Purpose <p>Osteochondral lesion of the talus (OLT) is characterized by articular cartilage and subchondral bone damage, leading to ankle pain and functional limitations. Some patients experience persistent pain and reduced functionality despite various treatments. Understanding the location and characteristics of pain in OLT may lead to good clinical outcomes. This study aimed to analyze pain characteristics and their relationship with intra-articular pathology in patients with OLT using the Self-Administered Foot Evaluation Questionnaire (SAFE-Q).</p> Materials and methods <p>A retrospective review was conducted on 32 ankles of 29 patients who underwent surgical treatment for stage 3 OLT of Anderson classification. The SAFE-Q scores, patient-reported outcome measures, and Ankle Activity Scores (AAS) were evaluated. The area of the bone marrow lesion on the magnetic resonance imaging, and the Hounsfield unit (HU) values on the computed tomography were measured. In addition, the cartilage condition of the osteochondral fragment and synovitis were scored under arthroscopy. The relationships between pain and these parameters were analyzed.</p> Results <p>Significant positive correlations were observed between pain and pain-related SAFE-Q scores and HU values in the bed of the OLT. No significant correlations were found between the pain scores and lesion size, synovitis, or cartilage condition. The median pain and pain-related subscale score (69.4 points) was used to classify patients into mild and severe pain groups. Severe pain was associated with lower HU values, whereas mild pain was associated with higher HU values.</p> Conclusions <p>HU values in the bed of OLT are associated with pain severity. Understanding pain mechanisms in OLT can enhance treatment strategies and improve clinical outcomes.</p> Level of evidence <p>4.</p>