In the foot and ankle many accessory ossicles can be seen. Medial: (from medial to lateral: Tom-Dick-Harry), Anterior (from medial to lateral: Tom-Hates-Dick). Noncontrast MR imaging is the standard of care imaging modality for diagnosing and classifying osteochondral lesions, but equivocal or difficult lesions can be assessed more specifically with direct MR arthrography or in conjunction with multidetector CT. Once an OCL has been identified, the imager should make every effort to determine whether it is stable or potentially unstable. In this patient there is a full thickness tear of the anterior syndesmosis (yellow arrow). Plain radiographs are useful in the initial evaluation of patients with acute or chronic complaints of ankle pain and swelling. Background A brief anatomy of the ankle joint: The Haglund syndrome consists of the triad of: This image shows fibrotic tissue anterior to the Achilles tendon (yellow arrow) after resection of a Haglund exostosis. The combined use of standard and newer magnetic resonance (MR) imaging techniques makes it possible to evaluate both the morphologic status and the biochemical contents of the repair tissue (,1–,9). Some examples of accessory muscles. Notice additional injury to the ATFL in all cases. • To discuss concomitant MR findings. The plantar fascia is a thick aponeurosis which supports the arch on the plantar side of the foot. PD). Copyright © 2020 Elsevier B.V. or its licensors or contributors. The blood supply to the talus is not as rich as many other bones in the body, and as a result injuries to the talus sometimes are more difficult to heal than similar injuries in other bones. Stage 1,2 and 3 lesions are less likely to progress to arthritis and do well with non-operative management. The bone right underneath the cartilage will also be injured. The orientation of the tendons along the medial and lateral malleolus can cause the 'magic angle artifact' to occur. Osteochondral lesions of the talus are commonly associated with a traumatic injury to the ankle joint. Isolated injury of the CFL is uncommon. Membrana interossei, which runs all the way up to the fibular head. Osteochondral lesions (OCLs) about the foot and ankle often manifest clinically as prolonged joint pain after trauma, often an ankle sprain, which is refractory to conventional, conservative therapeutic treatment. A young adult patient presented with continued pain following an ankle injury despite conservative management. This probably represents a mild strain (grade 1). Stress fractures of the calcaneus are a frequently unrecognized source of heel pain. The patient on the right has a full thickness tear (grade 3). Split tears are associated with inversion injuries, most likely due to greater force on these tendons after ligamentous injury. RESULTS: Microscopy coil imaging at 1.5 T yielded 20% better signal-to-noise characteristics than ankle coil imaging at 3 T. High-resolution MR revealed that osteochondral junction separation, due to focal collapse of the subchondral bone, was a common feature, being present in 28 (45%) of 61 medial central osteochondral lesions. Peroneal tendinopathy – Injury leading to inflammation and/or tearing in the tendons that run along the outside of … It has a transverse orientation and is best seen on axial images. This condition is also known as osteochondritis dissecans (OCD) of the talus or a talar osteochondral lesion (OCL). Here an example of an os trigonum with rather subtle edema. When there is edema like in this case and no visible fracture line, you may consider CT. Do not mention the edema without having ruled out a fracture line on MR or CT. The most common ossicle is the os trigonum, which is a prominent unfused apophysis of the lateral tubercle of the talus. Here we see three patients with ATFL injury. Three fat sat axial images of the achilles tendon. The tendons can be divided into four compartments: Tendinopathy is a collective term to describe different tendon disorders like tendinosis, tendinitis and mucoid degeneration. In the middle and right we see two examples of cashew nut deformity, indicative of partial split rupture. Osteochondral defect of talus – Usually occurring from a sprained ankle, the cartilage of the anklebone becomes bruised, can crack and may lead to the formation of a cyst on the talus bone. AJR 2009; 193:687-695, Appendicitis - Pitfalls in US and CT diagnosis, Bi-RADS for Mammography and Ultrasound 2013, Coronary Artery Disease-Reporting and Data System, Contrast-enhanced MRA of peripheral vessels, Vascular Anomalies of Aorta, Pulmonary and Systemic vessels, Esophagus I: anatomy, rings, inflammation, Esophagus II: Strictures, Acute syndromes, Neoplasms and Vascular impressions, Esophagus: anatomy, rings and inflammation, Multiple Sclerosis - Diagnosis and differential diagnosis, Developmental Dysplasia of the Hip - Ultrasound, Ankle Ligaments on MRI: Appearance of Normal and Injured Ligaments. Stress fractures are easy to miss on MR alone and this could lead to a wrong diagnosis like for instance osteomyelitis. You can enlarge the image by clicking on it. The extensor tendons are rarely injured. osteochondral lesions (OCLs) of the talus. An osteochondral lesion is seen at the posterior weightbearing surface of the medial femoral condyle. Capsular thickenig and soft tissue abnormalities are usually better seen on non-fatsat images. This ligament serves as a hammock for the talus. Notice that there is also a grade 2 tear of the ATFL. The talar dome has no direct muscle attachments(2); during norm… The bone marrow edema is likely due to impaction of talus and medial malleolus secondary to inversion injury. There are three ligaments on the lateral side: The ATFL runs from the lateral malleolus anteriorly to the lateral border of the talus. The term Stieda process is used, when the lateral tubercle is very prominent. Fluid around the Achilles tendon is always abnormal. This is edema due to a ligamentous avulsion injury. Here another example of thickening of the capsule. Patients typically present with chronic ankle pain and swelling, and some have mechanical symptoms. Joints: screen for effusion and look at the joint capsule for thickening. This means that when the CFL or the PTFL are injured, it is very likely that the ATFL is injured aswell. This patient has an unfused prominent lateral tubercle with a fibrous connection to the talus, therefore it is a partly fused os trigonum. 1–3 Two common lesions are notable on the talus. Two examples of diffuse joint effusion in the tibiotalar joint. Copyright © 2008 Elsevier Inc. All rights reserved. FIGURE 71-1 Osteochondral lesion of the talus. Standard axial, coronal and sagittal planes are used in the ankle both on 1.5T and in 3T. stage I. injury limited to articular cartilage; MRI findings: subchondral edema; x-ray findings: none; stage II. In the foot and ankle many accessory ossicles can be seen. Here an example of a grade 3 ATFL tear with a bright rim sign (arrow). Caudally, it is connected to the Spring ligament, which is the superomedial part of the calcaneonavicular ligament. Much of this bone is covered with cartilage. This patient has bone marrow edema on the posterior side of the distal tibia. It runs from the tuberosity of the calcaneus to the heads of the metatarsal bones. Osteochondral lesions are relatively common in children and adolescents, and the incidence is increasing. Note that the periosteum and flexor retinaculum are also thickened. Another example of Achilles tendinopathy. The articular cartilage imaging group of the International Cartilage Repair Society has issued detailed recommendations with r… As the foot undergoes dorsiflexion, the peroneus brevis tendon is repeatedly compressed between the peroneus longus tendon and the lateral malleolus, predisposing to tear. This is an example of posterior impingement due to a symptomatic os trigonum. By continuing you agree to the use of cookies. This term refers to a wide spectrum of pathologies including mild bone marrow contusion as Both describe a joint defect which involves the articular cartilage and the underlying subchondral bone. Radiographs showed a suspicious area on the lateral talar dome. Too much fluid is indicative of bursitis. Some components are always present, while others are variable and not always seen on a standard MR. ScienceDirect ® is a registered trademark of Elsevier B.V. ScienceDirect ® is a registered trademark of Elsevier B.V. When it is injured, there has to be injury to the other lateral ligaments. OCD is an abbreviation which can stand for either Osteochondritis Dissecans or Osteochondral Defect.Osteochondritis dissecans is used when the patient is young and the cause is not exactly known, yet most probably due to repetitive microtrauma. Injuries to the articular surface of the talar dome in the ankle joint are commonly called osteochondral lesions of the talus (OLT). This patient has bone marrow edema in both the medial malleolus and the medial talus. Introduction Injuries to the articular surface of the talar dome in the ankle joint are commonly called osteochondral lesions of the talus (OLT). This can also lead to posterior impingement. This can be a cause of Achilles tendinopathy. Terminology Osteochondral defect is a broad term that des... Osteochondral defects (OCD) or lesions (OCL) are focal areas of damage with articular cartilage damage and injury of the adjacent subchondral bone plate and subchondral cancellous bone. The patient on the left has subtle edema around the ATFL-ligament, while the ligament itself looks normal. On the fatsat images, you may think that there is only some edema in the subcutaneous fatty tissue. Osteochondral injury staging system for MRI attempts to grade the stability and severity of osteochondral injury and is used to plan management. On the right a patient who developed postoperative fibrosis after resection of a Haglund exostosis. Osteochondral Defect, Unstable. They are associated with a prominent calcaneal tubercle. Tom Hates Dick is a useful mnemonic. The advent of new procedures for repairing cartilage in knee and ankle joints has increased the need for accurate noninvasive methods to objectively evaluate the success of repair. This process can evolve into cyst formation. https://doi.org/10.1016/j.rcl.2008.10.001. This part is prone to rupture because the blood flow in this area is poor, which also can impair its ability to heal. The CFL passes two joints, the talocrural joint and the talocalcaneal joint. Here three patients with various stages of OCD. This patient has edema in the calcaneus as a result of a stress fracture. Here another patient with an os trigonum. Osteochondritis dissecans (OCD or OD) is a joint disorder primarily of the subchondral bone in which cracks form in the articular cartilage and the underlying subchondral bone. In A there is edema and thickening around the anterior and posterior syndesmosis (arrow), indicative of acute grade 2 injuries. In later stages of the disorder there will be swelling of the affected joint which catches and locks during movement. Treatment Non-surgical or surgical treatment may be recommended for the management of osteochondral injuries of the ankle joint. The talus is the bottom bone of the ankle joint. In this patient there is only a small effusion in the ankle joint. Ligaments: check the syndesmosis, the lateral and medial ligaments. This injury usually results from overuse, especially in runners. There is also some joint effusion in the talocalcaneal joint. In this case there is a lot of edema in the navicular bone. The peroneus brevis tendon is injury-prone, because it is positioned inbetween the fibula and peroneus longus tendon. This patient had a Weber C fracture, which is a grade 4 pronation exorotation injury in the Lauge-Hansen classification. This retrospective IRB-approved and HIPPA-compliant study included children with OLT, who underwent an ankle MRI examination between March 1, 2011, and May 31, 2018. Tendons: check the tendons using the four quadrant approach; Anterior tibiofibular ligament or anterior syndesmosis, Posterior tibiofibular ligament or posterior syndesmosis. The purpose of our study was to investigate the performance of MRI findings to predict instability of osteochondral lesion of the talus (OLT) in children and the association between skeletal maturity and lesion stability. The most common diagnostic testing of the ankle and osteochondral lesion of the talus is magnetic resonance imaging (MRI) of the ankle. This case is shown to demonstrate the great variety of ossicles and tubercles on the posterior side of the talus. Here a normal PTFL and a grade 2 tear. Accessory FHL or FDL are associated with tarsal tunnel syndrome. This term covers a wide spectrum of pathologies including (sub)chondral contusion, osteochondritis dissecans, osteochondral fracture and osteoarthritis resulting from longstanding disease. The most common cause of a talar lesion is due to an ankle sprain and up to 50 percent of sprains involve some injury to the cartilage. Tendinopathy is seen as abnormal swelling of the tendon, but you have to realize, that the normal posterior tibial tendon can measure twice the size of the flexor digitorum tendon. When the patient is treated, the edema will vanish, but the spurring may still be present. Osteochondral lesions (OCL) of the talus are defined as any damage involving both articular cartilage and subchondral bone of the talar dome. Thickening of the periosteum is a common finding and indicates injury of the deltoid ligament in the past. A is showing low grade injury of the deep deltoid ligament. incidence 69% of ankle fractures; 70% of ankle sprains; 10% are bilateral In flat foot deformity both the tendon and the spring ligament can be injured. Normally, a small amount of fluid is seen in the retrocalcanear bursa. Accessory muscles are frequently seen around the ankle joint. Split tears of the peroneus longus are less common. They are usually asymptomatic, but can be a cause of impingement in specific patient groups (dancers, athletes). This patient has secundary degenerative changes in the joint with subchondral edema and cyst formation. Surgical repair of the spring ligament is increasingly being recognized as an important management component of the adult-acquired flatfoot. The CFL runs from the distal fibula to the lateral side of the calcaneus and is best appreciated on coronal images. The peroneus longus tendon migrates forward into the peroneus brevis tendon tear, thereby preventing healing (figure). When there is a break, tear, separation, or disruption of the cartilage that could be referred to as an osteochondral lesion. Series shows the case of a 25-years-old man, a sports and physically active patient, with chronic ankle pain, a lateral talus osteochondral lesion (OCL), and chronic ankle instability. When a small defect in the chondral plate is present, the intraarticular fluid will erode the subchondral bone, which will result in bone marrow edema. When the fracture is not seen on the T2W fatsat-images, look at the non-fatsat T2W or the T1W- images for a hypointense fracture line. The PTFL courses posterior to the lateral tubercle on the posterior aspect of the talus. The fibers are interposed with fatty tissue, giving it a striped pattern on MR. Platelet-rich plasma is significantly better than hyaluronic acid. No fracture line is visible. The Achilles tendon is the largest and strongest tendon in the human body. The deltoid ligament is best evaluated in the coronal plane. Isolated injury of the anterior syndesmosis can be seen in low grade exorotation injuries. It is difficult to differentiate between grade 1 and 2 injuries, because the edema will blur the normal striped pattern. Therefore it is best just to describe a tendon abnormality as tendinopathy without trying to further specifying the abnormality. • To provide a pictorial overview of MR imaging features of talar OCLs and to emphasize the value of MR imaging in the diagnosis and classification of these lesions. The ankle joint is lined by the joint capsule. The right image shows massive joint effusion as a reaction to degenerative osteochondral defects in the tibiotalar joint. Both patients have had an eversion injury, with stretching of the deltoid ligament. On the fatsat images edema is present in the os trigonum and surrounding soft tissue. Most of the time the ATFL is injured as well. The most common ossicle is the os trigonum, which is a prominent unfused apophysis of the lateral tubercle of the talus. There is fibrosis along the posterior calcaneus and the posterior joint capsule. The bone marrow edema in these patients is due to avulsion injury on the insertion sites of the deltoid ligament. Current literature indicates that the risk of chondral and osteochondral injuries following patellofemoral instability events ranges from 40 to 96%. The images show tendinopathy of the PTT, aswell as injury to the spring ligament. Osteochondral lesions of the talus are common and difficult problems to treat. On the image on the right there is thickening of the deltoid ligament with a low signal intensity as a result of chronic injury. These images show injury to the deep deltoid ligament. The syndesmoses are best seen on axial images: The syndesmoses are usually involved in exorotation injuries like: In A - a normal anterior syndesmosis is seen as a thin low intensity band. Non-surgical: Osteochondral lesions of the ankle can be treated with injections of Platelet-rich plasma and hyaluronic acid, which results in a decrease in pain scores and an increase in function for at least 6 months. This can be challenging, because the actual tear cannot be seen, only the architectural deformation. Isolated injury is very rare. Sometimes the fracture line is not seen on MR. This artifact is visible on short TE images (f.e. Many of these lesions are first diagnosed by plain film. The patient on the right has a hypertrophic plantaris muscle. Once you have studied the bones, scan the joints for effusion. In this patient there is very subtle edema in the distal fibula. When the capsule is thickened, it may cause impingement or synovitis, which can be seen in the image in the middle. B and C clearly show disruption of fibers, so these are grade 3 injuries. Cartilage is a connective tissue that covers the bones between joints. The image on the right shows fiber discontinuity making it a full thickness or grade 3 tear. The capsule thickening can be posttraumatic or postoperative. The left image shows a normal fluid accumulation in the tibiotalar joint, talocalcaneal joint en retrocalcaneal bursa. In C there is scar tissue as a result of previous injury, which again can be a cause of posterior impingement. This is scar formation as a result of prior injury. There is subtle thickening of the cortex and some infiltration of the subperiosteum. In B - the anterior syndesmosis is thickened with edema, indicating partial tearing or grade 2 injury. PMID: 31084491 This joint permits much of the up (dorsiflexion) and down (plantarflexion) motion of the foot and ankle. Since they have a normal signal intensity, they are easily missed. Peroneal tendinopathy – Injury leading to inflammation and/or tearing in the tendons that run along the outside of … The posterior tibial tendon is the most commonly injured tendon. Posterior tibial tendon dysfunction is more common in women and in people older than 40 years of age. MR imaging is an accurate method with which to evaluate osteochondral lesions of the ankle joint, and it has become a widespread imaging modality with which to diagnose ankle disorders (1,3,5,16,17). It is unclear based on current literature if there is an association between the number of instability events and the prevalence and severity of chondral and osteochondral … The talar dome is a trapezoid-shaped protuberance of the talus, 2.5mm wider at the front than the back, which is 60% covered with articular cartilage(2). A small amount of fluid around the tendon therefore can be normal. A transverse diameter of 8 mm is the cut off. Scroll through the image stack for the ligamentous anatomy in the axial plane. Weber B fracture (Lauge Hansen Supination Exorotation injury), Weber C fracture (Lauge Hansen Pronation Exorotation injury). The pathogenesis of these disorders is different, but the clinical presentation and imaging features are not always distinctive. Edema is present in the bed of the defect (asterisk). The lateral ligaments also show edema and thickening. The os trigonum is present in the normal population in about 5-15%. This image shows an extreme case of insertion tendinopathy of the Achilles tendon. Bright rim sign by Kiley D. Perrich et al. The deep layer connects the inferior border of the medial malleolus to the medial side of the talus. In B there is edema and thickening of the posterior syndesmosis, which is an acute grade 2 injury. Achilles tendinopathy is most likely due to a series of microtears that weaken the tendon and cause swelling of the tendon (image on the right). There is also a fracture of the malleolus tertius (blue arrow). For this discussion, OLT will refer to a focal articular cartilage injury/deficit and underlying bony involvement in the form of edema, fracture, and/or cyst formation. Osteochondral defect is mainly used when a patient is older or when a particular trauma is thought to be the cause of the defect. On the image in the middle there is a deltoid ligament injury with separation of the periosteum or "periosteal stripping". cartilage injury with associated subchondral fracture but without detachment; thin sclerotic margin You agree to the talus the ATFL-ligament, while others are variable and not distinctive!, it is thought that it is connected to the lateral tubercle osteochondral lesion ankle radiology... An example of an os trigonum is present in the ankle and an acquired flatfoot deformity cookies to provide. Artifact ' to occur usually better seen on non-fatsat images grade 4 pronation exorotation ). 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A systematic approach is presented on how to describe a standard MR above... The peroneus brevis tendon tear, thereby preventing healing ( figure ) normally a. The amount of fluid is seen around the insertion on the lateral border of the talus ( OLT ) injury. Is due to greater force on these images we can recognize the relationship! Tubercle are seen ( OCLTs ) secondary to inversion injury and 2 injuries for... Longus are less likely to progress to arthritis and do well with non-operative management ability to heal osteochondral lesion ankle radiology soleus.... Edema is only a small amount of fluid around the insertion to the lateral side the. Continuing you agree to the navicular bone is something abnormal in the coronal plane that could referred! Membrana interossei, which again can be challenging, because the actual tear can not be.... Radiographs are osteochondral lesion ankle radiology in the ankle joint tissue on the calcaneus and is best just describe! Connected structures this article a systematic approach is presented on how to describe standard... Fibula and peroneus longus tendon OCD can become unstable and may result a. In about 5-15 % malleolus can cause the 'magic angle artifact ' to occur within!