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    Ankle

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    Hosham Mohamed
    The document provides guidance on performing MRI of the ankle joint, including recommended imaging protocols, anatomy visualized in different planes, and common MRI appearances of normal and abnormal structures. Key points covered include tendons and ligaments of the ankle, Achilles tendon injuries, peroneal tendon injuries, lateral collateral ligament injuries, tibiofibular syndesmotic complex, and osteochondral lesions. Common pathologies such as tendinitis, tenosynovitis, ruptures, and sinus tarsi syndrome are also discussed.

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    Ankle

    Uploaded by

    Hosham Mohamed
    87 views132 pages
    The document provides guidance on performing MRI of the ankle joint, including recommended imaging protocols, anatomy visualized in different planes, and common MRI appearances of normal and abnormal structures. Key points covered include tendons and ligaments of the ankle, Achilles tendon injuries, peroneal tendon injuries, lateral collateral ligament injuries, tibiofibular syndesmotic complex, and osteochondral lesions. Common pathologies such as tendinitis, tenosynovitis, ruptures, and sinus tarsi syndrome are also discussed.

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    The document provides guidance on performing MRI of the ankle joint, including recommended imaging protocols, anatomy visualized in different planes, and common MRI appearances of normal and abnormal structures. Key points covered include tendons and ligaments of the ankle, Achilles tendon injuries, peroneal tendon injuries, lateral collateral ligament injuries, tibiofibular syndesmotic complex, and osteochondral lesions. Common pathologies such as tendinitis, tenosynovitis, ruptures, and sinus tarsi syndrome are also discussed.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    87 views132 pages

    Ankle

    Uploaded by

    Hosham Mohamed
    The document provides guidance on performing MRI of the ankle joint, including recommended imaging protocols, anatomy visualized in different planes, and common MRI appearances of normal and abnormal structures. Key points covered include tendons and ligaments of the ankle, Achilles tendon injuries, peroneal tendon injuries, lateral collateral ligament injuries, tibiofibular syndesmotic complex, and osteochondral lesions. Common pathologies such as tendinitis, tenosynovitis, ruptures, and sinus tarsi syndrome are also discussed.

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    of 132

    MRI of The Ankle joint

    By
    Mamdouh Mahfouz MD
    Prof. Of Radiology
    Cairo University

    ssregypt.com
    Examination protocol
     Surface Coil
     8 cm field of view (FOV)
     256X 192 matrix
     3mm slice thickness / 1mm gaps
     Axial, Sagittal and coronal
     T1, T2, Gradient, STIR images
    Axial: Perpendicular to the long axis of the tibia

    Coronal: Perpendicular to the sole of the foot

    Sagittal:
    How to know the pulse sequences used ?!

    T1 T2* STIR
    Gradient Short T1 inversion recovery
    Common MR appearances
    T1 T2 Structure or lesions

    Low Low Cortical bone


    Tendons ( TP, PL ,PB,…)
    Ligaments (ATF,PTF, Deltoid,..)
    Common MR appearances
    T1 T2
    High Low Fat (subcutaneous, lipoma,…)
    Bone marrow
    Low High Fluid (effusion, cyst, ganglion)
    High High Blood (heamoarthrosis)
    Anatomy

    Tendons and ligaments

     Anterior
     Posterior
     Lateral
     Medial
    Posterior aspect

    Tendons: Achilles Tendon


    Ligaments: No
    Achilles tendon
    Normal tendon

     Uniform low signal


     Flat anterior surface
     Convex posterior surface
    Achilles tendon
    Sagittal, Axial

     The strongest and largest tendon


     Most commonly injured tendon in the foot
     No tendon sheath
     Flat or concave anterior aspect (axial)
     Bursa anterior to the tendon insertion
    Achilles tendon

     Rupture 2-6 superior to Os calcis

    25 % clinically missed
     Complete disruption
     Fraying, Corkscrewing
     Retraction [Fat, fluid, blood] in the gap
    Achilles tendon
    Sagittal T1 Sagittal STIR

    Torn tendon (corkscrew) Normal tendon


    Achilles tendon
    T1 T2*

    Complete tear with gap containing fat


    Achilles tendon

    Normal tendon Complete Tear


    Achilles tendon
    Chronic tear
    Achilles tendon
    Chronic tear
    Achilles tendon

     Partial tear -Focal thickening


    -Focal Signal

    T2* T2*
    Achilles tendon
    Tendinitis, peritendinitis
    Focal or fusiform thickening of the tendon
    Intermediate signal in T2 WIs

    STIR T2*
    Peritendinitis Normal
    Achilles tendon

    T1 T2* T2*

    Chronic tendinitis with focal Intra substance tear


    thickening & abnormal signal
    Achilles Tendon

    Tendenitis (fusiform thickening)


    Achilles tendon

    T2* T2*

    Chronic tendinitis with Chronic tendinitis with


    diffuse thickening partial tear
    Achilles tendon

    Retrocalcaneal bursa
    Normal retrocalcaneal bursa
    Abnormal retrocalcaneal bursa
    Bursitis in rheumatoid arthritis
    Lateral aspect

    Tendons: Peroneal tendons


    Ligaments :
     Tibiofibular syndesmotic complex
     Lateral collateral ligament
    Lateral aspect
    Tendons Peroneal tendons (Axial, Sagittal)

     Course posterior to the


    fibula
     Wellformed fibular groove
    →more tendon stabilization
     Common sheath down to the
    fibular tip then separate
     PB is anterior and inserts
    into the base of the 5th
    metatarsal + Middle cuniform
    bone
    Lateral aspect
    Peroneal tendons

    Cross section almost equal in size


    PB is just anterior to PL
     Rupture: •Uncommon
    • splitting of the PB tendon + Tenosynovitis
    DD bifurcated insertion (normal variant)
    The inability to identify clearly the two tendons on the
    lateral side of the ankle in sagittal images = Partial or
    complete rupture of one of them
    Peroneal tendons

    Normal peroneal tendons


    Peroneal tendons

    Complete rupture of PB tendon


    T2*
    T1

    Splitting of the PB tendon with lateral displacement of PL


    Peroneal tendons

    Convex retro malleolar groove


    → lateral dislocation and tears
    of PL, PB tendons
    Lateral Aspect

    Ligaments axial
     Tibiofibular syndesmotic complex
     Lateral collateral ligament
    • Anterior talofibular
    • Posterior talofibular
    • Calcaneofibular
    Seen at the level of the malleolar fossa (Indentation on
    the medial surface of the fibula)
    Lateral collateral ligament
    ATF= Anterior talofibular lig.
    PTF= Posterior talofibular lig..
    MF = Malleolar fossa
    Normal lateral collateral
    ligament
    Lateral aspect
    Ligaments Axial
     Lateral collateral ligament
    The anterior talofibular ligament is the most constant

    • Acute injury
    •Absence
    •Laxity
    •Partial disruption
    • Chronic injury [ generalized thickening]
    T2*

    Acute rupture of the anterior talofibular ligament with intact posterior


    talofibular ligament
    Chronic injury of anterior talofibular lig.
    Talar tilt angle
    Normally the angle is less than 40˚
    Angle > 10˚ compared to the normal side
    = torn anterior talo fibular & calcenofibular ligaments
    Limitations Pain- Force- laxity on the normal side
    Lateral aspect

    Ligaments Axial

    Tibiofibular syndesmotic complex


     Anterior tibiofibular ligament
     Posterior tibiofibular ligament
     Inferior transverse ligament (deep fibers of PTIF)
     Interosseous ligament

    Seen at the level of the talar dome


    Tibiofibular syndesmotic complex

    Talar dome level


    TIBIA
    ATbF= Anterior tibiofibular lig.
    PTbF= posterior tibiofibular lig.
    IT = inferior transverse lig.
    Tibiofibular syndesmotic complex
    Anterior aspect

    Tendons: Tibialis anterior


    Extensor H. longus
    Extensor digitorum longus
    Ligaments: No
    Traumatic injury of TA tendon
    Fluid within and around the tendon
    Traumatic laceration of TA tendon
    Fluid fills the area of tendon gap
    Medial aspect
    Tendon: Tibialis posterior
    Flexor digitorum longus
    Flexor H. longus
    Ligaments: Deltoid ligament
    Tibialis posterior rupture
    5th -6th decade [Females]
    Synovitis, trauma, steroid injection

    Common site of rupture at


    or within 6cm of navicular
    insertion
    Normally TP tendon is twice
    large as FDL or FHL
    Medial aspect

    Tendons: Tibialis posterior rupture

    Types
    I. partial tear with hypertrophy of the (4-5 times FDL,
    FHL)
    II. Partial tear with attenuated tendon or splitted tendon
    III.Complete tear with gap
    Type I : Tear of TP tendon
    Marked tendon thickening & abnormal signal
    Normal

    Type II : Longitudinal rupture of TP resulting in


    2 sub tendons
    Type II :
    Longitudinal
    rupture of TP
    resulting in 2
    sub tendons
    Medial aspect

    Tendons
    Tenosynovitis Inflammatory, infectious
    Acute: Synovial fluid around the tendon
    Chronic: Fluid + thickened tendon & synovitis
    FHL: Ballet dancers
    TP: Rhumatoid arthritis, old patients
    PL,PB: Spastic flat foot, young patients
    N.B: FHL may communicate with the ankle joint in 10-
    20% of cases
    Medial aspect
    Tendons
    Tenosynovitis

    Normal FHL Tenosynovitis


    Tendons
    Tenosynovitis

    Split of PB with tenosynovitis


    Peroneal tenosynovitis
    Fluid within the common peroneal sheath
    Tendons
    Tenosynovitis

    Chronic peroneal tenosynovitis


    Medial aspect
    Ligaments
    Deltoid ligament

    Talus

    Tibia Navicular
    Not seen on a single axial or coronal image

    Calcaneous
    TP & FDL tendons lie superficial to the deltoid
    ligament in axial & coronal planes [Landmark for the
    ligament]
    Medial ligaments
    T
    1. ant. Tibiotalar
    2. Tibio navicular
    3. Tibio spring
    4. Tibio calcaneal
    5. Post. Tibiotalar
    6. Springs
    DPTT= posterior tibiotalar Tibiotalar part of deltoid
    TC= Tibio calcaneal ligament

    PT= Tibialis posterior


    Sinus tarsi syndrome
    Contents: fat, nerve endings, vessels, ligaments
    Ligaments
    • Cervical ligament
    • Inter osseous (IOL)
    Sinus tarsi syndrome
    Minor subtalar instability
    Causes:
     Ligament disruption
     Synovitis (RA)
     Osteoarthritis
     Ganglion
     Gout
    Sinus tarsi syndrome
    MR Finding

     Torn ligaments + torn lateral collateral ligament


     Diffuse inflammation with synovitis
    Diffuse infiltration by fibrosis

    Normal

    Torn talocalcaneal (cervical) ligament


    Sinus tarsi syndrome

    Torn subtalar ligaments


    Sinus tarsi syndrome

    Inflammatory reaction in the sinus tarsi


    Type I: rupture TP tendon
    Tarsal tunnel syndrome

    Fibro-osseous tunnel extending from the


    medial malleolus to the tarsal navicular
    bone
    Bony floor [talus, calcaneous,
    sustentaculum tali]
    Fibrous roof [Flexor retinaculum]
    Multiple septations divide the tunnel into
    small compartments
    Contents TP,FHL,FDL,AVN
    Quadratus plantae

    TIS= transverse interfascicular septum


    Abductor hallucis
    Tarsal tunnel syndrome

    QP= Quadratus plantae AH= Abductor hallucis


    Tarsal tunnel syndrome

    Tarsal tunnel
    MPN= medial plantar nerve Split of PB tendon
    Tarsal tunnel syndrome
    Intrinsic or extrinsic tunnel compromise
    Intrinsic causes [SOL inside to tunnel]

     Ganglion
     Varicose veins
     Neuroma
     Lipoma
     Sarcoma
     Tenosynovitis
     Fibrosis
    Tarsal tunnel syndrome

    Varicose veins
    Tarsal tunnel syndrome

    Hemangioma
    Tarsal tunnel syndrome

    Synovial sarcoma in the tarsal tunnel infiltrating


    the ABH muscle
    Tarsal tunnel syndrome

    Extrinsic causes

     Trauma
     Hypertrophy of the ABH muscle
     Talocalcaneal coalition

    Talocalcaneal coalition
    stretching the tunnel
    Tarsal tunnel syndrome

    Post traumatic scar tethering the AVN with loss of


    the subcutaneous fat
    Osteochondral lesions
    Osteonecrosis

    Spontaneous
     Trauma
     Cortico steriods
     Marrow infiltrative lesions
    Reactive interface = inflammatory fibromesenchymal
    tissue= low signal line demarcating the margin of necrotic
    bone
    Osteonecrosis

    Talus most common


    Navicular  Kohler’s disease (Child)
     Mueller-Weiss syndrome (adult)

    2nd metatarsal head Freiberg’s disease


    Calcaneous Steroid treatment
    Osteonecrosis
    Stage I Trabecular compression +ve bone scan
    Marrow edema on MRI
    Osteonecrosis

    Stage II Subchondral cyst / incomplete


    separation
    Osteonecrosis

    Stage III
    Detached undisplaced Fragment
    Osteonecrosis

    Stage IV Detached displaced Fragment


    THANK YOU
    MAMDOUH MAHFOUZ MD
    Fig 8-61 Fig 8-63
    8-69
    8-70
    ‫‪6-31‬ص ‪ 161‬الكتاب االخضر‬
    8-99 8-103
    Achilles Tendon

    Partial tear
    Os trigonum
    ateral (Side) View of Normal Left Ankle

    Lateral (Side) View of Left Anklewith Grade III tear of ATFL


    Ankle Anatomy Muscle A P
    Ankle Anatomy Ligaments
    Ankle Anatomy Talar Intra-Articular Disorders
    Ankle Anatomy Subtalar Function
    Normal anatomy of the medial ankle .
    Osteonecrosis

    Stage I Trabecular compression +ve bone scan


    Marrow edema on MRI

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