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of the Art

Imaging of Acute
Capsuloligamentous Sports
Reviews and Commentary  n  State

Injuries in the Ankle and Foot:

Sports Imaging Series1
James M. Linklater, MBBS
The ankle and foot are commonly injured during sporting
Catherine L. Hayter, MBBS
activities. Clinical diagnosis can at times be challenging,
Dzung Vu, MD, MBBS, FRANZCO Hon
due to the complex anatomy and multiple sites of potential
injury. In the athlete, there is a reduced threshold for im-
aging to clarify diagnosis, guide prognosis, and treatment.
Diagnostic imaging is also helpful in evaluating ongoing
symptoms in the subacute or chronic setting.

q
 RSNA, 2017

1
 From Castlereagh Imaging, 60 Pacific Hwy, St Leonards,
Sydney, NSW, Australia 2065 (J.M.L., C.L.H.); and Depart-
ment of Anatomy, School of Medical Science, University of
Notre-Dame Australia, Sydney, Australia (D.V.). Received
November 11, 2015; revision requested January 6, 2016;
final revision received October 24; accepted November
16; final version accepted January 18, 2017. Address
correspondence to J.M.L. (e-mail: JamesLinklater@
casimaging.com).

q
 RSNA, 2017

644 radiology.rsna.org  n  Radiology: Volume 283: Number 3—June 2017

STATE OF THE ART: Acute Capsuloligamentous Sports Injuries in the Ankle and Foot Linklater et al
T
he ankle and foot are commonly
injured during sporting activities,
particularly those that involve run-
ning, jumping, and rapid change in di-
rection. Clinical diagnosis can at times
be challenging, due to the complex
anatomy and multiple sites of potential
injury. Diagnostic imaging can play an
important role in clarifying diagnosis
and guiding treatment at the time of
Essentials
nn Early MR imaging of the sprained
ankle in the elite athlete is com-
monly performed to distinguish
between injury to the lateral
ankle ligament complex, syndes-
motic ligament complex, and
transverse tarsal joint complex
and to clarify injury extent and
prognosis.
nn Initial stage of ligament scar re-
constitution involves formation of
ill-defined, edematous immature
scar tissue at the point of liga-
ment fiber disruption, becoming
more defined and less edematous
with time, with reduction in the
degree of thickening; scar
remodeling is complete 6–12
months after injury.
nn Low-energy Lisfranc ligament
complex injuries are common in
athletes; clinical findings may be
subtle, and up to 35% of injures
are initially misdiagnosed or
overlooked.
nn If radiographs are normal, MR
imaging can identify injury to the
interosseous Lisfranc ligament or
the plantar oblique C1-M2M3
ligament and the integrity of the
tarsometatarsal joint capsules
and intermetatarsal and intercu-
neiform ligaments.
nn Some athletes with first metatar-
sophalangeal joint capsuloliga-
mentous injury will experience
ongoing disabling symptoms;
lower grade injuries can be man-
aged conservatively and early
surgical intervention in higher
grade injuries can restore
stability.
Radiology: Volume 283: Number 3—June 2017  n  radiology.rsna.org 645
initial injury. This article reviews the
imaging appearance of common liga-
mentous and capsular sports injuries in
the ankle and foot.
Ankle Sprains
Most acute ankle sprains resolve with-
out complication and in the general
community do not require imaging
unless a fracture is suspected. Early
magnetic resonance (MR) imaging of
the sprained ankle in the elite or pro-
fessional athlete is now commonly per-
formed to distinguish between injury
to the lateral ankle ligament complex,
syndesmotic ligament complex, and
transverse tarsal joint complex and to
clarify the extent of injury and progno-
sis. Targeted ultrasonography (US) is a
valid alternative to MR imaging for the
differentiation of lateral ankle ligament
injury from syndesmosis injury.
Lateral Ankle Ligament Complex Injury
The lateral ligament complex of the an-
kle consists of the anterior talofibular
ligament (ATFL), calcaneofibular liga-
ment (CFL), and posterior talofibular
ligament (Fig 1). The typical lateral an-
kle ligament complex injury consists of
a plantar flexion inversion mechanism,
with resultant tear of the ATFL. There
may be concomitant CFL tear. The pos-
terior talofibular ligament is rarely torn
in an ankle sprain.
Radiography
Radiographs obtained after an an-
kle sprain will commonly show soft-
tissue swelling at the lateral aspect of
the ankle. Cortical flake-type avulsion
fractures are commonly seen in youn-
ger patients and probably account for
the majority of rounded or ovoid ossi-
cles seen in the anterolateral gutter in
adults. Easily missed fractures associ-
ated with ankle sprains include talar
dome, lateral process talus, postero-
lateral process talus, anterior process
calcaneus, and base of fifth metatarsal.
Radiographic Stress Tests
Ankle stress tests have been advocated
as a means of assessing the severity of
acute ankle sprains. Interpretation is,
however, limited by the wide range of
normal, the lack of specificity for the
ligaments injured and ability to assess
the severity of ligamentous injury (1).
MR Imaging
MR imaging techniques for the evalua-
tion of ankle sprains vary according to
radiologist preference, time constraints,
and the capabilities of the equipment.
Most commonly, a combination of high-
spatial-resolution two-dimensional fast/
turbo spin-echo proton density (PD)-
weighted and either fat-suppressed
PD-weighted or fast inversion recovery
(short inversion time inversion-recov-
ery [STIR]) sequences provide optimal
contrast resolution and spatial resolu-
tion (Tables 1, 2).
At MR imaging, the normal ATFL is
homogeneously of low signal intensity
on T1-weighted, T2-weighted, and PD-
weighted pulse sequences and is often
seen on a single axial image with the an-
kle in neutral flexion. Coronal sequences
provide short-axis images of the ATFL.
Sagittal acquisitions can also be helpful
in the evaluation of the proximal fibers.
Acute low-grade/interstitial ATFL
injuries are seen on PD-weighted or
fat-suppressed PD-weighted MR im-
ages as mild intraligamentous signal
hyperintensity, ill-definition of the lig-
ament, and pericapsular edema (2).
In the MR imaging report, the phrase
“ligament sprain” is imprecise and
should be replaced with “acute in-
terstitial injury” or “partial tear,” de-
pending on whether focal ligament
fiber discontinuity is evident. Higher
Published online
10.1148/radiol.2017152442  Content code:
Radiology 2017; 283:644–662
Abbreviations:
AITFL = anterior inferior tibiofibular ligament
ATFL = anterior talofibular ligament
CFL = calcaneofibular ligament
IIOL = inferior interosseous ligament
MTP = metatarsophalangeal
PD = proton density
PITFL = posterior inferior tibiofibular ligament
STIR = short inversion time inversion recovery
Conflicts of interest are listed at the end of this article.
STATE OF THE ART: Acute Capsuloligamentous Sports Injuries in the Ankle and Foot Linklater et al

Figure 1 grade acute injuries are seen as focal

ligamentous attenuation or complete
ligament fiber discontinuity (Fig 2).
The site of injury may be proximal,
midsubstance, or distal.
It is important to be familiar with
the MR appearance of the various stag-
es of scar reconstitution of the ATFL
following injury. The initial stage in-
volves formation of ill-defined edema-
tous immature scar tissue at the point
of ligament fiber disruption, of interme-
diate signal intensity on PD-weighted
and fat-suppressed PD-weighted se-
quences, with ill-defined margins (Figs
3a, 4), becoming gradually more de-
fined and less edematous with time,
with concomitant reduction in the de-
gree of thickening (Fig 3b) (3,4). Scar
remodeling is often not complete until
Figure 1:  Anatomy of the lateral ligament complex and syndesmotic
6–12 months after injury. In the MR im-
ligaments. The lateral ligament complex consists of the ATFL, CFL, and the aging report, the term chronic sprain
posterior (Post ) talofibular ligament (Lig ). The syndesmotic ligament complex is imprecise and is better replaced by
consists of the anterior (Ant ) inferior (Inf.) tibiofibular ligament (AITFL), the phrases encompassing concepts of ma-
inferior interosseous ligament (IIOL) (not shown), and the posterior inferior turity of ligament scar and remodeling,
tibiofibular ligament (PITFL). ligament fiber continuity, and presence

Table 1
MR Imaging of the Ankle at 3 T
Percentage Section In-plane TR (msec)/ Echo Train No. of Signals
Sequence FOV (cm) Phase FOV Thickness (mm) Matrix Resolution (mm) TE (msec) Length Acquired Acquisition Time

Sagittal PD weighted 15 100 2 512 3 410 0.3 3 0.3 3000/35 6 1 4 min 14 sec
Sagittal PD-weighted FS 15 100 2.5 512 3 410 0.3 3 0.3 3000/35 7 1 3 min 13 sec
Coronal PD weighted 14 75 3 576 3 432 0.2 3 0.2 3500/35 5 1 2 min 53 sec
Coronal PD-weighted TD 12 84.4 2.7 512 3 346 0.2 3 0.2 2300/38 8 3 2 min 50 sec
Axial PD weighted 15 75 3 512 3 307 0.3 3 0.3 3000/38 6 1 2 min 24 sec
Oblique axial STIR 15 68.8 3.5 320 3 187 0.4 3 0.4 3760/65 16 2 2 min 29 sec

Note.—Sixteen-channel phased-array receive-only ankle-foot coil. FOV = field of view, FS = fat saturated, TD = talar dome, TE = echo time, TR = repetition time.

Table 2
MR Imaging of the Ankle at 1.5 T
Percentage Section Thickness In-plane TR (msec)/ Echo Train No. of Signals
Sequence FOV (cm) Phase FOV (mm)/Gap (mm) Matrix Resolution (mm) TE (msec) Length Acquired Acquisition Time

Sagittal PD weighted 11 1 3/0.2 416 3 320 0.26 3 0.34 3225/34 10 2 3 min 33 sec
Sagittal PD-weighted FS 15 1 3/0.3 384 3 320 0.39 3 0.47 3500/30 9 2 4 min 20 sec
Coronal PD weighted 15 0.75 3.5/0 480 3 320 0.31 3 0.47 4165/34 9 2 3 min 57 sec
Coronal PD-weighted TD 11 0.8 3/0.1 416 3 256 0.26 3 0.42 3065/30 10 3 3 min 28 sec
Axial PD weighted 15 0.7 3.5/0.5 480 3 320 0.31 3 0.47 4020/32 10 2 3 min 17 sec
Oblique axial STIR 15 0.7 4/1 384 3 192 0.39 3 0.78 3915/42 12 2 3 min 23 sec

Note.—Eight-channel phased-array receive-only ankle coil. FOV = field of view, FS = fat saturated, TD = talar dome, TE = echo time, TR = repetition time.

646 radiology.rsna.org  n Radiology: Volume 283: Number 3—June 2017

STATE OF THE ART: Acute Capsuloligamentous Sports Injuries in the Ankle and Foot Linklater et al

Figure 2
Figure 2:  Full-thickness tears of the ATFL, CFL,
and deep deltoid ligament in a 20-year-old profes-
sional rugby league player. (a) Axial PD-weighted
MR image shows acute midsubstance full-thickness
tear of the ATFL (arrow) and deep fibers of the del-
toid ligament (arrowhead). (b) Coronal PD-weighted
MR image shows acute midsubstance full-thickness
tear of the CFL (arrowhead) and deep fibers of the
deltoid ligament (arrow).

or absence of redundancy of ligament

fibers. While the relationship between
the MR appearance of scarred ligament
fibers and clinical laxity has not been
extensively studied, the MR findings of
ligament fiber discontinuity and redun-
dancy of ligament fibers are likely to be
associated with clinical laxity (Fig 4).
Chronic lateral ligament complex insta-
bility is usually diagnosed on the basis
of clinical history, physical examination,
and routine radiographs. MR imaging
may be indicated to assess for intra-ar-
ticular disease, which may also result in Figure 3
functional instability symptoms (5). MR
imaging has been demonstrated to have
reasonable levels of accuracy (76%–
84%) and specificity (83%–92%) in di-
agnosing chronic ATFL tear (6). When
they occur, false-negative findings tend
to involve chronic tears at the talar or
fibular attachment, rather than in the
midsubstance of the ligament (6). In
the setting of chronic tear, there is gen-
erally a reasonably sized residual ATFL
stump that can be used for anatomic
lateral ligament complex reconstruction
(Fig 4b) (7).
On MR images, the normal CFL is
homogeneously hypointense at all pulse
sequences (8) and is best assessed on
coronal images. Patterns of acute injury
and scar healing are similar to those
seen with ATFL injury (Fig 2). With
complete tear of the CFL, there is con-
tinuity between the ankle joint and the
peroneal tendon sheath, resulting in
fluid decompression from the ankle into
the peroneal tendon sheath. Figure 3:  Scar remodeling of the ATFL following prior tear in a 25-year-old rugby league player. (a) Axial
PD-weighted MR image shows maturing hypertrophic scarring of the ATFL (arrowheads), with small area
US Examination of residual incomplete ligament fiber discontinuity (arrow). Note ill-defined ligament margins, ligament
US also provides direct and accurate thickening, and intermediate signal intensity. (b) Axial PD-weighted MR image 10 months later shows mature
visualization of the ATFL (9,10) and al- scar remodeling of the ATFL, with reduction in the degree of ligament thickening and signal intensity and
lows dynamic assessment during plantar reconstitution and resumption of well-defined ligament margins (arrowheads).

Radiology: Volume 283: Number 3—June 2017  n  radiology.rsna.org 647

STATE OF THE ART: Acute Capsuloligamentous Sports Injuries in the Ankle and Foot Linklater et al

Figure 4
Figure 4:  Ineffective scar healing of the ATFL in
a 25-year-old professional soccer player. (a) Axial
PD-weighted MR image shows subacute complete
proximal tear of the ATFL (arrowhead indicates
site of ligament fiber discontinuity), with thickened
edematous, immaturely scarred distal stump
(arrow). (b) Axial PD-weighted MR image 3 years
later shows residual ligament fiber discontinuity at
the point of previously demonstrated tear (arrow-
head), with residual distal stump of reasonable size
(arrows).

flexion and inversion or during anterior

drawer stress (11). When oriented per-
pendicular to the ultrasound beam, the
normal ATFL is mildly echogenic and
has a fibrillar architecture. Acute com-
plete tears are seen as an anechoic cleft
in the ligament, with redundancy of the
proximal and distal fibers. The point of
tear may become more obvious at plan-
tar flexion and inversion or on applica-
tion of anterior translational stress to
the foot (Fig 5). Interstitial injuries may
manifest as mild ligament thickening, ill-
defined, reduction in echogenicity, and
increased periligamentous vascularity at
Figure 5 power Doppler US.
US examination of the CFL is more
technically difficult, requiring a small
footprint probe, with marked angula-
tion of the probe to demonstrate the
fibular attachment. The intact CFL will
elevate the peroneal tendons with ankle
dorsiflexion. The sonographic appear-
ance of CFL injuries is similar to that
of ATFL injury. If the CFL is torn, it will
not elevate the peroneal tendons during
ankle dorsiflexion.

Posttraumatic Synovitis, Fibrous

Bands, and Meniscoid Lesion
The hemarthrosis associated with a
lateral ligament complex injury predis-
poses to a posttraumatic synovitis in the
anterolateral gutter, which, over time,
may become coalescent and undergo
hyalinized fibrosis (Fig 6) (7,12). The
Figure 5:  Split-screen US images of the left and right ATFL demonstrate a full-thickness tear of the ATFL
at the fibular (Fib) origin (arrowheads). With the application of anterior translational stress to the foot (anterior hyalinized fibrotic tissue may be round/
drawer test), the full-thickness tear is more conspicuous and there is anterior translation of the talus (Tal, linear in morphology or become trian-
arrows), when compared with the neutral position. gular/meniscoid in shape if it molds to
the contour of the anterolateral gutter
(Fig 7) (13). During ankle dorsiflexion,

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STATE OF THE ART: Acute Capsuloligamentous Sports Injuries in the Ankle and Foot Linklater et al
the meniscoid lesion may impinge on
the anterolateral margin of the talar
dome, causing pain and limiting activ-
ity. Synovitis and scar tissue may result
in similar symptoms in the absence of
a true meniscoid lesion. Syndesmotic
ligament complex injuries can also be
complicated by anterolateral impinge-
ment due to hypertrophic scar response
and synovitis at the inferior margin of
the AITFL. The AITFL is amenable to
arthroscopic debridement if there is
a poor response to rehabilitation and
corticosteroid injection (12,14).
MR Imaging
On high-spatial-resolution PD-weighted
images, synovitis manifests as linear/fi-
liform or conglomerate foci of interme-
diate signal intensity in the anterolat-
eral gutter (Fig 6). As the fibrous band/
meniscoid lesion matures, it becomes
of lower signal intensity (Figs 7, 8) and
may extend medially into the anterior
recess (15). As long as a high-spatial-
resolution MR technique with adequate
image contrast is used, direct or indi-
rect MR arthrography is not necessary
for diagnosis (16). Osseous anterolater-
al impingement is usually readily differ-
entiated from soft-tissue impingement
lesions at MR imaging (15).
US Examination
US demonstration of hypoechoic thick-
ening and hyperemia in the antero-
lateral gutter have been suggested as
sonographic criteria for diagnosis of
anterolateral soft-tissue impingement
lesions (17); however, the sensitivity
of these criteria appears to be limited
(17,18).
Syndesmotic Ligament Complex Injury
The syndesmotic ligament complex
consists of the AITFL, IIOL, and PITFL
(Fig 1). The distal tibiofibular syndes-
mosis is contiguous with, and forms
part of, the ankle joint. Together with
the deltoid ligament it constitutes one
of the primary ligamentous stabilizers
of the ankle mortise.
Syndesmotic ligament complex in-
juries are also referred to as “high ankle
sprains” and represent approximately
Radiology: Volume 283: Number 3—June 2017  n  radiology.rsna.org 649
Figure 6
Figure 6:  Axial PD-weighted MR image in a
22-year-old professional rugby league player
presenting with anterolateral impingement symptom
3 months after lateral ligament complex injury and a
history of prior syndesmotic ligament complex injury
shows a posttraumatic synovitis in the anterolateral
gutter, manifest as ill-defined intermediate-signal-
intensity foci (arrows) within an anterolateral gutter
effusion. In addition, there are foci of immature
fibrous band formation (arrowheads).
1% of all ankle sprains (19). External
rotation of the foot in dorsiflexion is the
commonest mechanism for a syndes-
motic injury (20). The injury virtually
always commences anteriorly, with se-
quential disruption of the AITFL, IIOL,
and then the PITFL. Typically, the PIT-
FL tear commences at the posterolat-
eral rim of the tibial plafond, similar in
morphology to tears of the anterior gle-
noid labrum, often with an associated
posterior malleolar periosteal strip.
Osseous failure and resultant posterior
malleolar fracture may occur in syndes-
motic injuries, in which case the PITFL
will usually remain intact. More severe
syndesmotic injuries may involve the
deltoid ligament.
The injury may propagate proximally
and extend through the distal fibular
shaft, resulting in a Weber C fracture.
Alternatively, the injury may propagate
Figure 7
Figure 7:  Axial PD-weighted MR image through
the anterolateral gutter in a 28-year-old professional
rugby league player who had sustained a prior
lateral ligament complex injury and presented sub-
sequently with anterolateral impingement symptoms
demonstrates a meniscoid lesion (arrow).
further proximally through the inter-
osseous membrane and exit laterally
through a fibular neck fracture (Maison-
neuve fracture). Weber B fractures are
also commonly associated with syndes-
motic injuries (21).
Athletes with syndesmotic sprains
typically report pain with push off and
pain and difficulty with dorsiflexion. No
single clinical test has been shown to
reliably diagnose syndesmotic injury
(22). Syndesmotic ligament sprains are
associated with a substantially longer
recovery time compared with ankle
sprains (19,20,23). An early and accu-
rate imaging diagnosis is therefore crit-
ical to guide patient treatment.
With appropriate treatment, most
undisplaced or minimally displaced syn-
desmotic injuries respond well to con-
servative treatment, with satisfactory
scar reconstitution of the injured liga-
ments. Residual ankle stiffness, swell-
ing, and pain after return to full activity
may occur (23). Common findings at
arthroscopy in this setting include re-
sidual tear of the PITFL and chondral
STATE OF THE ART: Acute Capsuloligamentous Sports Injuries in the Ankle and Foot Linklater et al
Figure 8
Figure 8:  Mature fibrous band in a 35-year-old
woman 1 year after ankle sprain manifests as
anterolateral impingement symptoms. Sagittal
PD-weighted MR image shows a thick, mature
fibrous band in the anterolateral gutter of the ankle
(arrowheads), separate to a normal-appearing
multifascicular AITFL (arrows).
fracture at the posterolateral rim of the
tibial plafond, which often responds
well to arthroscopic debridement
(24). Chronic syndesmotic widening
and instability is uncommon (25,26).
Heterotopic ossification at the site of
prior syndesmotic injury is relatively
common (19,20,23). Occasionally, het-
erotopic ossification can be a source of
persistent pain in athletes (27,28).
Radiography
Conventional radiographs may be neg-
ative in the setting of a syndesmotic
ligament complex injury or merely
show a nonspecific effusion (21,29).
The tibiofibular clear space on either
weight-bearing anteroposterior view
or mortise view is the single most reli-
able criterion for assessment of align-
ment, with an upper limit of normal
being 6 mm, measured 1 cm above
the ankle joint (30,31). Side-to-side
comparison weight-bearing anteropos-
terior views can be helpful in perceiv-
ing subtle widening. Widening of the
medial ankle joint space indicates con-
comitant disruption of the deep fibers
of the deltoid ligament, usually indicat-
ing the need for surgical syndesmosis
stabilization.
650 radiology.rsna.org  n Radiology: Volume 283: Number 3—June 2017
Radiographic Stress Tests
Radiographic stress tests are not widely
used to assess for syndesmotic instabil-
ity and have limited utility (20).
CT Imaging
Axial CT through the distal tibiofibu-
lar syndesmosis can demonstrate sub-
tle abnormalities in static syndesmotic
alignment, which may remain occult to
conventional radiographic assessment
(32–34). The anterior syndesmotic in-
terval at the superior margin of the
anterolateral tubercle of the tibia is
normally less than 2 mm. The measure-
ment should be made at the narrowest
intercortical distance (33). An alterna-
tive approach involves measuring the
cross-sectional area of the syndesmotic
recess at this level (35). Criteria for CT
quantification of static sagittal plane ma-
lalignment and rotational malalignment
are still in evolution. Subjective assess-
ment may be facilitated by scanning
both ankles. Weight-bearing cone-beam
CT of the ankle provides a more func-
tional assessment of syndesmotic align-
ment. There are no published data on its
efficacy and utility in evaluating syndes-
motic instability. CT can also be useful in
assessing adequacy of reduction of dia-
stases following surgical treatment (36).
MR Imaging
The normal AITFL is best visualized
on coronal and sagittal PD-weighted
MR images as a uniformly hypointense
multifascicular structure. The oblique
orientation of the AITFL limits assess-
ment on straight axial images, and in-
complete demonstration of individual
fascicles on an axial image should not
be misinterpreted as a tear. Oblique ax-
ial images parallel to the AITFL can be
used to demonstrate the entire course
of the ligament and may improve inter-
pretation, although this is not routine
clinical practice at this time (37,38).
Use of volumetric acquisitions would fa-
cilitate reconstructions in the appropri-
ate plane without additional time pen-
alty. It is hoped that further reduction
in acquisition time and improvements
in image contrast will make volumetric
sequencing a practical option in routine
clinical MR imaging of the ankle.
Interstitial injury of the AITFL
manifests as mild ligament signal hy-
perintensity on PD-weighted or fat-
suppressed PD-weighted images.
Acute complete tears manifest as a
fluid signal intensity defect in the lig-
ament, often best appreciated on sag-
ittal or coronal images (Fig 9a). There
may be associated widening of the syn-
desmosis anteriorly. In the subacute
stage, intermediate- to low-signal-in-
tensity immature scar response begins
to bridge the point of tear (Fig 9b).
Scar tissue is often hypertrophic in
the early stages, resulting in ligament
thickening. Over time, remodeling of
the scar response may reduce the de-
gree of ligament thickening and result
in a more homogeneously hypointense
appearance. There is often loss of def-
inition of individual ligament fascicles
in the scar-reconstituted AITFL (Fig
9c). There may be protrusion of scar
inferiorly into the anterolateral gutter
and a resultant meniscoid lesion, pre-
disposing to anterolateral impingement
symptoms. Bony spurs may develop at
the tibial or fibular attachment.
The normal IIOL is best visualized
on coronal images. When a syndesmot-
ic injury is suspected, the MR imaging
protocol should include axial and co-
ronal images that extend superiorly to
include the entire IIOL (Fig 10). Acute
tibial avulsions of the IIOL may be asso-
ciated with a subperiosteal hematoma,
which may ossify.
The PITFL is the strongest com-
ponent of the syndesmotic ligament
complex and consists of deep and su-
perficial components. The deep fibers
of the PITFL are also known as the
transverse ligament (39). The inferior
component of the deep fibers extends
below the articular surface and is tri-
angular in cross-sectional morphology,
resembling a labrum. Injuries to the
PITFL usually commence at the tibial
attachment of the deep, inferior fibers
toward the lateral margin and are usu-
ally best visualized on sagittal images
(Fig 11) but can also be appreciated on
coronal and axial images (Fig 10). Sagit-
tal fat-suppressed PD-weighted or STIR
images will also demonstrate the fre-
quently associated posterior malleolar
STATE OF THE ART: Acute Capsuloligamentous Sports Injuries in the Ankle and Foot Linklater et al

Figure 9

Figure 9:  Phases of scar healing of an AITFL tear in a 21-year-old professional rugby league player who presented with ankle pain and swelling after an acute
external rotation ankle injury. (a) Sagittal PD-weighted MR image shows acute full-thickness tear of all fascicles of the AITFL (arrowheads). Note posttraumatic fibrous
bands and synovitis in the anterolateral gutter related to prior ATFL tear (arrow). (b) Sagittal PD-weighted MR image obtained 5 weeks after injury shows ill-defined
immature scar formation (arrows). (c) Sagittal PD-weighted MR image obtained 2 years later shows mature scar reconstitution (arrows) of the AITFL.

Figure 10 Figure 11 chondral lesion (24,40). Hypertrophic

scarring of the PITFL at the tibial at-
tachment may predispose to posterior
ankle impingement symptoms (24).
Bony overgrowth may develop at the
tibial attachment of the PITFL following
a syndesmotic injury.

Figure 10:  Coronal PD-weighted MR image in a
19-year-old professional Australian Rules football player
who presented with acute ankle pain and swelling after
an external rotation injury demonstrates full-thickness
tear of the IIOL (arrowheads) and moderate grade
partial-thickness tear at the tibial attachment of the
deep inferior fibers of the PITFL (arrows).
Figure 11:  Sagittal fat-suppressed PD-weighted
MR image in a 22-year-old recreational male soccer
player who presented with failure to progress 6
weeks after an ankle sprain. Image shows subacute
moderate grade partial-thickness tear of the tibial
attachment of the deep inferior fibers of the PITFL (ar-
row), with associated posterior malleolar bone marrow
edema and periosteal elevation (arrowheads).
bone marrow edema and periosteal
elevation (Fig 11). Often there will be
an adjacent posterolateral tibial plafond
US Imaging
Tears of the AITFL are well demon-
strated on US scans (Fig 12) (9,41).
Acute tears of the AITFL usually man-
ifest as an anechoic cleft. The syndes-
mosis may be widened anteriorly com-
pared with the contralateral side or
there may be widening on dorsiflexion
external rotation stress (Fig 12) (42).
At the subacute stage, immature scar
response results in a less well-defined
hypoechoic appearance. There may
be associated increased vascularity on
power Doppler scans, extending inferi-
orly into the anterolateral gutter.
Deltoid Ligament Injuries and Medial
Soft-Tissue Impingement
The deltoid ligament complex consists
of deep and superficial layers (Fig 13).
The deep fibers of the deltoid ligament

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STATE OF THE ART: Acute Capsuloligamentous Sports Injuries in the Ankle and Foot Linklater et al

Figure 12

Figure 12:  Split-screen transverse US images through the left and right AITFL during dorsi-flexion external rotation stress in a
19-year-old male rugby union player who presented with acute pain and swelling after eversion, external rotation injury. On the left,
there is full-thickness tear of the AITFL with mildly retracted redundant ligament stumps (arrows) and pathologic widening of the ante-
rior syndesmotic interval to 6.9 mm (large calipers). On the right, the AITFL is intact (arrowheads) and there is no syndesmotic widening
on dorsiflexion external rotation stress (2.9 mm) (small calipers).

Figure 13

Figure 13:  Diagram of the deltoid ligament anatomy. (a) The deep deltoid comprises anterior (1) and posterior (2) fibers. (b) The superficial deltoid consists of
tibiotalar (4) (variably present), tibiocalcaneal (5), tibiospring (6), and tibionavicular (7) portions. Also illustrated is the superomedial spring (3) ligament.

have been subdivided into an anterior
and posterior component. The poste-
rior component is relatively large and is
constant and multifascicular. Although
it has been described as the deep pos-
terior tibiotalar ligament, it is more
practical to call it the deep deltoid. The
anterior component is smaller and vari-
ably present, blending with the antero-
medial gutter capsule. Although it has
been called the deep anterior tibiotalar
ligament, it is more practical, when pre-
sent, to call it the anterior tibiotalar fas-
cicle. The superficial fibers of the deltoid
ligament consist of a broad, continuous
fan-shaped structure. Anatomists have
variably separated the fibers into differ-
ent components according to their distal
insertions. The tibiocalcaneal compo-
nent is variably present, variable in size,
and often relatively thin (43). The tibio-
spring component is uniformly present
and generally the largest constituent of
the superficial deltoid (43). The tibiona-
vicular component is often not apprecia-
ble on MR images. A superficial tibio-
talar ligament has also been described;
however, on MR images it is inseparable
from the deep deltoid.
Isolated deltoid ligament injuries
are rare. Most injuries to the deep
fibers of the deltoid ligament are asso-
ciated with a lateral ligament complex

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STATE OF THE ART: Acute Capsuloligamentous Sports Injuries in the Ankle and Foot Linklater et al

Figure 14 toward the talar insertion (45,49) and

may at times be difficult to appreciate.
Acute complete tears of the superfi-
cial deltoid ligament usually occur to-
ward the medial malleolar attachment
(45,49) and often extend to involve the
anterior aspect of the flexor retinacular
insertion on the medial malleolus (49).
Scarring of the deep fibers of the
deltoid ligament manifests as low signal
intensity at all pulse sequences, with
loss of the normal fibrillar architecture.
There are frequently associated foci
of ossification within the scarred liga-
ment. There may be protrusion of scar
response and synovitis into the medial
gutter, either posteriorly or anteriorly,
predisposing to posteromedial or an-
teromedial impingement symptoms
(Fig 14) (50–53). On axial MR images,
with the ankle in neutral alignment, the
Figure 14:  Images in a 21-year-old woman who presented with anteromedial impingement symptoms normal posterior margin of the deep
following ORIF of a Weber C fracture and syndesmosis stabilization. (a) Sagittal PD-weighted MR image fibers of the deltoid ligament is approx-
shows incompletely remodeled hypertrophic scarring of the anterior tibiotalar fascicle and anteromedial gut- imately level with the midaspect of the
ter capsule (arrows). (b) Axial PD-weighted MR image shows incompletely remodeled hypertrophic scarring posterior tibial tendon. If scar tissue in
at the tibial attachment of the superficial deltoid (arrowheads) and incompletely remodeled hypertrophic the medial gutter protrudes beyond the
scarring along the line of the anterior tibiotalar fascicle, with protrusion of scar response in to the antero- posterior margin of the posterior tibial
medial gutter (white arrow), accounting for the anteromedial impingement symptoms. Also note a meniscoid tendon, the patient may be at risk for
lesion in the anterolateral gutter (black arrow). posteromedial impingement symptoms
(15). Avulsion fractures of the postero-
medial process of the talus can mimic
injury (44). This presumably relates to ongoing medial pain due to a grumbling posteromedial soft-tissue impingement
a rotational impaction or crush injury desmitis/ligamentitis involving the deep on MR images (15).
mechanism during plantar flexion and and/or superficial deltoid fibers. There
inversion, analogous to that which re- may be protrusion of scar in to the an- US Imaging
sults in a medial talar dome osteochon- teromedial or posteromedial gutter and The deep fibers of the deltoid ligament
dral fracture. In this setting the pattern resultant impingement symptoms. are readily visualized deep to the pos-
of injury ranges from a purely contu- terior tibial tendon. The superficial
sional injury, through to partial tear MR Imaging deltoid is also well demonstrated on
and occasionally, complete tear. Higher Injury to the deep deltoid ligament is usu- US scans. US can reliably demonstrate
grade syndesmotic ligament complex ally evident on axial, coronal, and sagittal complete tears of the deltoid ligament
injuries may be associated with tears of pulse sequences, manifest as signal hy- but is less accurate in detecting partial
the deep deltoid, reflecting tensile over- perintensity, thickening of the ligament, tears (54). In the setting of subacute
load due to a valgus, external rotation and loss of the normal striated appear- injury, amorphous scar tissue and sy-
mechanism of injury (45). ance. There may be associated ligament novitis may be seen protruding into
The excellent healing potential of the fiber discontinuity (Fig 2). In the setting the medial gutter, with associated in-
deltoid ligament complex is reflected in of concomitant lateral ligament complex creased vascularity on power Doppler
the low incidence of valgus instability injury, there are frequently “kissing bone scans. Side-to-side comparison is help-
following chronic deltoid ligament tear contusions” at the posterior aspect of the ful in confirming the abnormality. Post-
(46). When it occurs, valgus ankle insta- medial malleolus and medial talar body traumatic ossicles are also well demon-
bility due to chronic deltoid ligament tear and neck. Talar dome chondral injuries strated on US scans.
can result in substantial morbidity and are commonly associated with medial
require surgical reconstruction to prevent kissing bone contusions (48).
secondary posterior tibial tendon dys- Complete tears of the deep deltoid Spring Ligament Injury
function (47). More commonly, patients ligament in the setting of syndesmotic The spring ligament complex is the ma-
with deltoid ligament injury experience ligament complex injury usually occur jor static stabilizer of the arch of the

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STATE OF THE ART: Acute Capsuloligamentous Sports Injuries in the Ankle and Foot Linklater et al

foot during midstance (55). It consists
of the superomedial calcaneonavicular
ligament, the medioplantar oblique
Figure 15
calcaneonavicular ligament, and the
inferoplantar longitudinal calcaneona-
vicular ligament (56). It may be simpler
to refer to these ligaments as the su-
peromedial, plantar oblique, and plan-
tar longitudinal fibers of the spring
ligament.
Acute spring ligament injuries in
the athlete are uncommon. When they
occur, they most commonly involve the
superomedial fibers (Fig 15) and may
extend to involve the dorsal talonavicu-
lar joint capsule (57). Their clinical im-
portance relates to an association with
posttraumatic planovalgus deformity
(47). Untreated medial ankle instability
may result in overload of the posterior
tibial tendon with resultant tendon de-
generation, elongation, and tear. Early
surgical correction may prevent this
progression.

Radiographs
Weight-bearing radiographs may be
normal or may demonstrate lateral per-
italar subluxation of the navicular (58).

MR Images
Figure 15:  Images in 45-year-old recreational athlete who presented with recent-onset medial ankle pain
The spring ligament complex is read-
and swelling, with mild hindfoot valgus that resolves with activation of the posterior tibial tendon. (a) Sagittal
ily demonstrated on MR images (59)
fat-suppressed PD-weighted MR image shows coronally oriented tear of the superomedial fibers of the
spring ligament toward the navicular insertion (arrows). (b) Axial PD-weighted MR image shows thickened (Tables 3, 4). The superomedial fibers
edematous superomedial fibers of the spring ligament (arrowheads) and nonretracted tear plane toward the are best seen on axial and coronal
navicular insertion (black arrows). Note intact posterior tibial tendon (white arrow). PD-weighted images as a uniformly

Table 3
MR Imaging of the Midfoot at 3 T
Percentage Section In-plane TR (msec)/TE Echo Train No. of Signals
Sequence FOV (cm) Phase FOV Thickness (mm) Matrix Resolution (mm) (msec) Length Acquired Acquisition Time

Sagittal PD-weighted FS 13 100 2 448 3 336 0.3 3 0.3 2350/43 9 1 3 min 10 sec
Long-axis PD-weighted FS 12 100 2 384 3 307 0.3 3 0.3 2300/30 7 3 2 min 38 sec
Long-axis PD weighted 12 100 2 448 3 358 0.3 3 0.3 3000/31 9 3 3 min 5 sec
Short-axis PD-weighted FS 11 100 2 384 3 307 0.3 3 0.3 3830/34 5 2 4 min 7 sec

Note.—Sixteen-channel phased-array receive-only ankle foot coil. FOV = field of view, FS = fat saturated, TE = echo time, TR = repetition time.

Table 4
MR Imaging of the Midfoot at 1.5 T
Percentage Section Thickness In-plane TR (msec)/TE Echo Train No. of Signals
Sequence FOV (cm) Phase FOV (mm)/Gap (mm) Matrix Resolution (mm) (msec) Length Acquired Acquisition Time

Sagittal PD-weighted FS 13 NPW 3.1/0.2 352 3 288 0.42 3 0.45 3000/33 8 2 3 min 39 sec
Long-axis PD-weighted FS 12 NPW 2.2/0.2 320 3 224 0.37 3 0.53 2800/33 8 2 2 min 41 sec
Long-axis PD weighted 12 NPW 2.2/0.2 320 3 256 0.37 3 0.47 3600/31 10 3 4 min 48 sec
Short-axis PD-weighted FS 13 0.75 3/0.5 352 3 288 0.37 3 0.45 3645/33 6 2 4 min 30 sec

Note.—Eight-channel phased-array transmit-receive knee coil. FOV = field of view, FS = fat saturated, NPW = no phase wrap, TE = echo time, TR = repetition time.

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Figure 16 talonavicular-middle subtalar joint

Figure 16:  Transverse tarsal joint sprain in a 19-year-old professional rugby league player who presented
with ongoing anterior ankle pain 2 months after plantar flexion inversion injury. (a) Sagittal PD-weighted MR
image shows incompletely remodeled hypertrophic scarring of the dorsal talonavicular joint capsule at the
level of the dorsal talonavicular ligament (arrows). (b) More lateral sagittal PD-weighted MR image shows
subtle incompletely remodeled scarring of the dorsal capsule of the calcaneocuboid joint at the level of the
dorsal lateral calcaneocuboid ligament (arrow).
hypointense structure arising from the
distal superomedial aspect of the sus-
tentaculum tali and inserting broadly
on the plantar medial margin of the na-
vicular. The plantar oblique and plantar
longitudinal fibers are best seen on ax-
ial images.
In the setting of an acute injury
to the superomedial fibers of the
spring ligament, PD-weighted or fat-
suppressed PD-weighted MR images
demonstrate thickening and signal hy-
perintensity (60,61). Tears are most
commonly oriented in the coronal
plane, occurring adjacent to the navic-
ular insertion and are best appreciated
on sagittal and axial images (Fig 15)
(47). Adjacent bone marrow edema at
the plantar medial aspect of the talar
head, although nonspecific, may be
present in the setting of acute spring
ligament tear (62).
US Images
The superomedial fibers of the spring
ligament can be demonstrated on US
images as a mildly echogenic, well-de-
fined structure deep to the distal fibers
of the posterior tibial tendon (63).
Ligament visualization is facilitated by
abducting and pronating the foot. An
accessory navicular can obscure visu-
alization of the superomedial spring
ligament on US images (64). Partial-
thickness tears manifest as thicken-
ing, hypoechoic change and loss of the
granular echotexture of the ligament,
with hyperemia on color Doppler im-
ages. Full-thickness tears may be seen
as a complete defect in the ligament
(64). In the limited published series
with surgical correlation, the efficacy
of US in demonstrating a discrete tear
plane has been limited (60).
Transverse Tarsal Joint Injury
The transverse tarsal joint complex
consists of the talonavicular and middle
subtalar joints medially and the calca-
neocuboid joint laterally. The trans-
verse tarsal joint acts synchronously
with the subtalar and ankle joints dur-
ing gait (65).
Talonavicular–Middle Subtalar Joint
Complex
The talonavicular and middle sub-
talar joints are in communica-
tion and are thus referred to as the
complex. Talonavicular-middle subta-
lar joint complex injuries usually follow
a plantar flexion-inversion injury and
can clinically mimic a lateral ligament
complex injury (65). Typically there is
injury to the dorsal talonavicular joint
capsule at the level of the dorsal ta-
lonavicular ligament, sometimes ac-
companied by a cortical flake avulsion
fracture at the talar head or navicular.
There may be an associated posttrau-
matic synovitis at the dorsal recess of
the talonavicular joint, with hyperemia
in the dorsal capsule on US scans. On
MR images, the dorsal talonavicular
joint capsule in the acute or subacute
phase is usually thickened and hyper-
intense on PD-weighted and fat-sup-
pressed PD-weighted sequences (Fig
16a). An avulsion fracture fragment
may be subtle on MR images but is
clearly depicted on lateral radiographs.
There will commonly be an associated
impaction injury at the plantar margin
of the talar head, usually only appre-
ciable on MR images, manifest as bone
marrow edema at the plantar margin
of the talar head, focal depression
of the subchondral plate, and a focal
overlying chondral lesion. Higher en-
ergy injuries may be associated with a
subtalar dislocation, with concomitant
tear of the interosseous talocalcaneal
ligament.
Calcaneocuboid Joint
The calcaneocuboid joint constitutes
the lateral portion of the transverse
tarsal joint complex (65). Transverse
tarsal joint complex injuries may be
associated with a range of calcaneocu-
boid joint injuries, including intra-ar-
ticular fracture of the anterior process
of the calcaneus, dorsal medial calca-
neocuboid ligament injury (lateral limb
bifurcate ligament), dorsal lateral cal-
caneocuboid ligament injury (Fig 16b),
calcaneocuboid joint subluxation, and
calcaneocuboid joint chondral injury
(66).
Cuboid subluxation has been re-
ported in ballet dancers presenting
with lateral midfoot pain, weak push-
off, inability to “work through the foot,”
and reproduction of pain with dorsally

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Figure 17

Figure 17:  Anatomy of the Lisfranc ligament complex and midfoot liga-
ments: (a) plantar and (b, c) dorsal views. The Lisfranc ligament complex
consists of dorsal oblique, interosseous, and plantar oblique fibers, which
run between the medial cuneiform and the base of the second and third
metatarsals.

often describe a “pop” in the foot at

directed digital pressure on the plan-
tar aspect of the cuboid (67). Dynamic
US with comparison assessment of the
contralateral side can be helpful in con-
firming the diagnosis and directing ap-
propriate surgical repair (68).
Lisfranc Ligament Injury
The Lisfranc ligament complex runs
obliquely between the medial cune-
iform (C1) and the base of second
metatarsal (M2) and is vital to the
support of the tarsometatarsal joint
complex because of the absence of a
1–2 intermetatarsal ligament (69). The
Lisfranc ligament complex consists
of dorsal oblique, interosseous, and
plantar oblique fibers (Fig 17). The
interosseous Lisfranc ligament is the
strongest constituent of the Lisfranc
ligament complex. The plantar oblique
(C1-M2M3) ligament is the second
strongest constituent of the Lisfranc
ligament complex and consists of a
strong superficial band that inserts on
the base of the third metatarsal (M3)
and a less substantial deep band that
inserts on the base of the second meta-
tarsal (M2) (70,71). Disruption of the
C1-M3 band has been reported to be
the single best predictor of instability
at examination under anesthesia (72).
The dorsal oblique Lisfranc ligament is
the least substantial component of the
Lisfranc ligament complex (70).
Low-energy Lisfranc ligament
complex injuries are relatively common
in athletes, particularly in the various
codes of football, basketball, and gym-
nastics (73,74). Injuries most com-
monly result from an axial longitudinal
force to the foot in a plantar-flexed and
slightly rotated position (75). Patients
the time of injury and midfoot pain ag-
gravated by weight bearing (76). The
clinical findings of a Lisfranc ligament
injury may be subtle, and up to 35%
of injures are initially misdiagnosed
or overlooked (77). Delays in diagno-
sis can result in midfoot instability and
secondary posttraumatic degenerative
arthrosis (78,79). Review of higher en-
ergy midfoot injury is beyond the scope
of this article.
Radiographs
Radiographic diagnosis of Lisfranc in-
jury relies on demonstrating abnormal
midfoot alignment or an enthesial Lis-
franc ligament flake avulsion fracture at
the C1-M2 interval (“fleck” sign) (80).
Radiographs are more sensitive when
obtained during weight bearing (81);
however, the ability to weight bear in
the acute setting is often limited. A
comparison anteroposterior view of
the contralateral foot is often helpful
in evaluating alignment. Widening of
the interval between the medial cune-
iform and second metatarsal base and
the bases of the first and second meta-
tarsals are the most common and reli-
ably detected abnormalities in Lisfranc
injuries. A side-to-side difference of

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Figure 18

Figure 18:  Images in a 28-year-old semiprofessional rugby player who

presented with acute midfoot pain following axial load injury sustained during
a tackle. Weight-bearing radiographs obtained elsewhere had been reported
as normal. (a) Axial PD-weighted MR image shows full-thickness tear of the
interosseous Lisfranc ligament (arrow). (b) A more plantar axial PD-weighted
MR image shows complete full-thickness tear of the C1-M3 ligament (arrow).
(c) Image from examination under anesthesia during application of an abduc-
tion stress demonstrates lateral subluxation of the bases of the first and second
metatarsals (arrows) in relation to the adjacent cuneiforms.

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STATE OF THE ART: Acute Capsuloligamentous Sports Injuries in the Ankle and Foot Linklater et al
greater than 2 mm has been suggested
as an indication for surgical midfoot re-
duction and stabilization (75).
There is some variation in the ap-
proach to the imaging assessment and
management of subtle Lisfranc ligament
complex injuries, in which there is no
or minimal displacement on weight-
bearing radiographs. Some surgeons
find stress radiography under anes-
thesia useful in determining whether
to internally fix the midfoot (Fig 18)
(72). Some surgeons prefer CT to de-
tect subtle avulsion fractures or dis-
placement not evident on radiographs.
Others advocate the use of MR imag-
ing to determine the extent of capsulo-
ligamentous injury and help determine
whether examination under anesthesia
is indicated.
CT Images
CT is more sensitive than radiography
at demonstrating midfoot fractures and
subtle abnormalities in alignment in
the setting of Lisfranc ligament injury.
CT is particularly recommended in pa-
tients who have high-velocity midfoot
fractures or when fractures other than
small avulsion fractures are evident on
initial radiographs (82).
MR Images
High-spatial-resolution (2.0 3 0.3 3
0.3 mm) two-dimensional PD-weight-
ed and fat-suppressed PD-weighted or
STIR sequences in the long and short
axes of the midfoot can reliably dem-
onstrate the interosseous Lisfranc
ligament and the plantar oblique C1-
M2M3 ligament (83–86) (Tables 3, 4).
Volumetric fast spin-echo/turbo spin-
echo or gradient-echo pulse sequences
potentially offer higher spatial resolu-
tion and have been shown to increase
the number of minor midfoot ligaments
demonstrable at MR imaging (83), al-
though there has been no demonstrated
improvement in the assessment of mid-
foot stability.
In the acute setting, an interstitial
injury of the Lisfranc ligament man-
ifests as mild signal hyperintensity on
PD-weighted and fat-suppressed PD-
weighted or STIR images. Partial vol-
ume artifact associated with oblique
658 radiology.rsna.org  n Radiology: Volume 283: Number 3—June 2017
sampling of a bifascicular interosseous
Lisfranc ligament may simulate a low-
grade strain on long-axis images. This
can be clarified by correlation with
short-axis images. An acute complete
tear of the interosseous Lisfranc liga-
ment will be seen as a fluid signal in-
tensity defect in the ligament. A similar
spectrum of findings may be seen in re-
lation to the plantar oblique C1-M2, M3
ligament (Fig 18). Injury to the dorsal
oblique Lisfranc ligament is usually best
appreciated on short-axis images. Flake
avulsion fracture fragments are often
difficult to appreciate at MR imaging
and may be misdiagnosed as bone con-
tusions (82). The MR imaging report
should also comment on the integrity
of the tarsometatarsal joint capsules
and intermetatarsal and intercuneiform
ligaments, all of which may be injured
in association with Lisfranc ligament
complex injury.
First MTP Joint Capsuloligamentous
Injury (“Turf Toe”)
Injuries to the first metatarsophalan-
geal (MTP) joint capsuleligamentous
complex are relatively common in ath-
letes and may involve the collateral lig-
aments, plantar or dorsal capsule. The
first MTP joint experiences significant
load with running (two to three times
body weight) and jumping (eight times
body weight) (87). The medial and
lateral sesamophalangeal ligaments
(plantar plates) and the medial and
lateral sesamoids help to withstand
these stresses. The sesamoids articu-
late with articular facets at the plantar
margin of the first metatarsal head and
are linked by the intersesamoid liga-
ment. The medial collateral ligament
complex provides stability to valgus
stress, consisting of the medial collat-
eral ligament proper and the medial
sesamoid collateral ligament (meta-
tarsosesamoid ligament). The lateral
collateral ligament complex provides
stability during varus stress, consist-
ing of the lateral collateral ligament
proper and the lateral sesamoid collat-
eral ligament (metatarsosesamoid liga-
ment). The medial and lateral plantar
plates (sesamophalangeal ligaments),
two heads of flexor hallucis brevis,
abductor and adductor hallucis, and
the flexor hallucis longus tendon pro-
vide dynamic stability to dorsiflexion
stress. The insertion of the extensor
hallucis brevis tendon onto the dorsal
capsule and the extensor hallucis lon-
gus tendon help provide dynamic sta-
bility to plantar flexion stress.
A rising incidence of first MTP
joint capsular injury was first noted in
sports played on an artificial surface
(88). The term turf toe is now used to
cover a broad spectrum of capsuloliga-
mentous injury to the first MTP joint
(89). The most common mechanism
of injury is a valgus-hyperextension
force, resulting in disruption of the
first metatarsal head insertion of the
medial collateral ligament complex,
sometimes accompanied by extension
of the tear plane to involve the medial
sesamophalangeal ligament, with com-
plicating acute hallux valgus deformity
(90). Pure hyperextension injuries may
occur, resulting in isolated disruption
of the sesamophalangeal ligaments
(plantar plates), proximal migration
of the sesamoids, and chondral injury
at the dorsal aspect of the MTP joint
due to a concomitant axial load. Less
commonly, there may be a varus force,
resulting in tear of the lateral collat-
eral ligament and hallux varus defor-
mity (91). Hyperflexion injuries sus-
tained while playing beach volleyball
have been termed “sand toe” and are
usually associated with dorsal capsular
injury to the first MTP joint (92).
Some athletes with first MTP joint
capsuloligamentous injury will experi-
ence ongoing disabling symptoms that
may limit return to competition (93).
While lower grade injuries can be man-
aged conservatively, elective early sur-
gical intervention in higher grade in-
juries with anatomic primary repair of
the torn capsuloligamentous structures
can restore stability, allowing a full re-
turn to athletic activity (94).
Radiographs
Routine radiographs of the great toe
consist of anteroposterior weight-
bearing and lateral and oblique non–
weight-bearing views (91). In the
STATE OF THE ART: Acute Capsuloligamentous Sports Injuries in the Ankle and Foot Linklater et al

Table 5
MR Imaging of the First MTP Joint at 3 T
Percentage Section In-plane TR (msec)/ Echo Train No. of Signals
Sequence FOV (cm) Phase FOV Thickness (mm) Matrix Resolution (mm) TE (msec) Length Acquired Acquisition Time

Sagittal PD weighted 6 100 1.2 320 3 224 0.2 3 0.2 2520/41 7 2 3 min 36 sec
Sagittal PD-weighted FS 6 100 1.2 256 3 218 0.2 3 0.2 2400/39 7 2 3 min 23 sec
Long-axis PD-weighted FS 7 100 1.2 320 3 224 0.2 3 0.2 2300/38 7 2 3 min 19 sec
Long-axis PD weighted 7 100 1.2 384 3 269 0.2 3 0.2 2700/41 7 2 4 min 34 sec
Short-axis PD weighted 6 100 2 320 3 288 0.2 3 0.2 2300/40 9 2 4 min10 sec
Short-axis PD-weighted FS 6 100 2 256 3 230 0.2 3 0.2 3100/48 9 2 3 min 23 sec

Note.—Sixteen-channel wrist coil, if possible; otherwise, four-channel flex coil or loop coil. FOV = field of view, FS = fat saturated, TE = echo time, TR = repetition time.

Table 6
MR Imaging of the First MTP Joint at 1.5 T
Percentage Section In-plane TR (msec)/ Echo Train No. of Signals
Sequence FOV (cm) Phase FOV Thickness (mm) Matrix Resolution (mm) TE (msec) Length Acquired Acquisition Time

Sagittal PD-weighted 8 0.8 2 384 3 288 0.21 3 0.28 3850/28 10 2 3 min 12 sec
Sagittal PD-weighted FS 8 0.8 2 384 3 256 0.21 3 0.31 3100/28 8 2 3 min 25 sec
Long-axis PD-weighted FS 8 NPW 2 384 3 256 0.21 3 0.31 3200/28 8 2 3 min 31 sec
Long-axis PD weighted 8 NPW 2 384 3 256 0.21 3 0.31 2875/28 8 2 3 min 9 sec
Short-axis PD weighted 8 0.8 2 320 3 256 0.25 3 0.31 3625/28 8 2 3 min 16 sec
Short-axis PD-weighted FS 8 0.8 2 256 3 224 0.31 3 0.36 3500/28 8 2 2 min 55 sec

Note.—Quadrature single-channel receive-only wrist coil. FOV = field of view, FS = fat saturated, TE = echo time, TR = repetition time.

setting of acute trauma it is helpful
to image both first MTP joints on the
weight-bearing anteroposterior view,
increasing conspicuity of subtle prox-
imal retraction of the sesamoids as-
sociated with sesamophalangeal liga-
ment (plantar plate) disruption (95).
Radiographs may also detect capsular
avulsion fractures, impaction fractures
of the metatarsal head, malalignment,
sesamoid fractures and retraction.
Commonly, however, radiographs will
be normal (91).
MR Images
MR imaging of the first MTP joint is
the preferred imaging modality for
the assessment of capsuloligamen-
tous trauma, chondral and osteochon-
dral pathology, and sesamoid injuries
(96,97). Dedicated imaging of the
first MTP joint with appropriate sur-
face coils facilitates a high-resolution
technique (Tables 5, 6). A section
thickness of approximately 2 mm is
ideal for sagittal and long-axis images the medial collateral ligament proper
with an in-plane resolution of 0.3 mm (metatarsophalangeal ligament). In late
for PD-weighted and 0.6 mm for fat- subacute and chronic cases, if there is
suppressed PD-weighted sequences. successful scar healing, no residual tear
The orientation of the first MTP joint plane will be evident.
differs from that of the lesser MTP
joints. Sagittal and long-axis images of
the first MTP joint must be prescribed Conclusion
off a short-axis image, perpendicular The ankle and foot are commonly
to the intersesamoid axis for the sag- injured during sporting activities. In
ittal pulse sequence or parallel to the the athlete, there is a reduced thresh-
intersesamoid axis for the long-axis old for imaging to clarify diagnosis
pulse sequence. and guide prognosis and treatment.
In the acute setting, complete lig- Diagnostic imaging is also helpful in
ament tears are usually of fluid signal evaluating ongoing symptoms in the
intensity on PD-weighted and fat-sup- subacute or chronic setting. A sub-
pressed PD-weighted images, while stantial proportion of injuries will
interstitial tears are of intermediate remain occult to radiographic assess-
signal intensity (Fig 19). Sagittal im- ment, requiring further imaging with
ages best depict tears of the medial US, CT, or MR imaging. Early MR
and lateral sesamophalangeal ligaments imaging of the sprained ankle in the
(plantar plate). Short-axis images best athlete is now commonly performed
demonstrate tears of the sesamoid col- to distinguish between injury to the
lateral (metatarsosesamoid) ligaments. lateral ankle ligament complex, syn-
Long-axis images best depict tears of desmotic ligament complex, and

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STATE OF THE ART: Acute Capsuloligamentous Sports Injuries in the Ankle and Foot Linklater et al

raphy and MR imaging. Skeletal Radiol

Figure 19
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Figure 19:  Sagittal PD-weighted MR images in a 28-year-old professional rugby league player who
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Disclosures of Conflicts of Interest: J.M.L.
and validity of magnetic resonance imaging
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