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Pictorial Essay

MR Imaging of the Foot: Utility of Complex Oblique

Imaging Planes
David A. Rubin1, Jeffrey D. Towers, Cynthia A. Britton

functions in the plane of the scapula (oriented approximately

Successful MR imaging of the foot presents special chal-
lenges to the radiologist. Accurate and confident diagnosis 450 to the sagittal and coronal planes of the body), MR imag-
presupposes the ability to produce high-resolution images of ing in the oblique sagittal and coronal planes is routine.
obliquely oriented, relatively small structures. Orienting the
These oblique axes still lie perpendicular to the transaxial
foot within an appropriate local coil to bring such structures
plane and are prescribed graphically from a transverse
into an orthogonal imaging plane, or even into a conventional
image. To encode for an oblique series, two of the three
oblique plane, may be impossible or intolerably uncomfortable
for the patient. The frequent result is motion artifacts, which are orthogonal gradient coils are activated simultaneously.
accentuated when using a small field of view. However, when Standard oblique planes are not sufficient when a struc-
patients are comfortably positioned, the anatomy of interest ture of interest lies in a plane that is not orthogonal to any
often lies in a plane that is not orthogonal to any of the conven- standard plane. Such is the case with the midfoot and fore-
tional imaging planes. Fortunately, commercially available MR foot (Fig. 1). The hindfoot bones are oriented almost sagit-
imaging equipment can produce images in complex oblique tally, whereas the metatarsal heads lie in a coronal plane.
planes with relative ease. In this pictorial essay, we discuss the The midfoot lies oblique to the hindfoot and forefoot. The
technical considerations for expedient diagnostic MR imaging
metatarsals form an arch whose pitch and orientation con-
of the complex anatomy of the foot and illustrate our experi-
stantly change from the midfoot to the metatarsophalangeal
ences with this technique.
joints; the metatarsal bones may diverge slightly as well.
Last of all, the orientation of the phalanges to the metatar-
When a patient lies within the tubular bore of an MR scan- sals and to each other may be altered by deformities such as
ner, a section perpendicular to the long axis of the body is hammer toes. The result is that no orthogonal plane or sim-
called a transaxial plane. Transaxial images are obtained by pIe oblique plane fully describes the longitudinal axis of mid-
switching on the z-axis gradient coil during the slice-selec- foot or forefoot structures. Even turning the extremity-
tion portion of a pulse sequence. Standard sagittal and coro- which, because of limited space in a scanner, may be ana-
nal planes are similarly encoded during slice selection. tomically impossible or uncomfortable-cannot properly on-
These standard planes suffice for most musculoskeletal MR ent the entire foot for imaging. Our solution is to position
imaging. An extremity also may be turned so that relevant patients comfortably and then choose imaging planes based
anatomy lies within a standard plane. For example, we on the anatomy of interest. We refer to these as complex
examine the knee in slight external rotation, which is a com- oblique planes because they are oblique with respect to all
fortable resting position for most patients and which orients three standard orthogonal planes, and they must be graphi-
the anterior cruciate ligament in the sagittal imaging plane. cally prescribed from an oblique image rather than an
For some body parts, imaging in one of the standard orthogonal image. Slice encoding for a complex oblique
planes is impractical. Because the shoulder, for instance, imaging plane requires activation of all three gradient coils.

Received August 24, 1995; accepted after revision November 1 , 1995.

1 All authors: Department of Radiology, University of Pittsburgh Medical Center, 200 Lothrop St. , Pittsburgh, PA 1521 3. Address correspondence to D. A. Rubin.

AJR i996;166:i079-i084 036i-803X196/1665-i079 © American Roentgen Ray Society

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Fig. 1 .-Planes of foot.

A, Drawing of foot with sagittal and coronal planes depicted. Note different orientation of midfoot and hindfoot.
B and C, In forefoot, prescribing simple oblique sagittal plane from transaxial MR image (B) results in images that lie oblique to plane of individual
metatarsals and display parts of separate bones (C, compare with Figs. 3H and 31). M2 = second metatarsal base, M3 = third metatarsal head.

Technique recalled series), the desired complex oblique plane can be

All our studies were performed with a 1 .5-T Signa MR quickly obtained. We then perform the necessary diagnostic
system (GE Medical Systems, Milwaukee, WI) with stan- sequences in that plane, limiting coverage to the area of inter-
dard software (4.8x or 5x) and local coils. Current MR soft- est. Using this strategy, we often image for 10 mm or less
ware simplifies the prescription of complex oblique series. (Figs. 3 and 4). Even allowing time for patient positioning and
When a sequence is graphically prescribed, the reference additional diagnostic imaging sequences for other abnormali-
image and its axes become the frame of reference for the ties, we can do the complete examination in 30 mm. Without
prescribed series. If the reference image lies in a simple the complex oblique technique, 30 mm can be spent reposi-
oblique plane, then prescribing a series of images oblique
to it will result in images that are in a complex oblique
(sometimes called double-oblique) plane. For example, to
diagnose pathology within a single ray of the foot (the meta-
tarsal, phalanges, and intervening joints of one toe), we
generate long-axis images along the bones, which are per-
pendiculan to the joints by the following technique: Oblique
transverse (short-axis) images are prescribed from a sagit- F.
tal localizer perpendicular to the metatarsals (Figs. 2A-C).
MT P
Complex Oblique coronal images are prescribed through
the metatarsals from the resultant oblique axial images (Fig.
2E). In turn, these images are used to prescribe the com-
plex oblique sagittal images for diagnosis (Fig. 2F). Alterna-
tively, to investigate relationships among the bones of
adjacent rays (e.g. at the Lisfranc’s
, joints), we image in a
complex oblique coronal
scnibed from an oblique transaxial
plane (Fig. 2D) that is again pre-
image (Fig. 2C). Figures
__
2 and 3 illustrate the entire procedure. Referring clinicians Fig. 2.-Diagram showing acquisition of various complex oblique planes.
Patients are positioned comfortably either supine (A) or prone (B). Sagittal
at our institution find these images to be a useful road map, sequence is used to prescribe oblique transaxial (short axis) acquisition
especially in cases where surgical intervention is required. perpendicular to either midfoot or metatarsals (C). From oblique transaxial
images, complex oblique coronal plane may be chosen, for example, to
The necessity of mentally reconstructing anatomy by tracing
show medial structures (D) or lateral structures (E) of foot Note that center-
structures through multiple images and series is eliminated ing of subsequent oblique images (e.g., midfoot or forefoot) will depend on
because both the relevant pathology and the surgical land- location of image used for graphic prescription. We use former (D) to diag-
nose pathology of navicular bone and talonavicular relationship In midfoot
marks are often clearly displayed on a single image. (using midfoot oblique axial image for graphic prescription) and of first and
Producing several preliminary series simply to generate the second metatarsals and cuneiforms at midfoot-forefoot junction. Plane
appropriately oriented imaging plane may seem inefficient. illustrated in E is ideal for metatarsals, phalanges, and cuboid. Additional
complex oblique sagittal images (F) along long axis of individual metatarsal
However, by using relatively fast, preliminary sequences or phalanx can then be prescribed from complex oblique coronal images.
(short-repetition-time spin-echo or low-flip-angle gradient- MT = metatarsal, N = navicular, P = proximal phalanx, I = talus.
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Fig. 3.-Collegiate basketball player with pain over second metatarsal.

A, Plain films are normal. Two days following radiographs, MR imaging was performed with patient prone, ankle plantar-flexed, and 12.7-cm circular coil
under dorsum of foot. Total imaging time for four sequences was almost 9 mm.
B, Series 1 : Initial Ti-weighted sagittal image (400116 [TRITE]; matrix size, 192 x 256; one excitation; scan time, 83 see).
C and 0, Series 2: Ti-weighted oblique axial sequence (C, 400/14; matrix size, 192 x 256; two excitations; scan time 157 see) graphically prescribed along
short axis of foot from sagittal image (D). Asterisk = vitamin E capsule used as marker.
E.-G, Series 3: Ti-weighted complex oblique coronal sequence (E, with same imaging parameters as series 2), graphically prescribed from oblique axial
image (F) is automatically oblique to initial sagittal plane (G). Note that focal marrow abnormality (arrowhead in E) in second metatarsal shaft represents hem-
orrhage or edema at fracture site.
H-K, Series 4: Fat-suppressed fast spin-echo images (2000/90; matrix size, 128 x 256; four excitations; scan time, 132 see) of second metatarsal (H) and nor-
mal third metatarsal for comparison (1) demonstrates edema throughout shaft of second metatarsal, most intense in mid diaphysis, accompanied by edema in
adjacent periosteum and surrounding soft tissues. These images in true long axis of metatarsals (compare with 3B) were graphically prescribed from complex
oblique coronal series (J). Cross-referencing series 4 from oblique axial image (K) shows that series 4 is also oblique to this oblique axial plane. Asterisk = vita-
mm E capsule used as marker.
L, Radiograph 6 weeks later demonstrates healing stress fracture with periosteal (arrows) and endosteal new bone along second metatarsal shaft in same
location as shown by earlier MR study.
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Fig. 4.-Midfoot MR examination in dancer with suspected occult injury to Lisfranc’s joint.
A, Prescription for oblique axial sequence from sagittal localizer. Ca = calcaneus; N = navicular.
B, Prescription for complex oblique coronal series from oblique axial image.
C, Resultant fat-suppressed fast spin-echo image (2000/72 [TRITE]; matrix size, 256 x 256; four excitations; scan time, 260 5cc) shows normal ana-
tomic relationships, no edema, and intact Lisfranc’s ligament (arrowhead). Total imaging time for all sequences was less than 10 mm. ci = medial
cuneiform, C2 = intermediate cuneiform, Mi = first metatarsal, M2 = second metatarsal.

tioning the patient and repeating series where motion artifact radiographs are normal, a patient will refrain from activity and
due to an uncomfortably positioned patient yielded nondiag- radiographs will be repeated in approximately 2 weeks. At this
nostic images. time, callus should be visible. In high-performance athletes,
Because all three gradient coils must be activated simulta- however, refraining from practice and competition seems
neously, complex oblique imaging is inherently demanding unwarranted when a stress fracture is not present. In these
of gradient power. At times, successful imaging will necessi- selected patients, MR imaging in the plane of the painful
tate compromises in other imaging parameters that tax the metatarsal allows confident diagnosis well before plain film
gradient subsystem. These compromises include use of thin findings are evident [2] (Fig. 3). We prefer MR imaging to scm-
sections, a small field of view, short echo times, and a fast tigraphy, because the former can often demonstrate other
spin-echo sequence, which are often used in combination causes of pain, such as a distended intermetatarsal bursa or
[1]. As with any high-resolution extremity imaging, use of an interdigital neuroma [3], if a stress fracture is not found.
appropriate local coil is mandatory to ensure an adequate Midfoot injuries can also be evaluated with complex oblique
signal-to-noise ratio. For most patients we use a standard MR imaging. For instance, with injuries to the tarsometatarsal
send/receive whole-volume extremity coil, which provides a (Lisfranc’s) joints, which may occur during athletic activity and
homogeneous receptive field across the entire cross-section produce low-grade sprains of the Lisfranc’s ligament, radio-
of the foot. If the area of interest cannot be comfortably posi- graphs are normal [4]. The ligament is readily identifiable on
tioned in this coil (because of the size of the extremity or dis- MR images in the plane of the medial and intermediate cunei-
comfort due to the coil), we use a circular surface coil form bones (Fig. 4). Navicular stress fractures and the painful
centered over the suspected pathology. Although the recep- accessory navicular syndrome are also common injuries in
tive field of a circular surface coil is smaller and less homo- young athletes [5]. Although appropriately oriented MR
geneous than the receptive field of a whole-volume coil, the images can distinguish these two entities (Fig. 5), whose
high signal-to-noise ratio close to the face of the surface coil treatment often differs [6], distinguishing them with the rela-
is useful when examining relatively superficial structures tively low resolution of nuclear scintigraphy is difficult.
such as surface masses or metatarsal bones [1]. Forefoot osteomyelitis, especially in diabetic patients, may
also be difficult to distinguish clinically from other forefoot infec-
tions (cellulitis, soft-tissue abscess, infectious osteitis) or nonin-
Examples
fectious abnormalities (neuropathic arthropathy, malalignments).
We are frequently asked to examine a patient’s foot when MR imaging can aid diagnosis [7] by depicting the extent of bony
radiographically occult trauma is suspected. In the forefoot, and soft-tissue abnormality. Especially in cases where deformity
this usually involves metatarsal stress fractures. In most is present, we rely on complex oblique images that are oriented
cases, when the diagnosis is suspected and conventional along the bone orjoint in question (Fig. 6).
 AJR:i66, May 1996 MR IMAGING OF THE FOOT 1083
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,1’ -

Fig. 5.-i7-year-old soccer player with previous tarsal navicular stress fracture and recurrent midfoot pain. Increased activIty in medial navicular
bone on bone scan (not shown) was interpreted as another stress fracture.
A, Prescription for oblique axial series from sagittal Iocallzer.
B, Prescription for complex oblique sequence through navicular bone (contrast with plane chosen for Lisfranc’s joints In Fig. 4B). A = accessory
navicular bone, C = calcaneus, N = navicular bone.
C, Complex oblique coronal fat-suppressed fast spin-echo image shows deformity in navicular bone from previously healed stress fracture (arrows)
and, within accessory navicular bone and adjacent medial process of tarsal navicular, edema, which Is characteristic of painful accessory tarsal navic-
ular syndrome. A = accessory navicular bone, N = navicular bone, 1= talus.

Fig. 6.-Diabetic patient with hyperextension deformities of second and third metatarsophalangeal (MW) joints. Clinical question was whether deformities
were dueto infection. Because proximal phalanges were subluxated laterally and dorsally, metatarsaland proximal phalanx ofeach toe did nellie in single plane.
A, Oblique coronal Ti-weighted MR image(600/i6 [lB/TEl), derived from transaxial image, to be used as localizer for complex oblique sagittal sequence. 2 =
second metatarsal, 3 = third metatarsal.
B, Complex Oblique sagittal Ti-weighted MR image(5001i8)through second MTPjomnt shows marrow edema and cortical destruction of metatarsal head and
proximal phalanx, dorsal dislocation of MTPjomnt, and thickened mntermediate-signaHntenslty soft tissues. Septic arthritis with osteomyelltis of both bones was
found at surgery. M = metatarsal, P = proximal phalanx
C, MR image with parameters identical to Bshows adjacent third MW joint is subluxated, although bones show normal marrow and cortices. Superficial ccl-
lulitis effaces subcutaneous fat under metatarsal head. M = metatarsal, P = proximal phalanx.
 1084 RUBIN ET AL. AJR:166, May 1996
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Fig. 7.-37-year-old man with mass on dorsum of midfoot and second mass on dorsum of forefoot.
A, Oblique axial fat-suppressed fast spin-echo image through midfoot mass discloses fluid-filled cyst (arrow) arising adjacent to extensor digitorum
brevis muscle belly. Fluid is incidentally noted within sheath of flexor hallucis longus muscle (curved arrow). CU = cuboid, EDB = extensor digitorum
brevis muscle, N = navicular bone. Asterisk = vitamin E capsule used as marker.
B, Oblique axial image through forefoot shows fluid collection encircling extensor digitorum longus tendon to second toe (arrow). Asterisk = vita-

mm E capsule used as marker, i-S = first through fifth metatarsals.

C, Complex Oblique sagittal short-TI inversion recovery MR image oriented along extensor digitorum longus tendon shows fluid distending sheath
of tendon. At surgery, ganglion cyst was found arising from extensor digitorum brevis sheath of second toe, penetrating extensor digitorum longus
sheath, and extending into forefoot. LC = lateral cuneiform, N = navicular bone, I = talus.

Most masses of the foot can be imaged in standard planes REFERENCES

[8], but we have found the complex oblique imaging sections 1 . Rubin DA, Kneeland JB. MR imaging of the musculoskeletal system: techni-
helpful when a mass is closely associated with an obliquely cal considerations for enhancing image quality and diagnostic yield. AJR
oriented structure, such as digital tendon sheaths (Fig. 7) or i994;1 63:1155-1163
plantar fascia. 2. Lee JK, Yao L. Stress fractures: MR imaging. Radiology i988;i69:217-220
3. Erickson Si, Canale PB, Carrera GF, et al. Interdigital (Morton) neuroma:
The forgoing discussion illustrates only a few examples
high-resolution MR imaging with a solenoid coil. Radiologyi99l;181:833-836
of the ease and power of the complex oblique technique. 4. Curtis MJ, Myerson M, Szura B. Tarsometatarsal joint injuries in the ath-
We routinely use this technique for virtually all midfoot and lete. Am J Sports Med 1993:21:497-502
forefoot MR imaging and will often supplement hindfoot exami- 5. MillerTL, Staron RB, Feldman F, Parisien M, Glucksman WJ, Gandolfo LH.
The symptomatic accessory tarsal navicular bone: assessment with MR
nations (e.g., those done for posterior tibial tendon abnormali-
imaging. Radiology 1995:195:849-853
ties) with a complex oblique sequence prescribed along the 6. Mygind HB. The accessory tarsal scaphoid: clinical features and treat-
long axis of the structure in question. We use an analogous ment. Acta Orthop Scandi953;23:i42-isi
approach for MR imaging of the hand, finger, and elbow 7. Moore TE, Yuh WTC, Kathol MH, El-Khoury GY, Corson JD. Abnormalities of
selectively in cases where conventional orthogonal or the foot in patients with diabetes mellitus: findings on MR imaging. AJR
1991157:813-816
oblique images do not adequately demonstrate the anat-
8. Keigley BA, Haggar AM, Gaba A, Ellis BI, Froelich JW, Wu KK. Primary
omy of interest. tumors of the foot: MR imaging. Radiology 1989:171:755-759