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Pictorial Essay

Abnormalities of the Foot and Ankle: MR Imaging Findings

Patrik Aerts1 and David G. Disler

Although plain film radiography remains the appropriate specific, is often not sensitive in the early detection of stress
imaging technique used in the initial evaluation of ankle and foot fractures. Bone scintigraphy is sensitive, yet nonspecific.
disorders, MR imaging has rapidly become important because It Because of their ability to depict subtle changes in the bone
provides high soft-tissue contrast and multlplanar capability,
marrow, MR images can show acute fractures that are occult on
and because it can detect subtle marrow abnormalities. MR
conventional radiognaphs (Fig. 3). Depiction of growth plate
imaging is most useful for evaluating pathologic processes that
injury is easily shown by MR imaging, which is accurate in dem-
involve soft-tissue structures and for evaluating patients whose
clinical findings remain unexplained despite normal findings onstrating the physeal component of such fractures (Fig. 4).
with other imaging techniques. This pictorial essay illustrates Complications oftrauma can also be determined with MR imag-
various applications for MR imaging of the foot and ankle. ing, including osteomyelitis, fracture nonunion, osteonecrosis,
early growth plate closure, and secondary osteoarthritis (Fig. 5).
Osteochondritis dissecans is usually of traumatic origin [2].
Fractures and Associated Complications The medial posterior part of the talan dome is the most corn-
MR imaging has proved to be reliable in diagnosing stress monly involved site at the ankle, followed by the lateral ante-
fractures [1] (Figs. 1 and 2). Conventional radiography, although non dome. MR imaging is useful in evaluating osteochondnitis

Fig. 1.-Tibial stress fracture In 31-year-old I . ,, ,

woman with 2-month history of unexplained
leg pain. Sagittal Ti-weighted spin-echo MR
Image (500/12) of distal part of tibIa shows
fracture as line of low signal Intensity (arrows)
surrounded by poorly defined zones of dlmln-
ished signal representing edema. Although mi-
tlal radlographs were negative, subsequent
films obtained after MR imaging examination
showed linear zone of sclerosis at fracture site.

Fig. 2.-Healing stress fracture of distal die-

physic of second metatarsal bone in 41-year-
old woman wIth chronic foot paIn and negative
radlographs. Saglttal T2-weighted spIn-echo
MR image (1800/80) of second metatarsal bone
shows bridging bone as mntramedullary area of
decreased signal intensity (arrow). Note thick
cortIcal low signal representing callus bone
and Increased signal in surroundIng soft tis-
sues representing edema.

Received December 22, 1994; accepted after revision January 24, 1995.
TBoth authors: Department of Radiology, A-1i3, Albany Medical College, 43 New Scotland Ave., Albany, NY 12208. Address correspondence to D. G. Dislen.
AJR 1995;165:119-124 036i-803)(/95/i651-119 ©Amenican Roentgen Ray Society
 120 AERTS AND DISLER AJR:165, July 1995
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Fig. 3.-Acute fracture of posterior malleoius in 37-year- Fig. 4.-Salter-Harris type I growth
old woman with painful ankle after a fall. plate injury of distal tibial physis in i3-
A and B, Two consecutive axial T2-weighted spin-echo year-old girl after a fall. Initial radio-
MR images (2200/80) show hyperintense fracture line (white graphs showed irregular widening of
arrows) and surrounding edema in posterior malleolus at physis. Coronal T2-weighted fat-sup-
fracture site. Black arrows denote Intact posterior tibiofibu- pressed fast spin-echo MR image (3500/
lar ligament. MR imaging examination was obtained to 115) shows discrete asymmetric physeal
assess for possible ligament injury after initial and subse- widening (arrows). Hyperintense physeal
quent radlographs were negative. and subperlosteal signal is consistent
with edema and hemorrhage. vague
areas of increased signal in epiphysis
and metaphysis represent edema adja-
cent to fracture site.

Fig. 5.-5evere posttraumatic osteoarthritls in 42-year-old Fig. 6.-Osteochondral frac-

woman with occasional locking of ankle and plain films suggestive ture with displaced fragment in
of osteoarthritis. 27-year-old woman with chronic
A, saglttal Ti-weighted spin-echo MR image (500/12) shows mar- ankle pain. coronal T2-weighted
row-containing loose bodies (arrows) in posterior recess of ankle joint. fast spin-echo MR image (9900/
B, Sagittal reformation of coronal fat-suppressed three-dimen- 90) shows osteochondral defect
slonal spoiled gradient-echo MR image (6O/5/40) shows marked in medial talar dome as irregular
loss of cartilage thickness at anterior two thirds of tiblal articular crater (arrow) partially filled
margin and at mldtalar dome (arrows). Note normal cartilage thick- with hyperintense signal repro-
ness of subtalar joint. senting fluid. Fluid in crater can
indicate displaced or loose and
unstable fragments. (Courtesy
Mark Schweitzer, Philadelphia.)

dissecans because it allows visualization of the extent of bone contour irregularity, and discontinuity, are findings shown in
involvement and of overlying cartilage abnormalities. MR imag- abnormal ligaments
(Fig. 7) and tendons [1 , 3] (Figs. 8 and 9).
ing can show isolated chondnal fractures and loose bodies, and Fluid within tendon sheaths can indicate tenosynovitis (Fig. 10),
can distinguish stable from unstable lesions [2] (Fig. 6). although small amounts of fluid, especially in the flexor hallucis
longus tendon sheath, can be physiologic [1]. A special post-
traumatic condition is the sinus tansi syndrome, usually seen
Injuries to Ligaments and Tendons after a severe inversion injury. MR imaging can identify the sub-
Because of its multiplanar capability and the soft-tissue con- talar ligaments and show the pathologic changes in the tarsal
trast it provides, MR imaging is the ideal method for assessing sinus [4] (Fig. ii ). Systemic processes, such as xanthomatous
ligament and tendon integrity after injury. Increased signal and infiltration in patients with familial hypercholestenolemia, are
morphologic changes, including focal thickening or thinning, less common but are easily shown with MR imaging (Fig. 12).
 AJR:i65, July 1995 MR OF FOOT AND ANKLE ABNORMALITIES 121
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Fig. 7.-Anterior talofibular

liga- Fig. 8.-Chronic tendinitis of Achilles tendon In 29-year-old woman Fig. 9.-Complete tear of Achil-
ment tear in 60-year-old woman
with with pain behind right ankle. los tendon in 68-year-old woman
chronically swollen ankle and radio- A, Sagittal Ti-weighted spin-echo MR image (500/12) shows fusiform with rheumatoid arthritis. Saglttai
graphs that showed lateral Ilgamen- thickening of Achilles tendon with focal internal zones of higher signal three-dimensional spoiled gradi-
tous laxity. Axial T2-welghted fast Intensity representing interstitial tears (arrows). ent-echo MR Image (36/5/50) of
spin-echo MR Image (4000/95) B, Axial multiplanar gradient-echo MR Image (600/12/20) shows ankle shows complete disruption
shows disrupted margins of torn enlargement of Achilles tendon with abnormal convex shape of anterior of fibers of Achilles tendon with
anterior talofibular ligament (small tendon margin. Normal Achilles tendon should have concave anterior retraction (arrows). Tendon tears
black arrows). Joint effusion is margin. Note focal internal area of hyperintensity representing interstitial are common In patients with
present. Lateral collateral lIgament tear (arrow). Achilles tendon has no tendon sheath; edema of peritenon Inflammatory arthropathles, con-
tears usually Involve anterior talofib- (arrowhead) Is earliest sign of Achilles tendinitis. nective tissue diseases such as
ular ligament first; Identification of systemic lupus erythematosus, and
Intact anterior talofibular ligament hyperparathyroldism. Note stress
virtually excludes lateral collateral fracture of calcaneus (arrowheads).
ligament tear. Note subchondral
cysts in talus (long black arrows)
due to posttraumatlc osteoarthritis.
Multiple synovialcysts are shown as
well-delineated septate foci of high
signal IntensIty adjacent to extensor
digitorum longus tendon (arrow A),
peroneal tertlus tendon (arrow B),
flexor hallucis longus tendon (arrow
C), and peroneal tendons (arrow E).
A surgically proven ganglion cyst
(arrow D) is also shown.

Fig. 10.-Tenosynovitis of posterior tiblalls tendon in 58-year-old woman Fig. 11.-Posttraumatic sinus tarsi syndrome in 46-year-old
with soft-tissue swelling and pain at medial aspect of ankle. Radiographs woman with history of remote trauma and plain films suggesting
showed osteoarthrltis at ankle. osteochondral fracture of talus.
A, Sagittal T2-weighted spin-echo MR image (2000/90) shows fusiform A, Sagittal Ti-weighted spin-echo MR Image (600/15) shows loss
thickening of posterior tiblalls tendon (arrow) and fluid In tendon sheath of normal fat In sinus tarsi (arrow) as diffuse hypointense signal
(arrowheads). and loss of delineation of cervical and talocalcaneal interosseous
B, Axial proton density-weighted spin-echo MR image (2000/12) shows rela- ligaments.
tive increased size of posterior tiblalls tendon In cross section (arrow) com- B, Coronal T2-weighted spin-echo MR Image (2500/80) shows
pared to flexor digitorum longus tendon (arrowhead). Size of normal posterior edema as hyperintense signal In sinus tarsi (arrow). interosseous hg-
tibialls tendon on axial images should not exceed three times that of flexor ament Is partially seen (arrowheads). Hyperlntense areas on T2-
digitorum longus tendon. weighted Images correspond to nonspecific Inflammatory changes,
whereas hypointense areas correspond to fibrosis (4].
 122 AERTS AND DISLER AJR:165, July 1995
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Inflammatory and Infectious Conditions of Bone and

Soft Tissues
The high soft-tissue contrast, high resolution, and multipla-
nan capability of MR imaging exceed advantages offered by
other imaging techniques in detecting and evaluating soft-tis-
sue, joint, and bone infection. Cellulitis has an infiltrative signal
pattern in soft tissues with heterogeneous contrast enhance-
ment, whereas soft-tissue abscesses show rim enhancement
[1]. MR imaging shows the presence and the exact location of
foreign bodies and the extent of soft-tissue inflammation (Fig.
13). In the absence of previous surgery or trauma, MR imag-
ing has high sensitivity and specificity for detecting osteomy-
ehitis and for evaluating its extent (Figs. 14 and 15), and is
especially useful in detecting osteomyehitis in the presence of
adjacent soft-tissue infection. When there has been prior sun-
geny, trauma, on neunopathic arthnopathy, the diagnosis can be
difficult, requiring additional imaging techniques such as radio-
Fig. 12.-Xanthomatous infiltration of ankle tendons in 58-year-old nuchide bone scintignaphy and CT. Some authors have found
woman with familial hypercholesterolemla and unexplained chronic that the specificity of MR imaging is increased when IV con-
ankle swelling. Plain films showed pronounced swelling at ankle.
A and B, Axial proton density-weighted (2300/20, A) and axial T2- trast material is administered [5] (Fig. 16).
weighted (2300/80, B) spin-echo MR images show marked enlargement MR imaging is valuable in detecting arthritis because it
of Achilles tendon (solid straight arrow), peroneal tendon (curved can depict early synovial, cartilage, and enthetic changes,
arrow), and anterIor tiblalls tendon (open arrow). Note Internal low-sig-
nal trabeculations and heterogeneous areas of dIminished, intermediate, even when plain films show no abnormality (Fig. 17). IV
and Increased signal, typical of xanthomatous tendon infiltratIon. administration of contrast material can distinguish pannus

FIg. 13.-Soft-tIssue InfectIon due to FIg. 14.-Calcaneal osteomyelltis In 40- Fig. 15.-Hematogenous osteomyelths in 4-
wooden foreign body between first and sec- year-old diabetic woman with heel ulcer and year-old girl with Kawasaki dIsease, acute leg
ond metatarsal heads In 6-year-old boy with plain fIlms that showed periosteal new bone pain, and fever. Plain films showed destructive
foot swelling and fever after stepping on a formation at calcaneus adjacent to skin bone lesion in distal tibial dlaphysis. Saglttal Ti-
toothpick. Radiographs and sonography were defect. Sagittal
short-TI Inversion recovery weighted spin-echo MR Image (400112) obtained
normal. Axial short-TI Inversion recovery (STIR) MR Image (3000/80/150) shows deep to determine the extent of bone and soft-tissue
(STiR) MR Image (5000/20/150) shows small ulcer (arrowhead) along inferoposterior changes shows diffuse heterogeneously dimin-
abscess surrounding foreign body (arrow), aspect of foot wIth surrounding Inflamma- Ished signal intensity in dIstal tiblal diaphysis,
which was removed at surgery. Note extensive tory changes In soft tissues. Osteomyelltis metaphysis, and eplphysls. Note normal signal
surroundIng increased signal in soft tissues appears as marked hyperlntense signal In Intensity of marrow In talus. Abnormal signal
attributable to Inflammation and edema. calcaneal tuberosity (open arrows) adjacent crossing growth plate Is more typical of osteomy-
to soft-tIssue Inflammation. Note fluid In elWs than of neoplasla.
flexor hallucis longus tendon sheath (solid
arrow) and ankle joint. Because ankle joint
communicates with flexor hallucis longus
tendon sheath In 20% of patIents, fluid In
this tendon sheath is considered normal in
presence of ankle-joint effusion.
 AJR:165, July 1995 MR OF FOOT AND ANKLE ABNORMALITIES 123
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from joint effusion and hypervasculan pannus from fibrous fat and fluid within the lesion [8]. Synovial and ganglion
pannus [1 , 6]. MR imaging findings in deposition diseases cysts are identified when cysthike T2-bnight lesions are
such as gout have recently been described [7]. MR imaging shown in typical locations relative to joints and tendon
can show the extent of a tophus, its relationship to a joint, sheaths (Fig. 7).
and the presence of complications, including secondary
infection (Fig. 18).
Congenital Anomalies
Tumors and Tumorlike Conditions of Bone and Soft Tissues
Hindfoot coalition is a common congenital anomaly that
The MR appearance of tumors of the foot and the ankle is may be clinically manifested as a painful penoneal spastic f hat-
similar to that of tumors seen elsewhere. MR imaging is foot and tarsal tunnel syndrome. Calcaneonavicular coalitions
superior to CT for evaluating osseous and soft-tissue extent are most common, followed by subtalar coalitions. Coalitions
of tumor (Figs. 19 and 20). The multiplanar capacity and can have osseous, fibrous,on cartilaginous components. MR
improved soft-tissue contrast allow identification of tumor imaging is superior to CT for the diagnosis of fibrous coahi-
margins relative to neunovascuhan structures and joints (Fig. tions [9] (Fig. 23).
21). Detection of skip lesions and postsungicah monitoring
can also be provided by MR imaging [1]. Although nadiogra-
phy and CT remain superior in the detection and classifica-
Postoperative Follow-Up
tion of intralesional calcifications, MR imaging may provide a
tissue-specific diagnosis in certain situations. For example, Distinguishing recurrent tumor from posttherapeutic
a suspected aneurysmal bone cyst is diagnosed when fluid- changes remains difficult, but MR imaging is more sensitive
fluid levels are seen [8] (Fig. 22). An intraosseous hipoma than CT in delineating the extent of soft-tissue abnormalities
shows typical fat signal on all MR sequences, and hemangi- [1]. Furthermore, MR imaging may have a mole in the postop-
omas show areas of increased signal on both Ti - and T2- enative evaluation of nonneoplastic conditions such as ten-
weighted MR sequences because of the presence of mixed don and ligament repair (Fig. 24).

Fig. 16.-Brodle’s abscess In 15-year-old girl with swelling and pain over Fig. 17.-Psoriatic enthesitis at Fig. 18.-Secondarily Infected
medial malleolus after a fall. Plain films showed geographic zone of lucency origin of plantar aponeurosis In 23- tophaceous gout In 76-year-old man
in distal tiblal metaphysis with well-circumscribed sclerotic margins. year-old woman with psorlasis and with open drainage wound of great
A, AxIal T2-welghted fast spin-echo MR Image (4000/90) shows well- heel pain. Plain films obtained 2 toe. Plain films showed mild soft-
delineated multilobular high-signal lesion in distal tibial metaphysis. weeks before MR imaging examine- tissue prominence adjacent to first
Note small anterIorly located, surgically proven soft-tissue abscesses tion were normal. saglttal Ti- metatarsophalangeal joint. Axial T2-
(arrows) and poorly defIned bright signal In surrounding bone, repro- weighted spin-echo MR Image (500/ weighted fast spin-echo MR image
senting reactive bone marrow edema. Cultures of marrow and soft-tissue 16) of hindfoot shows focal concave (4000/95) shows heterogeneous
yielded Staphylococcus aureus. defect of calcaneal tuberosity at on- hyperintense soft-tissue sIgnal
B, Axial Ti-weighted spin-echo MR image (600/12) after IV administra- gin of plantar aponeurosls (arrow) (solid arrow) medial to fIrst metatar-
tion of contrast material shows rim enhancement of lesion and low sig- and surrounding low signal in mar- sal head. Noninfected gouty tophus
nal IntensIty of central fluid. row, representing edema. Is expected to be of lower sIgnal
IntensIty (7]. Note sinus tract to skin
(open arrow). Bone marrow sIgnal of
first metatarsal Is normal. Culture of
fluid revealed group B beta
hemolytic Streptococcus InfectIon,
and microscopic evaluation revealed
needle-shaped urate crystals.
 124 AERTS AND DISLER AJR:165, July 1995
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FIg.i9.-Hemangloendotheiloma Fig. 20.-Granular cell myoblas- Fig. 2i.-Osteosarcoma of calca- Fig. 22-Aneurysmal bone cyst
In 28-year-old man with ankle swell- toma in 46-year-old woman with neus in 12-year-old boy with painful, of talus in 45-year-old woman with
ing and pain. Radiognaphs showed plantar skin lesion and normal swollen hindfoot and radiographs ankle pain. Sagittal T2-weighted
multiple circumscribed lytic foci in radiographs. Sagittal Ti-weighted showing aggressive bone-forming spin-echo MR image (2000/80)
distal tibia, calcaneus, and talus. spin-echo MR image (600/12) with neoplasm in calcaneus and adjacent shows multicystic expansile lesion
MR Imaging was performed to narrow window settings shows soft tissues. Sagittal
fat-suppressed in proximal pole of talus. Fluid-
assess extent of neopiastic bone small inhomogeneous lesion lim- Ti-weighted spin-echo MR image (500/ fluid levels (arrows) are character-
and soft-tissue involvement. Sagit- Ited to cutaneous and subcutane- 12) after IV administration of gadopen- Istic of aneurysmal bone cyst but
tam short-TI Inversion recovery ous tissues along medial plantar tetate dimeglumine shows large lesion can occasionally be seen with giant
(STIR) MR image (1000/20/150) aspect of hindfoot (open arrow). with multiple foci of low signal, repro- cell tumor, telangiectatic osteosar-
shows typical multifocal, hypenn- MR imaging clearly showed tumor senting bone matrix in tumor. Note coma, and chondroblastoma.
tense, well-cIrcumscribed lesions extent limited to subcutaneous fat. extension of tumor into retrocalcaneal
In tibia, talus, calcaneus, cuboid Solid arrow indicates skin marker. fat (solid black arrows). Achilles ten-
bone, and medial cuneiform bone. don appears to be spared. Tumor
Note soft-tissue foci of tumor in extends Into quadratus plantae mus-
quadratus plantae muscle (arrows). dc (open arrows) and subtalar joint
(white arrows).

Fig. 23.-Fibrous calcaneonavicular coali-

tion in left foot of 18-year-old woman with foot
pain and penoneal spastic flatfoot. Axial Ti -
weighted spin-echo MR image (400/12) of both
feet shows normal fat (arrowhead) in right foot
(R) and narrowing of left calcaneonavicular
interspace compared with normal right side.
Low signal intensity in interspace of left foot
(L) represents fibrous tissue (arrow). (Courtesy
Mark Schweitzer, Philadelphia.)

Fig. 24.-A and B, Postoperative assessment

of lateral ankle ligament reconstruction of 48-year-
old woman with instability. Coronal T2-weighted
fast spin-echo MR images (4000/95) of ankle after
reconstruction with peroneus brevis tendon show
intact tendon (arrows, A) along its new course
through lateral malleolus (arrowhead, B).

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