Imaging of Ankle and Foot pain

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Amos Campbell
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1 Imaging of Ankle and Foot pain Pramot Tanutit, M.D. Department of Radiology Faculty of Medicine, Prince of Songkla University 1

2 Outlines Plain film: anatomy Common causes of ankle and foot pain Exclude: Acute trauma Joint diseases Osteomyelitis Bone tumors 2

3 Radiographic Anatomy Fore foot Mid foot Hind foot Lisfranc joint Chopart s joint 3

4 Radiographic Anatomy 4 mm 4

5 Radiographic Anatomy 5

6 Special views Lateral views with weight-baring 6

7 Special views Calcaneal view (Skier s view) 7

8 Special views 8

9 Special views M L metatarsal ridge Sesamoid views Skyline view 9

10 Bunion (Hallux valgus) A bony bump that forms on the joint at the base of the big toe due to the big toe pushes against the next toe forcing the joint get bigger and stick out. Red and sore skin Age > 40 years-old 10

11 Turf Toe Most common in football player: Hyperextension injury at 1 st MTP Injuries of the plantar capsuloligamentous complex of the first MTP joint or Plantar plate disruption MTP joint synovitis Flexor tendon sheath synovitis Persistent MTP hyperextension RadioGraphics 2001; 21:

12 Turf Toe: 12

13 Turf Toe Marrow edema Subchondral dark line Joint effusion Tenosynovitis of the FHL 13

14 Bipartite medial sesamoid Eur Radiol 2003; 13:L164-L177 14

15 Bipartite sesamoid vs fracture Fracture: Sharp Radiolucent Uncorticated line Two fragmnets often fit together MRI: marrow edema in recent fracture 99mTc-MDP bone scan: normal in bipartite Eur Radiol 2003; 13:L164-L177 15

16 Axial PDW-FS: Sesamoids M L MCL: thicker LCL: thinner T: FHL tendon T 16

17 Sesamoiditis Repetitive injury Marrow edema ( DDx stress response) Abnormal on STIR (normal on T1W) Both sesamoids Reactive soft tissue abnormality; tendinitis, synovitis, bursitis etc. RadioGraphics 2001; 21:

18 Sesamoiditis 18

19 19

20 20

21 Morton s neuroma Not true neoplasm; perineural fibrosis and nerve degeneration Intermetatarsal space; 3 rd and 2 nd Intermetatarsal ligament-level Relate with bursitis Iso-slightly hyperintense on T1W (muscle), iso-hypointense on T2W (fat), intense enhancement Radiology 2010; 255: RadioGraphics 2001; 21:

22 22

23 Bursitis Intermetatarsal bursae Adventitial bursae beneath metatarsal heads (pressure point) Low SI on T1W, high SI on T2W and STIR with peripheral enhancement. <= 3-mm in transverse diameter in the 1 st, 2 nd and 3 rd may be physiologic changes. RadioGraphics 2001; 21:

24 Stress Fractures Common at metatarsal bones: middle or distal of 2 nd, 3 rd, 4 th MT Runners, ballet, danacers, gymnasts, military recruits Altered weight bearing Hallux valgus Recent surgery of hallux Flattened foot RadioGraphics 2001; 21:

25 Periosteal reaction 25

26 Abnormal? 26

27 Diagnosis? C-sign Loss of talocalcaneal facet Talocalcaneal coalition 27

28 Tarsal Coalition An abnormal bony, cartilage or fibrous union between two or more bones of hind-and midfoot Most common: calcaneonavicular, talocalcaneal Secondary signs of coalition on lateral radiographs C-sign Talar beak Anteater sign pes planus Non-visualized middle facet AJR 2004; 182:

29 Calcified and swollen Achilles tendon Plantar calcaneal spur Posterior calcaneal spur Soft tissue swelling Avulsive fragments Loose body Plantar fasciitis Anterior impingement Eur Radiol 2007; 17:

30 Plantar fasciitis Most common cause of plantar heel pain Repetitive trauma or enthesopathy (AS, Reiter, PsoA) Plantar calcaneal spur MRI: fascial thickening involving proximal portion extending to calcaneal insertion. intermediate SI on T1W or PDW, high SI on T2W or STIR *** Fluid signal and blood Signal: plantar fascia rupture Edema of the adjacent fat pad and underlying soft tissue Marrow edema RadioGraphics 2000; 20: RadioGraphics 2000; 20:S181-S197 30

31 Erosion Edema 31

32 Plantar fibromatosis Localized fibrous proliferation arising from the superficial and medial aspect of the plantar fascia One or more nodules Low-intermediate SI on T1W, low SI on T2W, variable enhancement RadioGraphics 2001; 21: RadioGraphics 2000; 20:S181-S197 32

33 Type2 accessory navicular bone Eur Radiol 2003; 13:L164-L177 33

34 Type3 accessory navicular bone Eur Radiol 2003; 13:L164-L177 34

35 Os peroneum Eur Radiol 2003; 13:L164-L177 35

36 Os trigonum syndrome Eur Radiol 2003; 13:L164-L177 Eur Radiol 2007; 17:

37 Stieda process of the talus Eur Radiol 2007; 17:

38 Anterior tibial spur Anteromedial talar spur Soft tissue swelling Anterior impingement Eur Radiol 2007; 17:

39 Osteochondrosis dissicans Lateral VS Medial Trauma VS Non-Trauma? 39

40 OCD, unstable 40

41 Abnormal? Effusion? 41

42 Bursitis 42

43 Stress response Amorphous area of decreased marrow SI on T1WI and high SI on T2W or STIR. Adjacent soft tissue edema and enhancement May progress to stress fracture: low signal band contiguous with cortex on T1WI and T2WI. RadioGraphics 2001; 21:

44 Achilles tendinopathy Normal: uniformly low SI, flattened or slightly concave anterior border, < 1-cm in AP thickness RadioGraphics 2000; 20:

45 Tarsal tunnel syndrome Tarsal tunnel: fibro-osseous canal bounded by flexor retinaculum, medial surfaces of Talus and calcaneus. Posterior tibial nerve, 3 medial tendons (PT, FDL, FHL), posterior tibial vessels. RadioGraphics 2000; 20:

46 Thank you 46

17/10/2017. Foot and Ankle

17/10/2017. Foot and Ankle 17/10/2017 Alicia M. Yochum RN, DC, DACBR, RMSK Foot and Ankle Plantar Fasciitis Hallux Valgus Deformity Achilles Tendinosis Posterior Tibialis Tendon tendinopathy Stress Fracture Ligamentous tearing Turf