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