Clin Podiatr Med Surg

19 (2002) 285 – 307

MRI of soft tissue disorders of the ankle

Roger Kerr, MD*
Department of Radiology, Orthopaedic Hospital, 2400 South Flower Street, Los Angeles,
CA 90007, USA
Department of Radiology, Keck School of Medicine at the University of Southern California,
Los Angeles, CA 90089, USA

Before magnetic resonance imaging (MRI), the imaging assessment of soft

tissue disorders of the ankle was limited to computed tomography (CT), conven-
tional radiography, arthrography and tenography. CT and radiography do not have
the contrast resolution or multiplanar tomographic imaging capability of MRI.
Arthrography and tenography are invasive and allow only indirect visualization of
soft tissue structures. With MRI, the size, continuity and internal structure of
tendons and ligaments are demonstrated. Intra-articular and peri-articular soft
tissue masses may be sensitively detected and, in some cases, accurately
diagnosed based on their signal characteristics. The major nerve trunks, the fascia,
and the flexor and extensor retinacula may also be evaluated with MRI.
MRI of the ankle is most often obtained in patients who have failed
conservative management following injury, or present with chronic ankle pain
or instability. In an elite athlete, MRI may be used to assess an acute injury in
order to determine the injury extent and establish if surgery is indicated. Less
commonly, patients with an ankle mass or swelling, or with poorly localized signs
and symptoms may be examined with MRI. In the ankle region, MRI has been
shown to be particularly useful in assessing tendon injuries, in diagnosing occult
osteochondral lesions, and in the evaluation of mass lesions. It may have a
significant impact on clinical management. In one study, MRI of the ankle and
hindfoot established a diagnosis not achieved clinically in 47% of patients, and
prompted a change in treatment in 34% of patients [1].

Imaging technique
The ankle and hindfoot are imaged with an extremity surface coil, with the
patient supine and the ankle in neutral position or mild plantar flexion. Imaging is

* Department of Radiology, Orthopaedic Hospital, 2400 South Flower Street, Los Angeles,
CA 90007, USA.
E-mail address: Rkerr@laoh.ucla.edu (R. Kerr).

0891-8422/02/$ – see front matter D 2002, Elsevier Science (USA). All rights reserved.
PII: S 0 8 9 1 - 8 4 2 2 ( 0 2 ) 0 0 0 0 4 - 6
286 R. Kerr / Clin Podiatr Med Surg 19 (2002) 285–307

generally performed in three orthogonal planes but, in some patients, may

be tailored to a specific region or structure by utilizing an axial oblique or coronal
oblique plane, or by placing the ankle in dorsiflexion or plantar flexion. Standard
technique includes a 12– 16 cm field of view, a 3 –4 mm section thickness, and
T1-weighted and either fast-spin echo, fat-saturated, T2-weighted, or inversion-
recovery images. T1-weighted images primarily pro-vide anatomic definition,
whereas T2-weighted and inversion-recovery images are most valuable for
determining the presence of fluid, edema, hemorrhage, and fibrous tissue. On
inversion-recovery and fat-saturated T2-weighted images, fat is relatively low in
signal intensity. These pulse sequences are particularly useful for detecting a soft
tissue mass or edema, and for evaluating the marrow space.

Ligament injury
Most ankle injuries occur with forced plantar flexion and inversion, resulting
in injury to the lateral ankle ligaments. The anterior talofibular ligament is
weakest, and is torn first and most frequently (Fig. 1). As the force of injury
increases, the calcaneofibular ligament and the posterior talofibular ligament are
torn in sequence. MR signs of acute ligament tear include ligament discontinuity,
detachment, attenuation or thickening, intraligamentous increased signal intensity
on T2-weighted images, and extravasation of joint fluid beyond the normal
confines of the involved ligament. A chronically torn ligament may appear
attenuated or elongated and wavy, reveal diffuse or nodular thickening, or be

Fig. 1. Normal anterior talofibular ligament. On an axial T2-weighted image, the normal anterior
talofibular ligament appears as a well-defined, low signal intensity band (arrow).
 R. Kerr / Clin Podiatr Med Surg 19 (2002) 285–307 287

obscured by fibrous tissue or synovial proliferation (Fig. 2). The anterior and
posterior talofibular ligaments are best evaluated in the axial plane. The
calcaneofibular ligament may require both axial and coronal images to be
adequately demonstrated.
The anterior and posterior tibiofibular ligaments are usually torn in asso-
ciation with disruption of the interosseous membrane (syndesmosis injury), and
medial malleolar or fibular fractures. These ligaments have an oblique course,
and may normally appear discontinuous on axial MR images. Ligament
continuity may be inferred by viewing consecutive axial images. When torn,
these ligaments appear thickened, distorted, nodular, or grossly discontinuous.
Following syndesmosis injury, the interosseous membrane may undergo heter-

Fig. 2. Chronic partial tear of the anterior talofibular ligament. On an axial T2-weighted image the
ligament is diffusely thickened (arrows).
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otopic ossification that may be painful. On MRI, this may be confused with a
mass lesion (Fig. 3). Symptoms may be relieved by excision of this region of
ossification [2].
If primary surgical repair is being contemplated after an acute ankle sprain,
MRI may be used to document the extent of ligament injury. In patients with
chronic ankle pain or instability, MRI may be useful for assessing the ankle
ligaments and detecting associated lesions, such as an osteochondral fracture or
tendon abnormalities. MRI is limited in predicting the clinical outcome after
ankle sprain. There is a tendency toward a better outcome with partial anterior
talofibular ligament tear and an uninjured peroneal tendon sheath [3]. In one

Fig. 3. Post-traumatic ossification. (A) An AP radiograph reveals heterotopic ossification (arrows) of

the distal tibiofibular syndesmosis. (B) An axial T2-weighted image demonstrates a low signal
intensity mass (arrows) anterior to and between the distal tibia and fibula; t = tibia, f = fibula.
 R. Kerr / Clin Podiatr Med Surg 19 (2002) 285–307 289

Fig. 3 (continued ).

study, MR-arthrography was more sensitive than MRI in diagnosis of chronic

ligament tears, but is invasive and is rarely performed [4].

Anterolateral impingement
The anterolateral compartment is a space enclosed by the anterolateral aspect
of the talus and tibia, the anteromedial aspect of the fibula, and the anterior
tibiofibular, anterior talofibular, and calcaneofibular ligaments. Anterolateral
impingement is a syndrome that is usually seen after one or more ankle sprains.
It is produced by synovial hypertrophy, fibrotic scarring or, less commonly, an
accessory fascicle of the anteroinferior tibiofibular ligament. When this tissue is
present within the anterolateral gutter of the ankle, it may become entrapped
290 R. Kerr / Clin Podiatr Med Surg 19 (2002) 285–307

within the joint during dorsiflexion. Patients present with pain, swelling, limited
dorsiflexion, subjective instability, or weakness. Arthroscopic debridement and
partial synovectomy usually produce good or excellent results. Soft tissue
encroachment upon the anterolateral gutter is best seen on axial MR images
(Fig. 4). The reliability of MRI in achieving this diagnosis, however, has not been
established. Soft tissue fullness within the lateral gutter, without an associated
joint effusion, was an accurate indicator of this disorder in one study [5], yet
unreliable in another [6]. Other investigators concluded that the diagnosis may be
suggested when fluid in the lateral gutter outlines an abnormal soft tissue
structure separate from the anterior talofibular ligament (see Fig. 2) [7].

Osteochondral lesion of the talar dome

Any discussion of ankle injuries must include this lesion. It is an important
cause of persistent ankle pain following a moderate or severe ankle sprain.
Diagnosis is often delayed, due to coexisting injuries and subtle or absent
radiographic findings. Early detection is important, as untreated lesions may
progress to a more advanced stage with collapse of the articular surface and
development of osteoarthritis. Diagnosis and characterization of osteochondral
fracture of the talar dome is best accomplished with MRI. In two studies, this
lesion was demonstrated with MRI in 57% of patients with persistent pain six
weeks after injury and negative radiographs [8,9].

Fig. 4. Anterolateral impingement. On an axial T2-weighted image, a low-to-intermediate signal

intensity soft tissue mass (arrows) is anterior to the distal fibula and extends partially into the
anterolateral gutter.
 R. Kerr / Clin Podiatr Med Surg 19 (2002) 285–307 291

Osteochondral lesions have been classified into four stages, depending on

the integrity of the articular cartilage and the status of the subchondral
fragment. Stage I is a subchondral compression injury, with intact overlying
cartilage that is not visible on conventional radiographs. Stage II represents a
partially detached osteochondral fracture. In stage III, the fragment is com-
pletely separated from the fracture bed, but remains in anatomic position or is
slightly displaced. A stage IV lesion is completely displaced and lies free
within the joint. Stage IIA has been suggested to designate lesions that have
evolved into a subchondral cyst (Fig. 5) [10]. Lesions tend to progress in stage
with continued weightbearing. Fractures of the medial aspect of the talar dome
are usually deep and crater-like, whereas lateral lesions are usually flake-like
and are more readily displaced.

Peroneal tendon disorders

The peroneus brevis (PB) and longus (PL) tendons descend behind the lateral
malleolus within a shallow fibro-osseous groove, and insert on the fifth and first
metatarsal bases, respectively. These tendons are subject to tenosynovitis, tear,
dislocation, and entrapment. Symptoms are often non-specific and include lateral
ankle pain, instability, and lateral tenderness and swelling. MRI is useful in
determining the type and extent of peroneal tendon disorder and in distinguishing
it from other ankle and hindfoot conditions [11,12].

Fig. 5. Osteochondral lesion. A sagittal inversion recovery image reveals a partially cystic
osteochondral lesion of the medial aspect of the talar dome (large arrow). The overlying subchondral
cortical bone is slightly flattened and of decreased thickness (small arrows).
292 R. Kerr / Clin Podiatr Med Surg 19 (2002) 285–307

On MRI, a normal tendon appears as a low signal intensity structure on all

pulse sequences. However, if a portion of a tendon is oriented at 55 degrees to the
main magnetic field, it will reveal intermediate, rather than low, signal intensity
on T1-weighted images (Fig. 6). This is known as the magic angle effect [13].
This effect does not occur on T2-weighted images. Therefore, it can be dis-
tinguished from tendonopathy by the normal low signal intensity of this tendon
on T2-weighted images, compared to persistent increased signal intensity with
tendinosis or intrasubstance tear.
The PB tendon is susceptible to degeneration and tear as it courses behind the
retromalleolar groove. Axial MR images reveal an attenuated, C-shaped tendon,
partially surrounding the PL tendon (Fig. 7). The PL tendon is prone to tear as it

Fig. 6. Magic angle effect. On a sagittal T1-weighted image the peroneus brevis tendon (arrows) reveals
intermediate signal intensity. Compare to the low signal intensity of the peroneus longus tendon (PL).
 R. Kerr / Clin Podiatr Med Surg 19 (2002) 285–307 293

Fig. 7. Longitudinal split tear of peroneus brevis tendon. On an axial T1-weighted image, the split,
partially torn peroneus brevis tendon (curved black arrows) is medial and lateral to an intact peroneus
longus tendon (open arrow).

courses around the peroneal tubercle of the calcaneus and, within the midfoot,
under the cuboid bone (Fig. 8). Tears of this tendon at the midfoot often produce
non-specific symptoms and are underdiagnosed [14]. Factors predisposing to
lateral dislocation of the peroneal tendons include a flat or convex retromalleolar
groove, a torn or absent superior peroneal retinaculum, and a stretched
retinaculum, due to a low-lying PB muscle or an accessory peroneus quartus
muscle. Lateral dislocation may only occur in certain positions and require
dynamic MRI, obtained with varied degrees of plantar- and dorsiflexion, for
diagnosis. A radiographic clue to traumatic dislocation of the peroneal tendons
is a flake-like fracture off the posterior border of the lateral malleolus, due to
avulsion by the superior peroneal retinaculum. Stenosing tenosynovitis of the
294 R. Kerr / Clin Podiatr Med Surg 19 (2002) 285–307

Fig. 8. Partial tear of peroneus longus tendon. On a coronal T1-weighted image, the peroneus longus
tendon is enlarged and deformed (arrows) when viewed in cross-section as it courses inferior to the
cuboid; pb = peroneus brevis tendon; C = cuboid bone.

peroneal tendons may develop secondary to entrapment by displaced fragments

of a fractured calcaneus.

Posterior tibial tendon disorders

The posterior tibial tendon (PTT) maintains the longitudinal arch and is the
principal invertor of the foot. Most tears are chronic and present as a
progressive, painful, flatfoot deformity in middle-aged and elderly women
with no history of antecedent trauma. Medial swelling and tenderness are
typical, although lateral pain may be present, caused by impingement of the
calcaneus on the lateral malleolus (due to hindfoot valgus) or by an associated
 R. Kerr / Clin Podiatr Med Surg 19 (2002) 285–307 295

sinus tarsi syndrome. Tendinosis and partial and complete tears usually occur
where the tendon courses around the medial malleolus, and may be clinically
indistinguishable [15]. Athletes tend to present with tenosynovitis secondary
to overuse.
On MRI, the PTT is best assessed in cross-section on axial or axial-oblique
images [16]. It is normally twice the width of the adjacent flexor digitorum
longus tendon, and slightly smaller than the combined width of the peroneus
brevis and longus tendons. This tendon increases in diameter, and is of
intermediate, rather than low, signal intensity as it approaches its principal
insertion on the navicular tuberosity. With tenosynovitis, MRI reveals a
normal tendon surrounded by a moderate amount of fluid within the tendon
sheath. With partial tear, the tendon may be of increased or decreased
diameter, with variable intratendinous increased signal intensity (Fig. 9).
Avulsion of this tendon from its navicular insertion may be difficult to detect
with MRI, especially if chronic, because this portion of the tendon normally
increases in size and signal intensity. The presence of edema or hemorrhage
should lead to the correct diagnosis. When completely torn, the tendon is
absent, due to proximal and distal retraction of the torn ends. MRI accurately
demonstrates the extent of tear, and aids the surgeon in choosing between the
various surgical options [17]. The plantar calcaneonavicular or spring ligament
is an additional stabilizer of the longitudinal arch that should be evaluated on
MRI in patients with PTT dysfunction.

Fig. 9. Chronic posterior tibial tendon tear. On an axial T2-weighted image, the partially torn tendon is
enlarged (black arrow) as it extends into the hindfoot and is surrounded by a high signal intensity
tenosynovial effusion (open arrow).
296 R. Kerr / Clin Podiatr Med Surg 19 (2002) 285–307

Flexor hallucis longus tendon injury

The flexor hallucis longus (FHL) tendon courses through a fibro-osseous
tunnel posterior to the talus, between the medial and lateral tubercles. It travels
under the sustentaculum, into the plantar aspect of the foot, and inserts onto the
great toe. Athletes who perform push-off maneuvers and plantar flexion, such as
ballet dancers and soccer players, are prone to injury of this tendon.
The FHL tendon sheath communicates with the ankle joint in 20% of normal
patients and as a result, fluid is commonly seen within this tendon sheath on MRI.
Tenosynovitis is characterized by a disproportionate amount of fluid within the
FHL tendon sheath relative to the ankle joint (Fig. 10). With tendinosis or partial

Fig. 10. Flexor hallucis longus tenosynovitis. On an axial T2-weighted image, a large fluid collection
(black arrow) surrounds the flexor hallucis longus muscle and tendon (white arrow). There was no
tibiotalar joint effusion; M = medial malleolus, F = fibula.
 R. Kerr / Clin Podiatr Med Surg 19 (2002) 285–307 297

tear, this tendon reveals an increased diameter, with increased intrasubstance

signal intensity. Complete rupture of this tendon is unusual.

Anterior tibial tendon injury

The anterior tibial tendon (ATT) is the principal dorsiflexor of the foot and
ankle. It passes through the extensor retinacula at the ankle, and inserts on the
first cuneiform and first metatarsal base. Most patients with injury to this tendon
are over age 50. In athletes, this tendon is usually injured by acute or repetitive
forced plantar flexion of the foot, as may occur in skiing, downhill running, and
soccer. Tendon rupture produces a drop foot that can simulate L5 nerve root
impingement in the spine. Tenosynovitis usually occurs as this tendon courses
between the superior and inferior extensor retinacula. On MRI, this tendon is best
evaluated in the axial and sagittal planes. With tenosynovitis, there is a tendon
sheath effusion, whereas partial and complete tears reveal increased tendon width
and tendon discontinuity, respectively.

Achilles tendon disorders

Injuries to the Achilles tendon include acute and chronic peritendinosis,
tendinosis, and partial or complete tears. Achilles tendon disorders are classified
as non-insertional, usually involving the tendon 2 to 6 cm above the calcaneal
insertion, and insertional, involving the most distal aspect of the tendon. Achilles
tendon injury is most common in middle-aged adults who intermittently engage
in strenuous athletic activities, and in professional athletes and ballet dancers. It is
also seen in association with rheumatoid arthritis, gout, diabetes mellitus,
hyperthyroidism, and chronic renal failure. All ruptures of the Achilles tendon
are preceded by degenerative tendonopathy [18].
The Achilles tendon is partially surrounded by a thin membrane (the para-
tenon) rather than a synovial sheath. Non-insertional peritendinosis refers to
edema and scarring of the paratenon, or edema of the pre-Achilles fat pad. It is
seen in runners who increase their training regimen or run over uneven surfaces.
MRI reveals a feathery pattern of edema anterior to the Achilles tendon, or
thickening of the paratenon, usually at the posterior aspect of the tendon (Fig. 11)
[19]. The MR finding of pre-Achilles edema, associated with a normal tendon,
should be correlated with clinical findings, as it has been observed in asympto-
matic patients [20].
Tendinosis and tears of the Achilles tendon usually occur 2 to 6 cm above the
calcaneal insertion. In this area, the tendon is hypovascular, and is subjected to
maximal shear stress related to the normal twisted or spiral configuration of the
tendon fibers. On MRI, it may be difficult to distinguish between Achilles
tendinosis and a partial tear. On T2-weighted or inversion recovery images, both
298 R. Kerr / Clin Podiatr Med Surg 19 (2002) 285–307

may reveal fusiform or diffuse tendon enlargement, with normal signal intensity
or linear or globular foci of increased intratendinous signal intensity.
With a complete tear, the tendon is discontinuous, with frayed, irregular ends,
intratendinous and peritendinous signal abnormality, and sometimes tendon
retraction. The diagnosis of complete tear is best accomplished with axial
T2-weighted images. A small, intact plantaris tendon, medial to the Achilles
tendon, should not be confused with intact Achilles fibers (Fig. 12).
Insertional Achilles tendon abnormalities are usually due to repetitive over-
use or inflammatory arthritis. On MRI, insertional tendinosis is characterized
by one or more of the following abnormalities: intratendinous increased signal
intensity on T2-weighted images, with variable tendon enlargement; an
enlarged, fluid-filled retrocalcaneal bursa; superficial Achilles bursal fluid/

Fig. 11. Achilles peritendinitis. A sagittal fat-saturated T2-weighted image reveals extensive edema
(arrows) of the pre-Achilles fat pad.
 R. Kerr / Clin Podiatr Med Surg 19 (2002) 285–307 299

edema; peritendinous edema at the Achilles insertion on the calcaneus; or bone

marrow edema or erosion of the calcaneus [21]. Tendon enlargement, intra-
tendinous signal abnormality, and bursal fluid may be seen in asymptomatic
patients with chronic degeneration [20]. Increased volume of retrocalcaneal bur-
sal fluid, increased intensity of intratendinous signal intensity on T2-weighted
images, and calcaneal marrow edema tend to correlate with the presence of
symptoms [20]. Enlargement of the posterosuperior aspect of the calcaneal
tuberosity (Haglund’s deformity) may predispose to insertional tendinosis
and bursitis.
In patients with pain in the region of the Achilles tendon, MRI is useful in
distinguishing between intratendinous and peritendinous abnormalities, and for

Fig. 12. Achilles tendon rupture. On a coronal inversion recovery image, high signal intensity fluid
fills the tendon defect (large arrows). The intact plantaris tendon (small arrows) is medial to the
disrupted Achilles tendon.
300 R. Kerr / Clin Podiatr Med Surg 19 (2002) 285–307

demonstrating injury extent. It may be used to guide therapy and determine

prognosis for recovery of function [22]. Patients with partial intrasubstance tears
may undergo surgical exploration and debridement, based on the size of the
lesion shown by MRI. In patients with complete tears, MRI may be used to
determine the extent of tendon retraction, and thereby assist the surgeon in
choosing between approximating the tendon ends or using an allograft. Tendon
healing after surgery may also be assessed with MRI. In one study that followed
patients six months after surgical repair of a ruptured Achilles tendon, intra-
tendinous foci of high signal intensity on T2-weighted images that were greater
than 50% of the sagittal tendon diameter were associated with a clinically poor
preliminary recovery [16].
Achilles tendon xanthoma is a painless mass lesion that occurs in patients
with familial hypercholesterolemia. Bilateral involvement is typical. It is often
the initial clinical manifestation of this disease. Histology reveals tendon fibers
separated by foamy histiocytes that are packed with cholesterol and inflam-
matory cells. On MRI, areas of intermediate-to-high signal intensity are
interspersed between low signal intensity tendon fibers on both T1-weighted
and T2-weighted images. The involved tendon is usually diffusely, sometimes
massively, enlarged. When tendon enlargement is mild, the appearance may
overlap with that of chronic partial tear or tendinosis [23].

Accessory soleus muscle

The accessory soleus is an anomalous muscle whose origin may vary
within the proximal aspect of the leg. In the ankle, it courses between the
flexor hallucis longus muscle and the Achilles tendon. It may insert on the
Achilles tendon or on the superior or medial surface of the calcaneus. This
muscle may be associated with pain, swelling, limitation of ankle motion, or a
localized compartment syndrome, and symptoms usually increase with exer-
cise. MRI reveals a soft tissue mass in the typical location, with signal
characteristics of muscle on all pulse sequences (Fig. 13). MRI is useful for
diagnosis and in distinguishing this from soft tissue masses of neoplastic
origin [24].

Synovial disorders of the ankle joint

Pigmented villonodular synovitis (PVNS) is an uncommon disorder charac-
terized by proliferation of synovium. It may occur as a localized or diffuse
process within the joint. The ankle is the third most common joint involved, after
the knee and hip. Patients are usually in the third or fourth decade and present
with an insidious onset of pain and swelling. There is typically a joint effusion
that is often serosanguineous.
 R. Kerr / Clin Podiatr Med Surg 19 (2002) 285–307 301

Fig. 13. Accessory soleus muscle. On an axial T1-weighted image there is a bilobed mass with the signal
characteristics of muscle (arrows) within the pre-Achilles fat pad; fhl = flexor hallucis longus tendon.

Radiographs may reveal erosion of the underlying bone, with preservation of

joint space and bony mineralization. The erosions are usually well-defined, with a
thin sclerotic margin. In the ankle, PVNS usually occurs as the diffuse form and
has a characteristic appearance on MRI. It typically presents as a bulky,
synovium-based mass that extends outward from the joint. The mass usually
reveals intermediate signal intensity on T1-weighted images, and predominantly
low signal intensity on T2-weighted images, reflecting the accumulation of
hemosiderin (Fig. 14) [25].
Giant cell tumor of tendon sheath is a synovial proliferation originating in
tendonsheath. It has histologic features similar to PVNS, and occurs as a
localized or diffuse lesion. The localized form (also known as localized nodular
synovitis) is most common in the hand, at the volar aspect of the fingers. In the
302 R. Kerr / Clin Podiatr Med Surg 19 (2002) 285–307

Fig. 14. Pigmented villonodular synovitis. A sagittal T1-weighted image reveals multiple lobulated,
intermediate-to-low signal intensity masses about the tibiotalar and posterior talocalcaneal joints and
within the tarsal canal (arrows).

foot, it most often involves the first two toes [26]. There may be pressure erosion
in the underlying bone. The diffuse form of giant cell tumor of tendon sheath
tends to be larger, with an irregular, infiltrating appearance. On MRI, this lesion
reveals intermediate to low signal intensity on T1- and T2-weighted images
(Fig. 15). The extent of low signal intensity within the mass is proportional to the
hemosiderin content.
Synovial osteochondromatosis is an unusual cause of ankle pain, as it most
frequently affects the knee, elbow, hip, and shoulder. It represents chondroid
metaplasia of synovium, and may arise within a joint, bursa, or tendon sheath.
Synovectomy is the treatment of choice. The appearance on MRI varies,
depending on the age of the lesion. The signal intensity of uncalcified
chondroid bodies is intermediate on T1-weighted images, and intermediate to
high on T2-weighted images. Calcified or ossified lesions reveal low signal
intensity. A mature osteocartilaginous body may contain marrow and dem-
onstrate the signal characteristics of fat with a thin, peripheral rim of low signal
intensity bone.

Tarsal tunnel syndrome

The tarsal tunnel is a fibro-osseous channel at the medial aspect of the ankle
and hindfoot. It is located under, but also extends proximal and distal to, the
flexor retinaculum. Tarsal tunnel syndrome is produced by entrapment or
displacement of the posterior tibial nerve or its branches within this confined
space. Patients present with pain and paresthesia along the plantar and medial
 R. Kerr / Clin Podiatr Med Surg 19 (2002) 285–307 303

Fig. 15. Giant cell tumor of tendon sheath. A sagittal T2-weighted image reveals a low signal intensity,
soft tissue mass (large arrows) inferior to the flexor hallucis longus tendon (small arrows) as it courses
under the sustentaculum tali.

aspects of the foot and toes. The heel is usually spared, due to lack of impinge-
ment upon the medial calcaneal branch of the posterior tibial nerve. Muscle
weakness is a late, infrequent sign. Electrodiagnostic studies may be negative and
cannot be used to exclude the diagnosis.
On MRI, the tarsal tunnel is best evaluated in the axial plane. Nerve
entrapment or displacement may be caused by a variety of space-occupying
lesions, including neoplasms, ganglion cysts, and accessory or hypertrophied
muscles, as well as fracture deformity and post-traumatic fibrosis (Fig. 16). MRI
is particularly well-suited to evaluating this disorder, because the inciting lesion
often cannot be localized by the clinical findings [27]. It is useful in selecting
patients for surgery, as the best results are obtained in patients with mass lesions
304 R. Kerr / Clin Podiatr Med Surg 19 (2002) 285–307

Fig. 16. Tarsal tunnel syndrome. An axial T2-weighted image reveals a high signal intensity ganglion
cyst (arrow) within the tarsal tunnel, laterally displacing the medial (mp) and lateral (lp) plantar
nerves; T = talus, F= fibula.

[28]. Decompression of a ‘‘tight’’ overlying flexor retinaculum and excision of

venous varicosities yield inconsistent surgical results [28]. Varicosities are
commonly seen in the tarsal tunnel and their clinical significance should be
interpreted with caution.

Sinus tarsi syndrome

The space between the talus and calcaneus, anterior to the subtalar joint, is
termed the tarsal canal (medially) and the tarsal sinus (laterally). It contains
ligaments, a portion of the extensor retinaculum, nerves, fat, an arterial anasta-
mosis, and joint capsule. Patients with sinus tarsi syndrome may present with
lateral hindfoot pain, perceived hindfoot instability, and pain to palpation over the
tarsal sinus. Injection of local anesthetic into the sinus tarsi relieves the pain. The
most frequent cause is inversion injury. If the force of injury is sufficient,
disruption of the anterior talofibular and calcaneofibular ligaments is followed, in
sequence, by tear of the cervical ligament and the interosseous talocalcaneal
ligament within the sinus tarsi. Rupture of these ligaments may cause subtalar
instability. For this reason, the sinus tarsi should be evaluated in all patients who
undergo MRI of the ankle following injury. There is also an association between
tears of the posterior tibial tendon and sinus tarsi syndrome [29,30]. Subtalar
impingement may result from hypertrophy of synovium and fibrous tissue. In
patients with sinus tarsi syndrome, MRI may reveal ligament disruption and
inflammatory or fibrous tissue or cysts filling the sinus tarsi (Fig. 17). The sinus
 R. Kerr / Clin Podiatr Med Surg 19 (2002) 285–307 305

Fig. 17. Sinus tarsi syndrome associated with ganglion cyst. An axial fat-saturated, T2-weighted image
reveals a lobulated, partially septated fluid collection (arrows) within the sinus tarsi, extending into the
lateral soft tissue; C = calcaneus, T = talus.

tarsi ligaments may be obscured by this tissue, precluding their evaluation by

MRI [30].

Soft tissue tumors

Although uncommon, a variety of benign and malignant soft tissue tumors and
tumor-like lesions may arise in the ankle region. The incidence of these lesions
varies according to patient age. The most common benign lesions include lipoma,
ganglion cyst, hemangioma, and schwannoma. Soft tissue sarcomas of the ankle
are rare. Synovial sarcoma deserves mention, however, as it has a strong
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predilection to arise within the lower extremity, including the ankle region. It
typically occurs in young adults and often has an unfavorable prognosis.
Clinically, it may be mistaken for a benign process, due to a slow growth rate.
On MRI, synovial sarcoma usually reveals a heterogeneous pattern of signal
intensities, especially when it is greater than 5 cm in diameter. Smaller lesions
may have a non-specific appearance of intermediate signal intensity on T-1
weighted images, and intermediate to high signal intensity on T2-weighted
images [31].
Because of its excellent soft tissue contrast, MRI is useful for lesion detection
and assists surgical planning by documenting the extent of a mass lesion. For
example, on MRI, ganglion cysts often reveal small serpiginous extensions that
must be excised in order to avoid post-operative recurrence. Certain tumors or
tumor-like processes have a unique radiographic and MRI appearance that
allows accurate diagnosis [32]. Often, however, the benign or malignant nature
of a soft tissue mass cannot be predicted based on its appearance on MRI.

Summary
In summary, MRI has become the dominant imaging modality for assessing
soft tissue disorders of the ankle. It is useful in evaluating patients with acute or
chronic ankle pain or instability, and for diagnosis and staging of soft tissue mass
lesions. MRI often provides information that is essential to treatment planning of
a variety of traumatic, degenerative, and neoplastic lesions.

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