MRI AND ULTRASOUND IN DIAGNOSIS AND MANAGEMENT

A Regional Approach to Foot and Ankle MRI

Michael Sean Stempel
Division of Podiatry, The George Washington University, Washington, DC, USA
This chapter presents a regional anatomic approach to MRI applications in the foot
and ankle. From a clinical perspective, patients often describe their symptoms in terms
of the part of the foot that hurts and when and how it hurts. Clinical questioning and
physical diagnosis pursue this line as well, trying to narrow down the diagnostic possibilities. There are conditions that may blur the anatomic distinctions for forefoot,
midfoot, rearfoot, and ankle; involve more than one region of the foot simultaneously;
or occur in any area of the foot. The chapter also includes a separate section on the
presentations of inflammatory arthritides in foot and ankle joints.
Key words: foot; ankle; metatarsalgia; heel pain; tendon injuries; plantar plate; fracture

Introduction
Bone and soft tissue anatomy is particularly
complex within the foot and ankle, which together comprise 30 bones, with 6 major nerves
and 11 tendons crossing the ankle joint and
multiple muscular layers and compartments.
All of these structures are contained within a
discrete space evolved uniquely for bipedal ambulation. These factors often make the foot and
ankle a challenging diagnostic puzzle and also
challenge professionals charged with interpreting and clinically correlating MRI scans. The
close proximity of multiple tissue planes both
dorsally and plantarly and the sharp angular
changes at the ankle and arch make precise positioning vital and interpretation difficult. Consistent positioning protocols, proper coil selection, knowledge of lower-extremity anatomy,
detailed clinical information, and experience
reading these studies are all essential for obtaining clinically applicable results.
MRI is a useful diagnostic tool in the foot
and ankle precisely because of these anatomic
and functional complexities. Symptoms arise
from arthritides, trauma, systemic disease, and

Address for correspondence: M. S. Stempel, George Washington University, 2150 Pennsylvania Ave NW, Washington, DC 20037, USA. Voice:
202-741-2496; fax: 202-741-2490. [email protected]

overuse syndromes. Moreover, maladaptive

anatomic changes due to faulty biomechanics and poorly functioning shoe gear are often present. Though statistically less common
than elsewhere in the body, the foot and ankle
can be a site of soft tissue masses. Manifestations of systemic disease often present in the
foot. Owing to the superior soft tissue contrast
of MRI and its ability to reveal normal and
abnormal anatomy in multiple planes, applications for this technology in the foot and ankle
have increased over time. MRI both functions
as a diagnostic tool and facilitates the planning
of treatment for these conditions.

Imaging the Foot and Ankle

Intrinsic difficulties are encountered when
performing MRI of the foot and ankle owing
to the anatomic configuration of the foot and
leg. The anatomy will be distorted if the foot
is not positioned at close to 90 to the leg. If
the foot is in a plantar-flexed position, axial
views of the forefoot produce an oval-shaped
appearance of the metatarsal instead of a circular one owing to the obliquity. If the leg is externally rotated (the relaxed position when a person lies supine), the sagittal plane views of the
Achilles tendon may falsely reveal thickening,

MRI and Ultrasound in Diagnosis and Management: Ann. N.Y. Acad. Sci. 1154: 84100 (2009).
C 2009 New York Academy of Sciences.
doi: 10.1111/j.1749-6632.2009.04385.x 

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again owing to obliquity. Even with careful positioning of the limb, magic angle artifacts can
occur when a tendons angle is approximately
55 to the magnetic field. On T1 images this results in an area of increase signal intensity that
does not appear on the T2 image. This artifact
can also be corroborated by comparison with
the corresponding perpendicular view, which
reveals tendon diameter and the presence or
absence of fluid within the tendon sheath. A
small coil or extremity coil is used to improve
spatial resolution.
Pulse sequences of the lower extremity typically include T1- and T2-weighted images in
the three standard planes. When detailed clinical information is provided (and it is indicated),
only the clinically relevant region of the limb is
imaged. This allows narrower-width sections,
thus greater anatomic detail. For example, if
pathology is suspected in the forefoot, only the
distal half of the foot has to be included in the
field of view.
Gadolinium contrast media can be helpful when diagnosing infection, differentiating a
solid versus a cystic mass, assessing a suspected
Mortons neuroma, and evaluating rheumatoid
arthritis.
Correlating Clinical Information,
Physical Examination, and MRI
Evaluation
This chapter presents a regional anatomic
approach to MRI applications in the foot and
ankle. From a clinical perspective, patients often describe their symptoms in terms of the
part of the foot that hurts and when and how
it hurts. Clinical questioning and physical diagnosis pursue this line as well, trying to narrow down the diagnostic possibilities. For example, a patient with plantar fasciitis may describe
pain in the heel that is noticeable after periods
of rest, or a patient with a Mortons neuroma
may describe pain in the ball of the foot as
feeling like a sock that is bunched beneath the
toes.

Forefoot Symptoms
The forefoot is anatomically a densely
packed area of the foot and is subject to dramatic weight-bearing forces during the gait cycle. There are also effects due to compression
from the shoe toebox, not to mention the effect
of high-heeled shoes and obesity. Each metatarsophalangeal (MTP) joint comprises a functionally unique plantar ligament plate, crossed by
six tendons and bordered by several neurovascular bundles.
Patients often describe generalized symptoms in the ball of the foot, indicating a broad
area of discomfort or pain in the center of the
forefoot. They are often unaware that there is
one area or joint that is more focally painful
until asked to narrow it down, or the site is
localized during a physical examination. Exceptions are pain associated with the first MTP
joint, especially in the face of a hallux valgus
deformity, or hammertoe contractures that rub
against the shoe toebox. Key clinical symptom
descriptors of forefoot pain include a feeling of
a swelling or lump in the ball of the foot, shooting or radiating pain, a localized area of pain,
and patterns of radiating pain especially into
particular toes.
Physical examination should focus on isolating anatomic structures within the forefoot. The examination should include palpation of the MTP joint structures both dorsally
and plantarly; palpation of the intermetatarsal
spaces, putting the digits through their ranges
of motion; and loading the joints to evaluate
for subluxation. It is also useful to have the patient in a weight-bearing position to evaluate
for deviation of the digits.
Inflammatory Arthritides
The forefoot is the region of the foot most
commonly affected by inflammatory disease

Rheumatoid Arthritis
Inflammatory changes are present in the feet
of 90% of rheumatoid patients and are also

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often found early in the disease process. Erosive joint changes visible on MRIs are generally
comparable to those seen on plain film radiographs. Pannus has been reported to have a
slightly higher signal on T1-weighted images
and may be visualized better with contrast, but
this level of detail is not generally clinically significant. Tendonitis or partial tears may be visualized in tendons that overlie inflamed joints.
Rheumatoid nodules are commonly located
subcutaneously and can also involve joints, tendons, ligaments, and bursae. Although rheumatoid nodules in the foot represent only 1%
of all nodules, they can result in significant
symptoms when they are on the plantar surface or are compressed by shoes. MRI findings
for rheumatoid nodules are nonspecific. T1weighted images reveal the masses to be isointense to muscle, and there may be intense
heterogeneous enhancement on T2-weighted
images.1

Gout and Pseudogout

Standard radiographic findings, together
with clinical correlation and labs are sufficient
for diagnosis of gout. MRI does not typically
have a primary diagnostic role, but may reveal
tophaceous changes in patients previously not
known to have gout. Tophi are typically low in
signal on T1 and T2.

Pigmented Villonodular Synovitis

The condition known as pigmented villonodular synovitis causes synovial hypertrophy
with hemosiderin deposits resulting in a darkened appearance of the affected tissue. Tendon
sheaths, bursae, and joints may be affected, and
the etiology is unknown. MRI findings include
joint effusions with low signal enhancement of
thickened synovium on T2-weighted images.
Erosive and cystic changes of adjacent bone
may be present.

Mortons Neuroma/Intermetatarsal
Neuroma
Clinical Presentation. An intermetatarsal neuroma, known as a Mortons neuroma, when

Annals of the New York Academy of Sciences

present in its most common location between

the third and fourth MTP joints, is a frequent
cause of forefoot pain. The condition is more
accurately described as an inflamed schwannoma, not a tumor of the nerve, as the name
implies. The etiology of the perineural fibrosis, neural degeneration, and adjacent soft tissue inflammation has been attributed, but not
proven, to be caused by chronic nerve entrapment, repetitive trauma, and compression by
the adjacent metatarsal heads. There may also
be an influence of the anatomic difference in
the third intermetatarsal space innervation. Instead of being supplied by a single branch from
the medial or lateral plantar nerve as in the
other intermetatarsal spaces, there is a joining of a lateral branch of the medial plantar nerve and a medial branch from the lateral plantar nerve in the third intermetatarsal
space. The condition is reported more often in women, with womens dress shoes and
heel height taking the blame; however, this increased prevalence may be due to frequency
of presenting to a physician, not frequency of
occurrence.
Presenting symptoms are typically described
as a burning, dull, or throbbing pain in the ball
of the foot, and often as a sharp or electric radiating sensation into the third and fourth toes.
Similar symptoms attributed to the second and
third toes suggest a neuroma between the second and third MTP joints. This is an infrequent
occurrence and has to be differentiated from
a plantar plate tear, predislocation syndrome
of the second MTP joint, or excessive weightbearing loading of the second metatarsal.
MRI Findings. The appearance of an intermetatarsal neuroma on MRI is typically as a
teardrop-shaped soft tissue mass between the
metatarsal heads that projects inferiorly into
the plantar subcutaneous fat pad. Signal intensity is intermediate on T1-weighted images
and usually low on T2-weighted images owing to adjacent fibrosis.2 Radiology literature
reports findings indicating fluid within the intermetatarsal bursa when it is inflamed; however, intraoperative findings and postsurgical

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Figure 1. Mortons neuroma: An oblong low signal mass is seen between the third and
fourth metatarsal heads on the coronal T2 fast spin-echo with fat-saturation images. The
Mortons neuroma does not enhance significantly on the axial T1-weighted images with fat
saturation after gadolinium administration, making it difficult to visualize.

pathology reports do not commonly relate the

presence of a bursal structure. The use of contrast can enhance imaging of this lesion, with
diffuse uptake within the mass seen when a
neuroma is present (Fig. 1A, B).3

Plantar Plate Disruption/Lesser

Metatarsophalangeal Joint
Predislocation Syndrome
Clinical Presentation. This condition, only recently delineated as a clinical entity, is often
not appreciated in its early stages or is misdiagnosed. Its presentation can mimic an interdigital neuroma, a plantar soft tissue mass, stress
fractures, and generalized pain in the ball of
the foot dubbed metatarsalgia. Patients describe a broad area of pain involving the central portion of the ball of the foot and often
the sensation, but not the presence, of a lump
or swelling plantarly in this area. A change in
the alignment of their toes with splaying, mild
swelling, or their toe no longer touching the
ground when standing may be noted.
This condition most commonly presents in
the second MTP joint. The increased prevalence of presentation in this location has been
attributed to factors resulting in excessive loading of the second ray during gait. Examples of
these factors include restricted range of motion

in the first MTP joint due to hallux rigidus, diminished propulsion due to hallux valgus, the
first metatarsal functioning in a dorsiflexed position in propulsion, and an excessively long
second metatarsal relative to the length of the
first. Predisposing conditions may include synovitis of the MTP due to rheumatoid arthritis,
spondyloarthropathies, and poorly designed or
badly chosen shoes.
Clinical findings differ with progression of
the condition. Initially, in the predislocation
phase, there is inflammation of the MTP joint.
Subtle splaying of the affected toe from the adjacent one may be observed with mild edema
at the base of the toe. Dorsal subluxation of
the toe with resultant lack of purchase on the
ground when standing occurs when the plantar plate of the MTP becomes attenuated or
ruptured near the insertion into the base of
the proximal phalanx. With progression of the
condition, the toe continues to sublux dorsally
and ultimately often deviates medially, crossing over the hallux. The Lachman drawer test,
pushing the proximal phalanx dorsally while
holding the metatarsal in a fixed position, will
reveal subluxation as well as pain in the plantar
plate in a positive test.4
MRI Findings/Application. Imaging of the MTP
shows the plantar plate best in the sagittal and

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Figure 2. Plantar plate rupture: Sagittal T1 and sagittal T2 fast spin-echo with fat-saturation
images of the forefoot at the level of the second MTP joint show discontinuity of the low signal
plantar plate at the distal aspect of the joint.

coronal planes. T1-weighted images may reveal

edema within the joint, attenuation, a tear in
the plantar plate, and dorsal displacement of
the digit. On T2-weighted images the normal
plantar plate is a curvilinear low-signal structure. When torn, the plate appears discontinuous with an increased T2 signal at the site
of the tear. T sagittal plane perspective may
reveal increased signal intensity in the plantar aspect of the joint compatible with edema
or disruption of the plantar plate ligament.
There may also be associated tenosynovitis.
Important MRI findings in the differential diagnosis of this condition include metatarsal
stress fractures, intermetatarsal neuromas, and
plantar or intermetatarsal soft tissue masses
(Fig. 2A, B).

First MTP Joint Pain

Hallux valgus deformities and arthritic
changes in the first MTP joint would rarely
require the use of MRI as a primary diagnostic tool. However, significant changes may
be noted within this joint incidentally when
evaluating for other conditions or in the presence of various inflammatory arthritides such
as rheumatoid arthritis, gout, and osteoarthritis. MRI is a useful modality for diagnosis of
sesamoiditis, sesamoid fractures, and sesamoid
dislocation/subluxation (turf toe).

Sesamoiditis
Clinical Presentations. Symptoms of pain in the
plantar aspect of the first MTP joint can
present acutely, and standard radiographs are
utilized to reveal a sesamoidal fracture. However, for evaluation of long-standing pain in
this region of the joint or when a fracture is
not evident, MRI can assist in differentiating
among osteonecrosis, stress fractures, and localized inflammation, as well as distinguishing between an acute fracture and a bipartite
sesamoid.
MRI Findings/Applications. Marrow edema
within a sesamoid bone may be noted by increased signal intensity on T2-weighted images
and a decreased signal on T1-weighted images.
Osteonecrosis is revealed by low signal intensity
on both T1- and T2-weighted images. Fractures appear as a distinct linear area of low signal intensity on T1- and high or low intensity
on T2-weighted images.5

Turf Toe
This hyperextension injury of the first MTP
joint results in a sprain of the plantar ligament complex. The injury may also result in
a sesamoid or phalangeal base fracture. Axial or sagittal MRIs would reveal increased
signal in the plantar capsule on T2-weighted
images.6

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Bursitis: Plantar, Intermetatarsal

A bursa within the forefoot may be revealed
by axial T2-weighted or STIR images. Bursae appear with high signal intensity and enhance with contrast. Typically these bursae
are located plantar to the deep transverse intermetatarsal ligament and within the intermetatarsal space and are found accompanying
neuromas or inflamed joints.7
Midfoot Symptoms
When a patient presents with a chief concern of pain in the arch or midfoot, there is,
as with the forefoot, a broad range of anatomic
structures that may be responsible for the symptoms. Moreover, the symptoms may have their
origin in a different region of the foot. It is beneficial to have the patient try to pinpoint an
area of intensity or the site of onset and try
to correlate symptoms to weight bearing, gait,
or shoe pressure. Symptoms related by the patient include soreness in the arch when walking,
deeper symptoms within the joints of the midfoot complex, localized swelling or soreness in
this region of the foot, and pain that radiates
distally or proximally.
Soft Tissue Structures
The midfoot/arch is the most common region in the foot for the presence of soft tissue masses, ganglion cysts, and plantar fascia fibromas. The extensor synovial sheaths
cross the tarsometatarsal joints here. Underlying arthritic changes in the joints of the midfoot, compression from shoe gear, and direct
trauma to the dorsal aspect of the foot can
result in injury to the overlying extensor tendons, tendon sheaths, and cutaneous nerves.
Moreover, there are several notable tendon
insertions functionally important in gait: the
tibialis anterior and tibialis posterior at the
navicular; the peroneous brevis at the fifth
metatarsal base; and the peroneous longus,
which inserts plantar to the tarsometarsal

joints medially after wrapping beneath the

cuboid.
Plantar Fibromatosis
Plantar fibromatosis lesions are fibrous connective tissue nodules that proliferate along the
medial band plantar fascia as single or multiple
lesions. They appear with low to intermediate
signal intensity on T1- and T2-weighted
sequences and usually enhance with contrast.
If the lesions are symptomatic adjacent
tissue edema may be present, with increased
signal intensity indicating inflammation
(Fig. 3A, B, C).
Ganglion Cysts
Ganglion cysts can appear in any region of
the foot and are most commonly found in regions with synovial tendon sheaths, such as the
dorsal foot and the anterior, medial, and lateral ankle. Clinical symptoms associated with
these cysts are often due to compression of adjacent nerves, rubbing of the lesion against shoe
gear, and concern over the appearance of a
possible soft tissue tumor. T2-weighted images
demonstrate high intensity within the cyst. T1weighted fat-suppressed contrast images show
no enhancement, indicating a cyst.8 Enhancement of the thin cyst wall and septations may
be seen, if present (Fig. 4A, B).
Tenosynovitis
Tenosynovitis can occur anywhere there are
synovial sheaths surrounding tendons within
the foot and ankle. This inflammatory condition, which causes fluid to surround the circumference of the tendon, may occur owing to
stress on the tendon. Etiologies include stress
due to repetitive motion or overuse, inflammatory arthritis, or infection. Stenosing tenosynovitis occurs when there are loculated collections of synovial fluid within the tendon sheath.
In the foot this is most commonly seen in the
flexor hallucis brevis.

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Annals of the New York Academy of Sciences

Figure 3. Plantar fibromatosis: Sagittal T1 and T2 fast spin-echo with fat-saturation images
show a lobulated soft tissue mass in the plantar soft tissues. The mass is low signal on T1
images with regions of high signal intensity on T2 images. Contrast enhancement, which can
be variable in plantar fibromatosis, was seen in this patient

Figure 4. Ganglion cyst: Coronal T2 fast spin-echo with fat-saturation and sagittal STIR
images of the foot demonstrate a well-defined, slightly lobulated mass dorsal to the middle
cuneiform. On the sagittal image it is seen at the level of the marker placed on the patients
skin denoting the site of the palpable mass. The mass is bright on both sequences, consistent
with a fluid-filled ganglion cyst.

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Figure 5. Tenosynovitis: Axial and coronal T2 fast spin-echo with fat-saturation images at
the ankle show high T2 signal compatible with fluid surrounding all of the medial tendons at
the ankle. The tendons themselves appear normal. The findings represent tenosynovitis.

MRI findings in the presence of tenosynovitis

are that there is fluid of low signal intensity on
T1-weighted images and high signal intensity
on T2-weighted images, that synovial fluid is
seen circumferentially around the tendon, and
that the tendon may be normal or abnormal in
diameter and signal intensity (Fig. 5A, B).9
Skeletal Structures
Skeletal origins of midfoot pain include
metatarsal stress fractures, navicular fractures, accessory navicular bones, Lis Francs
joint dislocation, avulsion injuries in the tarsometatarsal joints, and arthritic changes in the
tarsometatarsal joints.

Metatarsal Stress and Insufficiency

Fractures
Stress fractures in the foot most commonly
appear in the neck or shaft of metatarsals two,
three, and four; however, these fractures can
also occur in the metatarsal bases, navicular, and calcaneus. High-energy or abnormal
repetitive loading of the normal bone induces
stress fractures. Normal levels of activity applied to abnormal bone induce insufficiency
fractures. The clinical presentation is typically
that of pain in the forefoot or midfoot with
weight bearing. There may be accompanying

localized edema, erythema, or calor. A diagnosis is usually made by plain film radiographs;
however, the cortical break and early callus formation is only evident after approximately 2
weeks. The diagnosis can be made earlier, or
in cases with strong clinical suspicion without
radiographic findings, with use of a radionucleotide bone scan or an MRI. The latter will
reveal an area of low intensity signal on T1 and
high intensity on T2 or STIR images. With
progression, the fracture line and bone callus
become visible. In the elderly or osteoporotic
patient, MRI is more sensitive and specific than
radionucleotide scans (Fig. 6A, B, C).10

Accessory Navicular
An accessory navicular bone can cause
symptoms due to degenerative changes or
trauma to the fibroligamentous attachment
with the primary navicular bone. MRIs that reveal increased marrow edema, evident in coronal and sagittal STIR images, correlate with degenerative changes in this articulation. In the
presence of a symptomatic accessory navicular bone, the posterior tibial tendon should be
evaluated for tears.11

Lis Francs Injuries

Trauma significant enough to result in joint
dislocation or avulsion of the tarsometatarsal

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Annals of the New York Academy of Sciences

Figure 6. Metatarsal stress fractures: AP view of the foot demonstrates subtle transverse
lucent lines through the proximal shafts of the second and fifth metatarsals. The line at the fifth
metatarsal is best visualized at the lateral cortex. Axial T1 and axial T2 fast spin-echo with
fat-saturation images show a linear low-signal fracture line in the proximal aspect of the fifth
metatarsal with surrounding bone marrow edema, which is dark on T1-weighted images and
bright on T2-weighted images. A similar appearing stress fracture was seen in the second
metatarsal on MRI.

ligaments requires significant force. Plain film

radiographs are usually sufficient to diagnosis
these injuries. Subtle injuries to Lis Francs joint
can be missed on plain film radiographs. In
the case of the neuropathic diabetic patient,
Charcot osteoarthropathy may be missed until
there is complete joint collapse. Coronal and
axial T2 and STIR images may demonstrate
disruption of ligaments or displacement at the
metatarsal cuneiform joints. In a case of early

Charcot joint (neurotrophic osteoarthropathy),

changes are typically of low signal intensity in
the bone marrow on T1, T2, and STIR images. In a case of complete joint fragmentation and/or collapse, acute inflammation manifests as high signal intensity with marrow and
tissue edema on T2-weighted images.8 Differentiation from osteomyelitis in this phase
may be difficult without an accurate clinical
history.

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Rearfoot Symptoms
As above, there is considerable overlap of
symptoms among regions of the foot. Some
patient-described symptoms can be clearly
identified as rearfoot, such as plantar or posterior heel pain. However, posterior tibial tendon
tears can result in symptoms that localize from
the medial malleolus to the navicular, or, in
another example, tarsal tunnel syndrome can
cause symptoms along the entire plantar aspect
of the foot though its origin is at the junction
of the foot and ankle. For the purposes of this
section, rearfoot pain encompasses symptoms
that typically are described by patients as being
within the hindfoot.
Plantar Calcaneal Pain: Plantar Fasciitis
Patients typically present with pain in the
plantar heel that manifests after periods of
rest, especially upon rising after sleep. Initial
walking activity usually eases the symptoms
temporarily, but then they intensify with prolonged weight bearing. This condition has been
attributed to repetitive weight-bearing stress
exacerbated by hyperpronation, worn out or
poorly made shoes, obesity, intensive sports activities, flatfootedness, or several of these factors combined. Seronegative arthritides such as
anklylosing spondylitis, reactive arthritis, psoriatic arthritis, as well as rheumatoid arthritis and gout should all be included in the
broad list of differential diagnoses for heel
pain. Pain with palpation elicited at the medial calcaneal tubercle plantarly, just distal to
the weight-bearing surface, is indicative of insertional fasciitis or fasciosis. Plantar tenderness
more proximal than the fascial attachment suggests infracalcaneal bursitis, whereas pain with
medial and lateral compression of the heel may
indicate a calcaneal stress fracture. In some
cases inflammation may be present along the
length of the medial band of the plantar fascia, and may have to be differentiated from
flexor hallucis longus tendonitis. One should
also check for accompanying insertional ten-

derness of the posterior tibial tendon at the

navicular.
MRI of plantar fasciitis is rarely indicated
as a primary diagnostic tool, as clinical history
and physical examination nearly always lead to
a diagnosis of the condition. Should MRIs be
sought owing to diagnostic complexities such
as lack of clinical response or concomitant diagnoses, the images would reveal thickening
(normally 4 mm) of the fascia near its calcaneal
insertion, intermediate signal on T1 and high
signal on T2.9 Adjacent tissue edema may be
present, with erosions or spur formation at the
calcaneus. Rupture of the plantar fascia is rare,
but if suspected is best diagnosed with MRI. A
fascial rupture is apparent as a separation of the
ligament with accompanying edema and hemorrhage, seen as a high signal on T2 images.
Calcaneal stress fracture should also be ruled
out when evaluating these studies and images
should be evaluated for inflamed bursae plantar
posteriorly (Fig. 7A, B).
Posterior Calcaneal Pain

Achilles Tendonitis
Tendonitis of the Achilles tendon typically
arises from mechanical origins; however, it
can also be attributable to multiple arthritides
such as rheumatoid arthritis and the spondyloarthropathies. The patients pain is typically
increased after periods of rest and initially decreases with activity. Pain is typically aggravated by dorsiflexing the foot at the ankle, as
well as with pressure, with palpation at the calcaneal insertion, or with compression of the
tendon between two fingers. The inflammatory changes have been attributed to degenerative changes within the body of the tendon
and tendonosis is a more accurate term. The
Achilles tendon does not have a synovial sheath.
The paratenon is present along the anterior surface of the tendon. Edema visualized on MRIs
in this region corresponds to inflammation of
this structure, as opposed to tenosynovitis. Advanced degenerative changes or partial tears
and ruptures typically occur within a region

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Annals of the New York Academy of Sciences

Figure 7. Plantar fasciitis: Two sagittal STIR images show mild thickening of the proximal
portion of the plantar fascia near its insertion on the calcaneus. Signal intensity changes are
seen in the adjacent subcutaneous soft tissues with increased signal on the STIR images.

Figure 8. Partial tear of the Achilles tendon: Axial T1 and axial T2 fast spin-echo with
fat-saturation images demonstrate thickening of the Achilles tendon with intrasubstance high
signal on the T1- and T2-weighted images at the insertion compatible with partial thickness
tear.

4 cm proximal to the calcaneal insertion. Retrocalcaneal bursitis and erosive bone changes
at the tendon insertion can accompany the
condition.
Normal tendon anatomy is revealed on sagittal and axial T1- and T2-weighted images as
well as on STIR axial and sagittal images. In
axial images the tendon should appear flat or
somewhat concave on the anterior surface. A
convex appearance indicates abnormal thickening of the tendon. The anterior and posterior
surfaces should appear parallel on properly positioned sagittal images.12 The plantaris tendon
is located anteromedially to the Achilles tendon

and can be mistaken for a partially torn Achilles

tendon. Tendon changes that may be present
include an acute complete tear, an acute partial tear, a chronic partial tear, and tendonosis
(Fig. 8A, B).

Retrocalcaneal and Pre-Achilles Bursitis

Inflammation of the retrocalcaneal bursa is
revealed with deep palpation of the space anterior to the Achilles tendon just proximal to the
calcaneal insertion. Pressing medially and laterally, just proximal to the dorsal calcaneus and
anterior to the Achilles tendon, produces pain.
MRI findings on sagittal T1-weighted images

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Stempel: Foot and Ankle MRI

Figure 9. Sinus tarsi syndrome: On sagittal and coronal T1-weighted images there is
obliteration of fat in the sinus tarsi. The normally high-signal fat seen on T1 imaging is
replaced with fluid or scar tissue that is lower in signal intensity on these images. In advanced
cases, associated osteoarthritis at the subtalar joints with subchondral cysts, as was seen in
this patient, can occur.

may reveal bone erosion, and T2-weighted images would reveal high-intensity signal corresponding to an enlarged bursa. There may be
accompanying Achilles tendon changes such
as thickening, inflammation, or calcification in
these images.
The pre-Achilles (retro-Achilles) bursa is located subcutaneously, superficial to the Achilles
insertion and is tender to light palpation. This
bursa is typically aggravated by pressure from
the shoe heel counter. Sagittal and axial T2weighted images reveal signal intensity within
the bursae when they are inflamed.
Accompanying the above conditions may be
a Haglunds deformity and enlargement of the
posteriosuperior calcaneus. This has also been
dubbed a pump-bump deformity, which often results in inflammation of the pre-Achilles
bursae.
Rearfoot Pain

Sinus Tarsi Syndrome

Patients with sinus tarsi syndrome relate lateral foot pain and a feeling of instability in the
heel. The condition most commonly occurs as
a result of trauma, typically inversion injuries.
Inflammatory arthritides, gout, ganglion cysts,

and structural foot deformities are responsible

for about 30% of cases. Palpation of the sinus
tarsi typically produces pain, and as deep pressure on this space is often perceived as uncomfortable, the clinician should palpate the contralateral sinus tarsi for comparison. The sinus
is formed by the space between the talus and
the calcaneous laterally. The shape of this canal
is wide laterally and tapers medially. Within
this space is a fatty plug, a neurovascular bundle that contributes to proprioception in the
rearfoot and five ligaments. The most functionally important of these is the talocalcaneal ligament. It has been determined that injury to the
ligaments and/or the nerve within the canal
is responsible for the symptoms of pain and
instability.
Abnormalities within the sinus tarsi are revealed on sagittal and coronal MRIs. T1 images
reveal fat obliteration, with intermediate signal instead of high signal with a visible talocalcaneal ligament passing through it, as expected.
T2 images reveal inflammatory changes with
high signal or chronic fibrosis with low signal
(Fig. 9A, B).

Tarsal Tunnel Syndrome

Entrapment or compression of the posterior
tibial nerve within the tarsal tunnel can result

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in plantar symptoms in the heel, forefoot, and

the midfoot. In some cases there can be pain
in the medial ankle as well. Described symptoms include burning, tingling, electric shooting sensations, and a viselike pressure on the
ball of the foot. Anatomically, the tarsal tunnel extends from just proximal to the medial
malleolus and then courses distally to the abductor hallucis muscle belly. It is bordered by
the flexor retinaculum superficially and the calcaneus on the deep surface. Within this space
course the posterior tibial nerve, artery, and
vein; the posterior tibial tendon; the flexor digitorum longus tendon; and the flexor hallucis
longus tendon. Compression of the posterior
tibial nerve as it passes within this space can be
due to ganglion cysts, varicosities in the accompanying vein, synovial thickening or tumors in
the sheaths of the neighboring tendons, posttraumatic bone or ligament changes; it has
also been attributed to hyperpronatory foot
types.13
The initial diagnosis is made from the patients history and a physical examination.
Percussion of the posterior tibial nerve may result in a Tinels sign, and sustained dorsiflexion and eversion of the foot may trigger pain
symptoms. Nerve conduction velocity testing
of the posterior tibial nerve may reveal diminished conduction velocity distal to the tarsal
tunnel. MRI is useful when trying to determine
etiology, specifically when a space-occupying
lesion is suspected. Ganglion cysts and nerve
sheath changes are among the most common
abnormal MRI findings, both appearing as a
homogeneous low signal on T1-weighted images and high signal intensity on T2-weighted
images. Use of gadolinium contrast assists in
distinguishing between a cyst and changes in
the nerve sheath.
Tarsal Coalitions
Coalition of the tarsal bones is present in 2
6% of the population, and is present bilaterally
in 50% of cases. Osseous, cartilaginous, or fibrous coalition of the calcaneonavicular joint

is the most common, followed by the talocalcaneal joint, with these two accounting for 90%
of cases. Symptoms are typically due to disruption of a fibrocartilaginous bridge or fracture
of an osseous bridge. Severe pain with motion within the rearfoot may result in spasm
of the peroneal musculature and a resultant
flatfoot deformity. Initial diagnosis is by characteristic plain film radiographic findings: talar beaking, elongation of the anteriosuperior
calcaneus, an osseous bar between bones, and
obliteration of calcaneal facets. CT and MRI
provide detailed images of the coalition type
and anatomic location of the coalition. MRI
has the advantage of also revealing accompanying areas of inflammation or impingement.
Osseous coalitions produce signal intensity of
the bone marrow, low signal on T1 and T2 with
fibrous coalitions, and an intermediate signal
with cartilaginous coalitions.8
Ankle Symptoms
Again, as above, there is considerable overlap of symptoms between the ankle and other
regions of the foot. Changes may occur in various structures at the ankle level anatomically
and continue into the rearfoot and midfoot
or present with symptoms in these more distal
regions.
Soft Tissue: Tendonitis
There are four groupings of tendons at the
ankle, with 11 tendons crossing the ankle joint:
the long flexors and posterior tibial medially,
the peroneals laterally, and the tibialis anterior and long extensors anteriorly. The Achilles
and plantaris tendons also pass the ankle joint
posteriorly, but they have already been discussed. With the exception of the Achilles tendon, all of the ankle tendons are within synovial
sheathes. MRI evaluation of these sheathed
tendons is similar in all cases, but the posterior tibial, flexor hallucis longus, and peroneal
tendons have the greatest clinical significance

Stempel: Foot and Ankle MRI

and receive special attention here. Tendons

in the foot and ankle may undergo degenerative changes, tear, or develop synovitis owing to the same host of reasons encountered
throughout the body; however, the repetitive
stress and microtrauma on key functional tendons in gait are often of clinical significance in
both evaluation and treatment of these conditions. Conditions that have been attributed to
tendon tears and degeneration include acute
trauma, rheumatoid arthritis, diabetes, gout,
medications, tumors, xanthomas, and calcific
tendonitis.
MRI reveals tendon pathology best in transverse plane images. The exception to this is
the Achilles tendon, which is also well imaged
in the sagittal plane. Contrast use is not typically indicated. Normal tendon anatomy is revealed as low signal intensity on T1-weighted
images owing to water molecules being tightly
held by the tendon substrate. Increased signal
may be noted at the point of tendon insertion
or owing to the fusing of several tendons or
the magic angle effect. The synovial sheath
is not normally visible and the tendon should
appear uniformly round, oval, or flat. When
tendon abnormalities are present, changes are
seen on T2-weighted images. Specifically these
may include high signal within the tendon, suggesting degeneration or partial tear, and high
signal around the tendon circumferentially, indicating synovitis. Other findings in symptomatic tendons include complete separation
of the tendon, anatomic subluxation, deposits
within the tendon (calcium hydroxyapatite, calcium pyrophosphate crystals, gouty tophi, xanthomas), and tumors (giant cell tumor, clear cell
sarcoma).9
Medial Ankle Tendons

Posterior Tibial Tendon

The posterior tibial tendon is a powerful inverter of the foot that stabilizes the midtarsal
joints during gait. When function in this tendon
is diminished owing to inflammatory or degenerative changes, unopposed pronatory forces

97

result in progressive dysfunction and arch collapse. Posterior tibial tendon symptomatology
shows an increased prevalence in patients with
rheumatoid arthritis. However, it is difficult to
differentiate between tendon changes that are
due to arthritic changes in the rearfoot and
those that are caused by inflammatory tendon
dysfunction that has resulted in subtalar joint
collapse.14
The typical clinical presentation and progression of what has been called posterior
tibial tendon dysfunction syndrome is as follows. Initially pain and localized clinical signs
of inflammation present along the course of
the posterior tibial tendon at the medial malleolus or navicular insertion. Tears and deformity are not present at this stage, with
typical MRI findings being of tenosynovitis.
With progression due to continued overuse,
increased signal intensity within the tendon
may be seen on T1 images with eventual appearance of tendon tears. T2-weighted images
demonstrate increased fluid within the tendon
sheath.
Clinically, signs of inflammation increase
greatly and there may be a lowering of the
arch, as tendon integrity is lost. T2 axial views
at the ankle best reveal partial tears and surrounding fluid. Progression to a complete tear
is not as common as the loss of tendon function
and collapse of the foot into a pes-valgo planus
attitude. With loss of muscular function, the
calcaneus maintains an everted position when
bearing weight. When the patient attempts a
single-limb heel raise on the affected limb,
the heel does not invert as it would normally.
Late-stage progression results in degenerative
changes in the rearfoot, chronic pain, and a
fixed flatfoot deformity. Complete tears of the
posterior tibial tendon, whether as a result of
trauma or degenerative processes, appear as a
gap on axial and sagittal images with surrounding inflammation. With collapse of the arch, the
presence of the plantar calcaneonavicular ligament (spring ligament) should be confirmed on
short TE spin-echo axial and sagittal images
(Fig. 10A, B).15

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Annals of the New York Academy of Sciences

Figure 10. Posterior tibial tendon dysfunction: On axial T1 and T2 fast spin-echo with fatsaturation images the posterior tibialis tendon is enlarged. Linear intrasubstance high signal
intensity seen on the T1-weighted image represents a partial tear of the tendon.

Flexor Digitorum Longus

The flexor digitorum longus courses deep
to the posterior tibial tendon and superficial to
the neurovascular bundle. This tendon is an uncommon source of clinical symptoms. Synovial
changes could potentially lead to compression
of the posterior tibial nerve.

Flexor Hallucis Longus (FHL)

This medial tendon is rarely injured and seldom a source of clinical symptoms, but it may
be stressed by certain activities such as soccer
or ballet. Tenosynovitis may be seen at the level
of the sesamoids plantar to the first MTP joint
or as it passes posterior to the talus. Caution
is indicated in diagnosing synovitis of this tendon, as communication of the tendon sheath
and the ankle joint posteriorly has a prevalence
of 20%. This anatomic characteristic can result in a greater presence of fluid surrounding the FHL in the absence of tendon pathology. Asymmetrical fluid accumulation would
indicate stenosing tenosynovitis. This condition can occur when an os trigonum (accessory ossicle at the posterior talus) is present.
T2-weighted images in the axial and sagittal
planes best reveal fluid surrounding the FHL
tendon.

Lateral Ankle Tendons:

Peroneal Tendons
MRI of the peroneal tendons is typically performed to evaluate for tenosynovitis and tendon tears or to reveal a subluxed tendon position. The peroneal brevis tendon, coursing
behind the head of the fibula, above the peroneal tubercle of the calcaneus, and inserting
into the base of the fifth metatarsal, is a powerful everter of the foot. The peroneus longus
tendon shares a common tendon sheath as it
passes superficially to the peroneus brevis behind and beneath the fibular head. Distal to
the superior retinaculum they have their own
tendon sheathes. When the limb is in the gait
cycle, the peroneus brevis assists in pronation
of the foot. The peroneus longus tendon has
been described as both a pronator/everter of
the foot and as a supinator. The longus tendon
inserts on the medial side of the foot, beneath
the first metatarsalmedial cuneiform joint, after coursing beneath the cuboid. In closed kinetic chain motion (heel and forefoot on the
ground) the longus tendon supinates the foot
by plantar-flexing the first ray. In open kinetic
chain motion (the heel off of the ground and
forefoot weight bearing) the longus tendon may
result in eversion while continuing to exert a

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Stempel: Foot and Ankle MRI

Figure 11. Peroneus brevis and longus tears: Axial T1 and T2 fast spin-echo with fatsaturation images at the level of the hindfoot show splits of the peroneus brevis and longus
tendons. The partial tears give the tendons an irregular appearance, which is best appreciated
on the T2-weighted image.

Figure 12. Osteochondral lesion: Coronal T1 and coronal T2 fast spin-echo with fatsaturation images of the ankle demonstrate abnormal bone marrow signal at the lateral
talar dome. There are several areas of decreased T1 signal and increased T2 signal in the
subchondral bone with preservation of the overlying articular cartilage compatible with a
Stage 1 osteochondral injury.

plantar-flexory force on the first ray. When the

foot is being thrown into excessive inversion
that may result in an ankle sprain, the peroneal muscles, particularly the brevis, activate
and strongly contract to regain balance. This
action may be responsible for some incidences
of synovitis, tendon tears, tendon subluxation,
and avulsion fractures at the fifth metatarsal
base. T2-weighted axial images may best reveal subluxations or dislocation of the lateral
tendons (Fig. 11A, B).

Anterior Ankle Tendons:

Tibialis Anterior, Extensor Hallucis,
and Digitorum Longus
Tenosynovitis, tears, or ruptures infrequently
affect these synovial tendons. As with other tendons, imaging is best accomplished with T2weighted or STIR in the axial and sagittal
planes.
Osteochondral injuries to the cartilage of the
talar dome result from inversion or eversion

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Annals of the New York Academy of Sciences

sprains at the ankle. Strong rotational forces

that result in ligament sprains or tears can result in contusion or fractures of the subchondral bone of the talus, within the ankle mortise.
The BerndtHardy classification stages these
injuries based on the depth of the lesion and
the displacement of the resultant fragment. The
clinical presentation is persistent ankle pain and
diffuse edema at the joint, usually with a history of prior ankle trauma. MRI detects these
lesions well in all stages, whereas plain film radiographs may not reveal changes in the early
stages. T2-weighted images show breaks in the
cartilage continuity, missing or displaced fragments, and high signal intensity around nondisplaced fragments (Fig. 12A, B).16
Conflicts of Interest

The authors declare no conflicts of interest.

References
1. Sanders, T.G., R. Linares & A. Su. 1998. Rheumatoid nodules of the foot. MRI appearances mimicking
an indeterminate soft tissue mass. Skeletal Radiol. 27:
457460.
2. Zanetti, M., T. Ledermann, H. Zollinger & J. Hodler.
1997. Efficacy of MR imaging in patients suspected
of having Mortons neuroma. AJR Am. J. Roentgenol.
168: 529532.
3. Terk, M.R., P.K. Kwong, M. Suthar, et al. 1992. Mortons neuroma: Evaluation with MR imaging performed with contrast enhancement and fat suppression. Radiology 189: 239241.

4. Yu, G.V., M.S. Judge, et al. 2002. Predislocation syndrome. J. Am. Podiatr. Med. Assoc. 92: 182199.
5. Taylor, J.A.M., D.J. Sartoris, G. Huang, et al. 1993.
Painful conditions of the first metatarsal sesamoid
bones. Radiographics 13: 817830.
6. Zanetti, M., S.C.L. Steiner, B. Seifert, et al. 2002.
Clinical outcomes of edema-like bone marrow abnormalities of the foot. Radiology 222: 184188.
7. Yu, J.S. & J.R. Tanner. 2002. Considerations in
metatarsalgia and midfoot pain: An MR imaging
perspective. Sem. Musculoskeletal Radiol. 6: 91104.
8. Berquist, T.H. 2006. MRI of the Musculoskeletal System,
5th ed.: 499, 515. Lippincott Williams & Wilkins.
Philadelphia.
9. Kaplan, P.A. et al. 2001. Musculoskeletal MRI , 1st ed.:
5859, 410413. W.B. Saunders. Philadelphia.
10. Dunfee, W.R., M.K. Dalinka & J.B. Kneeland. 2002.
Imaging of athletic injuries to the foot and ankle.
Radiol. Clin. North Am. 40: 289312.
11. Miller, T.T., R.B. Staron, F. Feldman, et al. 1995.
The symptomatic accessory tarsal navicular bone:
Assessment with MR imaging. Radiology 195: 849
853.
12. Miller, T.T., R.B. Staron, F. Feldman, et al. 1995.
The symptomatic accessory tarsal navicular bone:
Assessment with MR imaging. Radiology 195: 849
853.
13. Jenkins, W.J. 2004. Approach to the patient with foot
and ankle pain. In Current Rheumatology Diagnosis and
Treatment. J.B. Imboden et al. Eds.: 5165. McGrawHill Professional. New York.
14. Michelson, J., M. Easley, F.M. Wigley & D. Hellman.
1995. Posterior tibial tendon dysfunction in rheumatoid arthritis. Foot Ankle Int. 16: 156161.
15. Yao, L., A. Gentili & A. Cracchiolo. 1999. MR imaging findings in spring ligament insufficiency. Skeletal
Radiol. 28: 245250.
16. Magee, T.H. & G.W. Hinon. 1998. Usefulness of MR
imaging in the detection of talar dome injuries. AJR
Am. J. Roentgenol. 170: 12271230.