10.1186/1471-2474-14-s2-o2

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[133] Prevalence of Asymptomatic Talar Bone Marrow Edema in Professional Ballet Dancers: Preliminary Data From a 2-Year Prospective Study. Orthopaedic Journal of Sports Medicine. 2023. DOI: 10.1177/23259671231159910

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