Foot, Ankle, and Calf

Ovid: Musculoskeletal Imaging Companion

Editors: Berquist, Thomas H.
Title: Musculoskeletal Imaging Companion, 2nd Edition
> Table of Contents > Chapter 6 – Foot, Ankle, and Calf

Chapter 6
Foot, Ankle, and Calf
Thomas H. Berquist




Plane Sequence Thickness/Skip Matrix FOV Acquisitions
Scout Coronal SE 200/10 Three 1 cm 256 × 128 24–32 1
Axial T2 FSE*4000/93 5 mm/0.5 mm 256 × 256 24–32 2
Axial T1 SE 450/17 5 mm/0.5 mm 256 × 256 24–32 1
Coronal or sagittal T2 FSE* 4000/93 5 mm/0.5 mm 256 ×256 24–32 2
Scout axial or sagittal SE 200/10 Three 1 cm 256 × 128 16–20 1
Sagittal T1 SE 450/17 3.5 mm/0.5 mm 512 × 512 12 1
Sagittal PD FSE 2000/15 3.5 mm/0.5 mm 256 × 256 12 1
Coronal DESS 23.3/7.7 1 mm/0.2 mm 256 × 256 12 1
Axial PD FSE 3170/19 3.5 mm/0.5 mm 256 × 256 10 2
Axial T2 FSE 4000/93 3.5 mm/0.5 mm 256 × 256 10 2
Scout sagittal SE 200/10 Three 1 cm 256 × 128 8–16 1
Oblique axial T1 SE 450/17 3 mm/0.5 mm 256 × 256 10–12 1
Oblique axial T2 FSE* 4000/93 3 mm/0.5 mm 256 × 256 10–12 2
Oblique coronal DESS 23.5/7.7 1 mm/0.2 mm 256 × 256 10–12 1
Sagittal T1 SE 450/17 3 mm/0.5 mm 256 × 256 10–12 1
Sagittal T2 FSE* 4000/93 3 mm/0.5 mm 256 × 256 10–12 2
Additional Sequences
STIR 5680/109/165 4 mm/0.5 mm 256 × 256 10–24 2
Contrast-enhanced SE* 450/17 3–4 mm/0.5 mm 256 × 256 10–24 1
* Fat suppression.
†Image plane
perpendicular to the sagittal to obtain true cross-sections of the
forefoot. SE, spin-echo; FSE, fast spin echo; DESS, double-echo steady
state; STIR, short TI inversion recovery; FOV, field of view; PD,
proton density.
Suggested Reading
Berquist TH. MRI of the musculoskeletal system, 5th ed. Philadelphia: Lippincott Williams & Wilkins; 2006:430–556.
A, Sakoloff RM, Theudorou DJ, et al. Visualization of ankle tendons and
ligaments with MR imaging. Influence of positioning. Foot Ankle 2002;23:554–559.


Fractures/Dislocations: Ankle Fractures—Pediatric
FIGURE 6-1 The five Salter-Harris fracture patterns.


FIGURE 6-2 AP (A) and lateral (B) radiographs demonstrating marked swelling with a Salter-Harris Type IV (arrows) tibial fracture and Type II fibular fracture (arrow) as the result of an inversion injury.


FIGURE 6-3 AP (A) and lateral (B) radiographs of an eversion injury with opening of the tibial physis (arrow) and an incomplete fibular fracture (open arrow).
Suggested Reading
Rogers LF. Radiology of epiphyseal injuries. Radiology 1970;96:289–299.


Fractures/Dislocations: Ankle Fractures—Pediatric: Triplane Fracture


FIGURE 6-4 Triplane fracture seen from the front and side (A) and from the articular surface and with fragments separated (B).



FIGURE 6-5 AP (A) and lateral (B) radiographs demonstrate a triplane fracture (arrows). Coronal (C) and sagittal (D) reformatted CT images define the fractures (arrow) and degree of displacement.
Suggested Reading
Cone RO III, Nguyen V, Flournoyr JG, et al. Triplane fracture of the distal tibial epiphysis. Radiologic and CT studies. Radiology 1984;153:763–767.


Fractures/Dislocations: Ankle Fractures—Pediatric: Juvenile Tillaux
FIGURE 6-6 Mechanism of injury for juvenile Tillaux fractures.


FIGURE 6-7 AP radiograph shows a Salter-Harris III fracture—juvenile Tillaux fracture (arrows).
Suggested Reading
DC, Rajmaira S. Distribution of physeal and nonphyseal fractures in
2,650 long bone fractures in children aged 10 to 16 years. J Pediatr Orthop 1990;10:713–716.


Fractures/Dislocations: Ankle Fractures—Pediatric Complications


FIGURE 6-8 Prior Salter-Harris IV fracture of the distal tibia. AP (A) and lateral (B) radiographs demonstrate premature closure and angular deformity of the anteromedial growth plate (arrow). The physis remains open laterally and posteriorly (open arrow). Standing radiographs (C)
in a different patient with an old physeal fracture on the right and
leg length discrepancy and angular deformity of the articular surface (lines).
Suggested Reading
Spiegel PG, Cooperman DR, Laros GS. Epiphyseal fractures of the distal ends of the tibia and fibula. J Bone Joint Surg 1978;60A:1046–1050.


Fractures/Dislocations: Ankle Fractures—Adult


FIGURE 6-9 (A) Joint effusion (arrow) seen on the lateral radiograph. Coronal T2- (B) and sagittal fat-suppressed T2- (C) weighted images demonstrate a large effusion (open arrows) with a lateral talar dome fracture (arrow).
Suggested Reading
Arimoto HR, Forrester DM. Classification of ankle fractures. An algorithm. AJR Am J Roentgenol 1980;135:1057–1063.


Fractures/Dislocations: Ankle Adult—Supination-Adduction Injuries
Inversion (supination)-adduction injury. The forces cause a transverse
fracture below the joint line (Stage I) or ligament tear. With
continued stress a steep oblique fracture of the medial malleolus
occurs (Stage II).


FIGURE 6-11 Supination-adduction injury with a transverse fracture of the lateral malleolus (arrow) below the level of the ankle joint (line).
FIGURE 6-12 Supination-adduction Stage II injury with an oblique fracture (arrow) of the medial malleolus and avulsed fragments from the lateral malleolus (arrow).
Suggested Reading
Lauge-Hansen N. Fractures of the ankle. II. Combined experimental-surgical once experimental roentgenologic investigations. Arch Surg 1950;60:957–985.


Fractures/Dislocations: Ankle Adult—Supination Lateral Rotation Injuries
Supination-lateral rotation injuries. The talus causes posterior
fibular displacement with disruption of the anterior distal
tibiofibular ligament (Stage I). If force continues a spiral fracture
of the fibula occurs just above the joint line (best seen on the
lateral view) (Stage II). Continued force results in a posterior tibial
fracture or tear in the posterior distal tibiofibular ligament (Stage
III) and finally a transverse medial malleolar fracture or deltoid
ligament tear (Stage IV).


FIGURE 6-14 Supination-lateral rotation Stage II injury. AP (A), mortise (B), and lateral (C) radiographs. The fracture is only clearly demonstrated on the lateral (C) view (arrows).
Suggested Reading
Berquist TH. Radiology of the foot and ankle, 2nd ed. Philadelphia: Lippincott Williams & Wilkins; 2000:171–280.


Fractures/Dislocations: Ankle Adult—Pronation-Abduction Injuries
Pronation (eversion)-abduction injuries. Medial tension causes a
transverse malleolar fracture or deltoid ligament tear (Stage I).
Continued force results in disruption of the distal anterior and
posterior tibiofibular ligaments or a posterior tibial fracture (Stage
II) followed by an oblique fibular fracture near the joint line best
seen on the AP radiograph (Stage III).


FIGURE 6-16 Pronation-abduction Stage III injuries. (A) There is a transverse medial malleolar fracture (white arrow), tibiofibular ligament tears with separation of the tibia and fibula (open arrows), and an oblique fibular fracture (black arrows). (B) Widening of the medial ankle mortise (white arrow) caused by a ligament tear with increased tibiofibular distance (open arrows) and oblique fibular fracture (black arrows).
Suggested Reading
Arimoto HR, Forrester DM. Classification of ankle fractures: An algorithm. AJR Am J Roentgenol 1980;135:1057–1063.


Fractures/Dislocations: Ankle Adult—Pronation Lateral Rotation Injuries
Pronation-lateral rotation injuries. Medial tension results in a low
transverse medial malleolar fracture or deltoid ligament tear (Stage
I), followed by tearing of the distal anterior tibiofibular ligament
and interosseous membrane (Stage II). With continued force a high
(>6 cm) fibular fracture occurs (Stage III) followed by a posterior
distal tibiofibular ligament tear or avulsion fracture (Stage IV).


FIGURE 6-18 Pronation lateral rotation Stage IV injury with a transverse medial malleolar fracture (small arrow), disruption of the tibiofibular and interosseous ligaments (arrowhead), and a high fibular fracture (large arrow).
Suggested Reading
Arimoto HR, Forrester DM. Classification of ankle fractures: An algorithm. AJR Am J Roentgenol 1980;135:1057–1063.


Fractures/Dislocations: Ankle Adult—Plafond Fractures (Pilon)


Mortise view of a tibial plafond fracture reduced with external
fixateur and tibial screws. Note the residual articular deformity (arrow).
Suggested Reading
Bonar SK, Marsh JL. Tibial plafond fractures: Changing principles of treatment. J Am Acad Orthop Surg 1994;2:297–304.
Ovadia DN, Beals RK. Fractures of the tibial plafond. J Bone Joint Surg 1986;68A:543–551.


Fractures/Dislocations: Ankle Adult—Complications


FIGURE 6-20 AP (A) and lateral (B)
radiographs demonstrating severe posttraumatic arthritis with osseous
fragments in the joint and marked tibiotalar joint asymmetry.
Suggested Reading
Pettrone FA, Gail M, Pee D, et al. Quantitative criteria for prediction of results of displaced fracture of the ankle. J Bone Joint Surg 1983;65A:667–677.


Fractures/Dislocations: Talar Fractures—Talar Neck
FIGURE 6-21 Lateral radiograph of the foot showing a comminuted talar neck fracture (arrow).


Hawkins sign. AP radiograph after fixation of talar neck and medial
malleolar fractures. The lateral talus is sclerotic, indicating loss of
flow. There is normal subchondral osteopenia (arrow) medially.
Suggested Reading
Daniels TR, Smith JW. Talar neck fractures (review). Foot Ankle 1993;14:225–234.
Hawkins LG. Fractures of the neck of the talus. J Bone Joint Surg 1970;52A:991–1002.


Fractures/Dislocations: Talar Fractures—Body, Head, Process Fractures
FIGURE 6-23 Lateral radiograph of a posterior talar body and process fracture (arrow).


FIGURE 6-24 Coronal CT image demonstrating talar body fractures (arrows) entering the posterior subtalar joint.
Suggested Reading
Boack DH, Manegold S. Peripheral talar fractures. Injury 2004;35(S2):B23–B25.
Sneppen O, Christensen SB, Krogsoe O, et al. Fracture of the body of the talus. Acta Orthop Scand 1977;48:317–324.


Fractures/Dislocations: Talar Fractures—Talar Dome Fractures
FIGURE 6-25 Coronal T1- (A) and fat-suppressed sagittal T2-weighted (B) images demonstrate marrow edema and a subtle nondisplaced talar dome fracture (arrows).


FIGURE 6-26 Mortise view of a slightly displaced lateral talar dome fracture (arrow).
Suggested Reading
TWI, Janzen DL, Kendall H, et al. Detection of radiographically occult
ankle fractures following acute trauma. Positive predictive value of
ankle effusion. AJR Am J Roentgenol 1995;164:1185–1189.


Fractures/Dislocations: Talar and Subtalar Dislocations
FIGURE 6-27 Subtalar and talonavicular dislocation. (A) AP view of the ankle showing the talus (T), calcaneus (C), and navicular (N). The calcaneus is rotated under the talus. (B) Oblique view showing the talus lateral to the calcaneus.
Suggested Reading
Detenbeck LC, Kelly PJ. Total dislocation of the talus. J Bone Joint Surg 1969:51A:283–288.


Fractures/Dislocations: Calcaneal Fractures—Intra-articular
FIGURE 6-28 Lateral radiograph in a patient with a comminuted calcaneal fracture. Böhler’s angle measures 10 degrees.


FIGURE 6-29 Comminuted intra-articular calcaneal fracture. Axial (A,B) and coronal (C) CT images clearly show fragment position and articular involvement.


Suggested Reading
Crosby LA, Fitzgibbons I. Computerized tomographic scanning of acute intra-articular fractures of the calcaneus. J Bone Joint Surg 1990:72A:852–859.
Daftary A, Haims AH, Baumgartner MR. Fractures of the calcaneus: A review with emphasis on CT. Radiographics 2005;25:1215–1226.


Fractures/Dislocations: Calcaneal Fractures—Extra-articular
FIGURE 6-30 Lateral radiograph of an anterior calcaneal process fracture (arrow).
FIGURE 6-31 Lateral radiograph of a calcaneal tuberosity avulsion fracture.
Suggested Reading
Gilheany MF. Injury to the anterior process of the calcaneus. Foot 2002;12:142–149.


Fractures/Dislocations: Midfoot Injuries


FIGURE 6-32 Patterns of Lisfranc fracture/dislocations. (A) Type A: total incongruity; (B) Type B: partial incongruity; (C) Lateral dislocation; (D) Type C or divergent with total displacement (A) and partial displacement (B).



FIGURE 6-33 Lisfranc fracture/dislocation. (A) AP radiograph shows a fracture/dislocation (arrow) at the tarsometatarsal joints. There is also a dislocation (arrowhead) of the second metatarsophalangeal (MTP) joint. CT images in the axial (B), sagittal and coronal (C,D) planes demonstrate widening of the 1–2 metatarsal bases (arrow) with multiple osteochondral fractures (arrowheads).
Suggested Reading
Karasick D. Fracture and dislocation of the foot. Semin Roentgenol 1994;29:152–175.
Makawana NK, Van Lefland MR. Injuries of the midfoot. Curr Orthop 2005;19:231–242.


Fractures/Dislocations: Forefoot Injuries—Fifth Metatarsal Fractures
FIGURE 6-34 Oblique radiograph demonstrating the three zones of the proximal fifth metatarsal. There is an ununited Jone’s fracture (arrow) in Zone 2.
FIGURE 6-35 Avulsion fracture of the fifth metatarsal base in Zone 1 (arrow).


Suggested Reading
Ekrol I, Court-Brown CM. Fractures of the base of the fifth metatarsal. Foot 2004;14:96–98.
DJ, Theodorou SJ, Kakitubata Y, et al. Fractures of the fifth
metatarsal base: anatomic and imaging evidence of pathogenesis of
avulsion of the plantar aponeurosis and short peroneal tendon. Radiology 2003;226:857–865.
FIGURE 6-36 Crush injury. (A) AP radiograph demonstrates complex comminuted metatarsal fractures. (B) Fractures were reduced using K-wire fixation.



Fractures/Dislocations: Forefoot Injuries—Metatarsophalangeal Fracture/Dislocations
FIGURE 6-37 Dislocations. (A) AP radiograph with first MTP dislocation and displacement of the sesamoids (arrows). (B) Dorsal dislocation of the second proximal interphalangeal joint (arrow). After reduction (C) there is an obvious associated osteochondral fracture (arrow).
Suggested Reading
Karasick D. Fractures and dislocations of the foot. Semin Roentgenol 1994;29:152–175.


Fractures/Dislocations: Stress Fractures
Location Cause
Metatarsals Marching
Prior surgery
Rheumatoid arthritis
Tarsals Long-distance running
Calcaneus Jumping
Sesamoids Marching
Distal tibia Running
Distal fibula Running
Parachute jumping


FIGURE 6-38 AP radiographs of a healing third metatarsal stress fracture.


FIGURE 6-39 Calcaneal stress fractures. (A) Radionuclide scan demonstrates marked uptake in the calcaneus. (B) Sagittal fast spin-echo T2-weighted image with fat suppression demonstrates a calcaneal stress fracture (arrows) with surrounding edema.
Suggested Reading
Daffner RH. Stress fractures. Skel Radiol 1987;2:221–229.


Soft Tissue Trauma/Overuse Syndromes: Ligament Injuries
Technique Features of Ligament Tears
Stress Views
AP Tibio-talar shift >2 mm compared with normal side
Varus/Valgus Joint opening (talar tilt) >5 degrees compared with normal side
Arthrography Calcaneofibular tear-contrast fills peroneal tendon sheaths
Syndesmotic tear-contrast extends beyond recess
Medial tear-contrast extravasates medially
Tenography Contrast enters ankle joint from peroneal tendon sheath
MRI ↑ signal intensity and thickening with partial tears on T2-weighted sequences
↑ signal intensity with segments separated in complete tears on T2-weighted sequences
AP, anteroposterior; MRI, magnetic resonance imaging.


FIGURE 6-40 Stress views. Normal ankle (A) and injured (B)
ankle shows that the joint laterally on the injured side is 10 degrees
greater than the normal side because of tears in the calcaneofibular
and anterior talofibular ligaments.
FIGURE 6-41 Arthrogram of the left ankle shows contrast anteriorly (arrow)
because of an anterior talofibular ligament tear. The peroneal tendon
sheaths do not fill indicating the calcaneofibular ligament is intact.


FIGURE 6-42 (A) Axial T2-weighted MR image showing a joint effusion with a torn anterior talofibular ligament (arrow). (B) Coronal image showing a talar dome fracture with marrow edema and a torn calcaneofibular ligament (white arrow).
Suggested Reading
Berquist TH. Imaging of orthopedic trauma, 2nd ed. New York: Raven Press; 1992.


Soft Tissue Trauma/Overuse Syndromes: Peroneal Tendon Injuries
FIGURE 6-43 AP radiograph demonstrating a flake fracture (arrow) caused by peroneal tendon dislocation.


FIGURE 6-44 Peroneal tendon anatomy.


FIGURE 6-45 (A) Sagittal proton density-weighted image of the normal low signal intensity peroneal tendons. (B) Sagittal proton density-weighted image shows a torn tendon (arrow) at the fibular tip and only one tendon (lower arrow) distally.
Suggested Reading
DiGiovanni BF, Fraga CJ, Cohen BE, et al. Associated injuries found in chronic lateral ankle instability. Foot Ankle Int 2000;21:809–815.
Khoury NJ, El-Khoury GY, Saltzman CL, et al. Peroneus, longus, and brevis tendon tears. MR imaging evaluation. Radiology 1996;200:833–841.


Soft Tissue Trauma/Overuse Syndromes: Achilles Tendon


FIGURE 6-46 Ultrasound of Achilles tendon tear. Transaxial (A) and longitudinal (B) images of a left Achilles rupture. (Courtesy of J. W. Charboneau, Mayo Clinic, Rochester, MN.)


FIGURE 6-47 MRI of Achilles tear. Axial (A) and sagittal (B) T2-weighted images showing high signal intensity fluid (arrow) resulting from a complete tear of the Achilles tendon.
Suggested Reading
Schweitzer ME, Karasick D. MR imaging of disorders of the Achilles tendon. AJR Am J Roentgenol 2000;175:613–625.
Tuite MJ. MR imaging of the tendons of the foot and ankle. Semin Musculoskeletal Radiol 2002;6:119–131.


Soft Tissue Trauma/Overuse Syndromes: Medial Tendon Injuries


FIGURE 6-48 Medial tendon and tarsal tunnel anatomy.


FIGURE 6-49 Standing AP (A) and lateral (B) radiographs of the foot in an elderly female with posterior tibial tendon tears. (A) There is medial soft tissue swelling (open arrows)
bilaterally. The foot is pronated with the talar axis (T) projecting
medially, and the navicular (N) is rotated laterally. The second
metatarsal axis (2) is medial to the talocalcaneal angle. (B)
The calcaneal inclination (CI) angle is reduced to 11 degrees. The
talus is plantar flexed, increasing the talocalcaneal (TC) angle to 60
degrees. The talar first metatarsal angle (TF) should be zero, but in
this case it is -28 degrees.



FIGURE 6-50 MRI of a posterior tibial tendon tear. (A) Normal sagittal image with posterior tibial (PT) and flexor digitorum longus (FDL) tendons clearly demonstrated. (B)
Sagittal proton density image showing the flexor digitorum longus (FDL)
with no posterior tibial tendon because of a complete tear with
Suggested Reading
Garth WP. Flexor hallucis tendinitis in ballet dancers. J Bone Joint Surg 1981;63A:1489.
Karasick D, Schweitzer ME. Tear of the posterior tibial tendon causing asymmetric flatfoot. Radiographic findings. AJR Am J Roentgenol 1993;161:1231–1240.
Schweitzer ME, Karasick D. MR imaging of disorders of the posterior tibialis tendon. AJR Am J Roentgenol 2000;175:627–635.


Soft Tissue Trauma/Overuse Syndromes: Anterior Tendon Injuries
FIGURE 6-51 MRI of a partial anterior tibial tendon tear. Axial (A) and sagittal (B) T2-weighted images showing thickening and increased signal intensity in the anterior tibial tendon (arrow).
Suggested Reading
Gallo RA, Kolman BH, Daffner RH, et al. MRI of tibialis anterior tendon rupture. Skel Radiol 2004;33:102–106.
Khoury NJ, El-Khoury GY, Saltzman CL, et al. Rupture of the anterior tibial tendon. Diagnosis with MR imaging. AJR Am J Roentgenol 1996;167:351–354.


Soft Tissue Trauma/Overuse Syndromes: Plantar Fasciitis
Sagittal fat-suppressed fast spin-echo T2-weighted image of the normal
plantar fascia. There is uniform thickness with low signal intensity (arrowheads).


Active plantar fasciitis. Thinning and irregularity of the fascia with
increased signal intensity above and below the fascia an this sagittal
T2-weighted image.
FIGURE 6-54 Chronic plantar fasciitis. Sagittal T1-weighted image shows thickening of the fascia (arrowhead) near the calcaneal attachment.


FIGURE 6-55 Ruptured plantar fascia. T2-weighted sagittal image demonstrating a complete tear (arrow) in the plantar fascia with laxity distally.
Suggested Reading
Berkowitz JF, Kier R, Radicel S. Plantar fasciitis. MR imaging. Radiology 1991;179:665–667.
Theodorou DJ, Theodorou SJ, Farooki S, et al. Disorders of the plantar fascia: Review of MR imaging appearances. AJR Am J Roentgenol 2001;176:97–104.


Soft Tissue Trauma/Overuse Syndromes: Bursitis
FIGURE 6-56 Bursae of the heel.


FIGURE 6-57 Retrocalcaneal bursitis. Sagittal T1-weighted (A) and T2-weighted (B) MR images showing fluid distending the bursa (arrowhead) and bone erosion (open arrow in A).
Suggested Reading
Bottger BA, Schweitzer ME, El-Nousam KI, et al. MR imaging of normal and abnormal retrocalcaneal bursae. AJR Am J Roentgenol 1998;170:1239–1240.


Soft Tissue Trauma/Overuse Syndromes: Os Trigonum Syndrome
FIGURE 6-58 Computed radiography lateral view of the ankle showing an os trigonum with edema in the pre-Achilles fat (open arrow) caused by os trigonum syndrome.


FIGURE 6-59 MRI of os trigonum syndrome. Sagittal (A) and axial (B) T2-weighted images showing fluid in the region of the os trigonum (arrowheads in A) and edema (open arrow) and tendon sheath fluid (arrowhead) around the flexor hallucis longus tendon because of associated tendinitis.
Suggested Reading
Wakely CJ, Johnson DP, Watt I. The value of MR imaging in diagnosis of an os trigonum syndrome. Skel Radiol 1996;25:133–136.


Soft Tissue Trauma/Overuse Syndromes: Tarsal Tunnel Syndrome
Posttraumatic fibrosis
Talocalcaneal coalitions
Soft tissue masses
Ganglion cysts
Synovial hypertrophy
Hypertrophy of abductor hallucis muscle
Muscle anomalies


FIGURE 6-60 Enlarged veins causing tarsal tunnel syndrome. Axial (A) and sagittal (B) fat-suppressed T2-weighted images showing dilated veins or varices in the tarsal tunnel (arrows).
Suggested Reading
Pfeiffer WH, Cracchiolo A. Clinical results after tarsal tunnel decompression. J Bone Joint Surg 1994;76A:1222–1230.


Soft Tissue Trauma/Overuse Syndromes: Sinus Tarsi Syndrome
FIGURE 6-61 Sinus tarsi syndrome. Sagittal T1-weighted (A) and T2-weighted (B) images showing abnormal signal intensity in the tarsal sinus and bone erosions (arrows).
Suggested Reading
MA, Spreitzor AM. MR imaging of the tarsal canal and sinus. Normal
anatomy, pathologic findings, and features of sinus tarsi syndrome. Radiology 1993;186: 233–240.
N, Chung CB, Lai Y, et al. Tarsal sinus: Arthrography, MR imaging, and
pathologic findings in cadavers and retrospective study data in
patients with sinus tarsi syndrome. Radiology 2001;219:802–812.


Soft Tissue Trauma/Overuse Syndromes: Impingement Syndromes


FIGURE 6-62 Anterolateral impingement syndrome. CT images with bone (A) and soft tissue (B) settings showing hypertrophy of the capsule (arrow) and a marginal osteophyte (open arrow).


FIGURE 6-63 Sagittal T1-weighted image of an old partial ligament tear with soft tissue thickening (arrow) anterolaterally.
Suggested Reading
Robinson P, White LM. Soft tissue and osseous impingement syndromes of the ankle. Role of imaging in diagnosis and management. Radiographics 2002;22:1457–1471.
Rubin DA, Tishkaff NW, Britton CA, et al. Anterolateral soft tissue impingement of the ankle. Diagnosis using MR imaging. AJR Am J Roentgenol 1997;169:829–835.


Soft Tissue Trauma/Overuse Syndromes: Midfoot and Forefoot Syndromes
Condition Imaging Approaches
Metatarsalgia Clinical diagnosis, radiographs
Sesamoiditis Sesamoid views, radionuclide scans, MRI
Osteochondritis Radiographs
Synovitis Contrast-enhanced MRI
Hallux rigidus Radiographs
Turf toe Radiographs, MRI
Neuromas Ultrasound, MRI
Stress fractures Radiographs, MRI, CT for midfoot
MRI, magnetic resonance imaging; CT, computed tomography.


FIGURE 6-64 Stress fracture. Subtle periosteal new bone (arrow) in the distal second metatarsal as the result of a healing stress fracture.
FIGURE 6-65 Sesamoid fracture. Lateral radiograph of the forefoot demonstrates sclerosis and fracture of the medial sesamoid (arrowhead).


FIGURE 6-66 Axial T1-weighted image demonstrating a Morton’s neuroma (arrow).
Suggested Reading
Berquist TH. Radiology of the foot and ankle, 2nd ed. Philadelphia: Lippincott Williams & Wilkins; 2000:105–170.


Neoplasms/Tumorlike Conditions: Skeletal Lesions—Benign


FIGURE 6-67 Aneurysmal bone cyst. (A) Radiograph showing an expanding lesion of the second proximal phalanx. Coronal T1-weighted (B) and axial (C) and coronal (D) T2-weighted images showing a septated lesion with fluid–fluid levels on the axial image (C).
Suggested Reading
Johnston MR. Epidemiology of soft-tissue and bone tumors of the foot. Clin Podiatr Med Surg 1993;10:581–607.
Unni KK. Dahlin’s bone tumors: General aspects and data on 11,087 cases. Philadelphia: Lippincott-Raven; 1996.


Neoplasms/Tumorlike Conditions: Skeletal Lesions—Malignant



FIGURE 6-68 Ewing sarcoma of calcaneus. (A) Routine lateral radiograph showing bone sclerosis. (B) Sagittal T2-weighted image showing irregular signal intensity with joint fluid. Ewing sarcoma of calcaneus. (A) Routine lateral radiograph showing bone sclerosis. (B) Sagittal T2-weighted image showing irregular signal intensity with joint fluid. (C) CT of chest showing a metastatic nodule (arrow).
Suggested Reading
Unni KK. Dahlin’s bone tumors: General aspects and data on 11,087 cases. Philadelphia: Lippincott-Raven; 1996.


Neoplasms/Tumorlike Conditions: Soft Tissue Lesions—Benign


FIGURE 6-69 Peroneal tendon ganglion cyst. (A) Radiograph showing focal lateral swelling (arrows). Coronal T2-weighted (B) and axial T1-weighted (C) images showing a homogenous low-intensity lesion on T1-weighted image (C) and high-intensity lesion on T2-weighted (B) images.
Suggested Reading
Kirby SJ, Shereff MJ, Lewis MM. Soft tissue tumors and tumor-like conditions of the foot. Analysis of 83 cases. J Bone Joint Surg 1989;71A:621–626.


Neoplasms/Tumorlike Conditions: Soft Tissue Lesions—Malignant
FIGURE 6-70 Synovial sarcoma. Coronal T1-weighted (A) and axial proton density (B) images showing a multicystic loculated lesion that could be confused with a benign process.
Suggested Reading
Weiss SW, Goldblum JR. Enzinger and Weiss’s soft tissue tumors. 4th ed. St. Louis, Mosby; 2001.


Arthritis: Osteoarthritis (Degenerative Joint Disease)


AP view of the forefoot showing osteoarthritis of the first MTP joint
with asymmetric joint space narrowing, bone sclerosis, and a
subchondral cyst (arrow).
Suggested Reading
Bancroft LW, McLeod RA. Arthritis. In Berquist TH, ed. Radiology of the foot and ankle, 2nd ed. Philadelphia: Lippincott Williams & Wilkins; 2000:281–314.


Arthritis: Rheumatoid Arthritis


FIGURE 6-72 Rheumatoid arthritis limited to the fifth MTP joint (arrow) (A) and involving all MTP joints with erosions and joint subluxation (B).
Suggested Reading
Bancroft LW, McLeod RA. Arthritis. In: Berquist TH, ed. Radiology of the foot and ankle, 2nd ed. Philadelphia: Lippincott Williams & Wilkins; 2000:281–314.


Arthritis: Psoriatic Arthritis
FIGURE 6-73 (A)
AP view of the great toe with asymmetric joint destruction and bone
proliferation at the base of the distal phalanx characteristic of
seronegative spondyloarthropathies. (B)
Characteristic swelling and joint space changes in the great toe with
ankylosis of the fourth toe caused by psoriatic arthritis.
Suggested Reading
Avila R, Pugh DG, Slocumb CH, et al. Psoriatic arthritis. A roentgenologic study. Radiology 1960;75:691–701.


Arthritis: Reiter Syndrome
FIGURE 6-74 (A) Sausage digit in Reiter syndrome. Characteristic diffuse swelling with erosions and proliferation of the distal joint. (B) Poorly defined spur (arrow) and swelling at the plantar aspect of the calcaneus caused by Reiter syndrome.
Suggested Reading
Peterson CC, Silbiger ML. Reiter’s syndrome and psoriatic arthritis. Their roentgen spectra and some interesting similarities. AJR Am J Roentgenol 1967;101:860–871.


Arthritis: Ankylosing Spondylitis
FIGURE 6-75 Poorly defined proliferative changes in the posterior and plantar aspects of the calcaneus caused by ankylosing spondylitis.
Suggested Reading
El-Khoury FV, Kathol MH, Brandser EA. Seronegative spondyloarthropathies. Radiol Clin North Am 1996;34:343–357.


Arthritis: Neurotrophic Arthropathy
FIGURE 6-76 AP (A) and lateral (B) radiographs showing characteristic fragmentation in the midfoot as the result of neurotrophic arthritis.
Suggested Reading
RH, Morrison MJ, Beabout JW. Diabetic neuropathy in the foot. Patient
characteristics and patterns of radiographic change. Foot Ankle 1983;4:15–22.
Moore TE, Yuh WTC, Kathol MH, et al. Abnormalities of the foot in patients with diabetes mellitus: Findings on MR imaging. AJR Am J Roentgenol 1991;157:813–816.


Arthritis: Gout
Gout. Extensive erosive changes in the first MTP joint, primarily the
metatarsal head. Note the tophaceous soft tissue mass medially.
Suggested Reading
Ya JS, Chung C, Recht M, et al. MR imaging of tophaceous gout. AJR Am J Roentgenol 1997;168: 523–527.


Arthritis: Calcium Pyrophosphate Deposition Disease
FIGURE 6-78 CT of ankle. Coronal CT image demonstrating cartilage calcification.
Suggested Reading
Pascual E. The diagnosis of gout and CPPD arthropathy. Br J Rheumatol 1996;35:306–308.


Infection: Osteomyelitis


FIGURE 6-79 Osteomyelitis. (A) Lateral radiograph of the calcaneus shows lytic changes posteriorly. (B) Coronal CT image demonstrates a sequestrum (arrow) in the area of infection. (C) Sagittal T2-weighted MR image shows areas of bone infection (arrow) and fluid in the soft tissues (open arrows).
Suggested Reading
HP, Morrison WB, Schweitzer ME. MR image analysis of pedal
osteomyelitis: Distribution, patterns of spread, and frequency of
associated ulceration and septic arthritis. Radiology 2002;223:747–755.


Infection: Soft Tissue Infection
FIGURE 6-80 Axial T2-weighted MR image demonstrating an abscess (arrow) after puncture wound to the foot.
Suggested Reading
Laughlin JT, Armstrong DG, Corporusso J, et al. Soft tissue and bone infection after puncture wounds in children. West J Med 1997;166:126–128.
HP, Morrison WB, Schweitzer ME. Is soft tissue inflammation in pedal
infections contained by fascial planes? Analysis of compartmental
involvement in 115 feet. AJR Am J Roentgenol 2002;178:605–612.


Infection: Joint Space Infection
FIGURE 6-81 Joint space infection. (A) Coronal T2-weighted image showing a joint effusion with two areas of bone involvement (arrowheads). (B) Sagittal T1-weighted image showing abnormal signal intensity (arrowhead) from infection extending from the joint.
Suggested Reading
Brower AC. Septic arthritis. Radiol Clin North Am 1996;34:293–310.


Infection: Diabetic Foot
A: Soft Tissue Swelling and/or Erythema with No Ulceration
Radiograph Clinical Features Next Steps
Positive Suspicious for infection Biopsy and treat
Negative Low index of suspicion Three-phase bone scan
If negative, stop
If positive, MRI
Negative High index of suspicion T2-weighted, STIR, or contrast-enhanced MRI
If positive, treat
If negative, follow
B: Soft Tissue Ulceration
Radiograph Clinical Features Next Steps
Positive Suspicious for infection Biopsy and treat
Negative Low index of suspicion Débride and treat ulcer (no drainage or obvious infection)
Negative High index of suspicion T2- or contrast-enhanced MRI or radionuclide WBC or granulocyte scans
Positive, biopsy and treat
Negative, treat ulcer
C: Neuropathic Arthropathy with or without Ulcer
Radiograph Clinical Features Next Steps
Positive Suspicious for infection Biopsy and treat
Hypertrophic arthropathy Suspicious for infection Contrast-enhanced MRI or radionuclide WBC or granulocyte scans
Positive, biopsy and treat
Negative, follow
STIR, short TI inversion recovery; WBC, white blood cell; MRI, magnetic resonance imaging.


FIGURE 6-82 Diabetic patient with heel ulcer (open arrow) and abnormal signal intensity in the calcaneus caused by osteomyelitis.
Suggested Reading
Lipsky BA, Pecasaro RE, Wheat LJ. The diabetic foot: Soft tissue and bone infection. Infect Dis Clin North Am 1990;4:409–432.
WB, Schweitzer ME, Wapner KL, et al. Osteomyelitis in feet of
diabetics: Clinical accuracy, surgical utility, and cost effectiveness
of MR imaging. Radiology 1995;196:557–564.


Pediatric Disorders: Terminology

Term Definition
Talipes Congenital deformity of the foot
Pes Acquired deformity of the foot
Valgus Orientation of bones distal to a joint away from the midline
Varus Orientation of bones distal to a joint toward the midline
Adduction Displacement of bones or anatomic part in transverse plane toward the axis of the body
Abduction Displacement of bones or anatomic part in a transverse plane away from the axis of the body
Equinus Fixed plantar flexion of the foot
Calcaneus Fixed dorsiflexion of the foot
Cavus Raised longitudinal arch
Planus Flattened longitudinal arch
Pediatric Disorders: Normal Angles of the Foot and Ankle


FIGURE 6-83 Normal simulated weight-bearing views of the pediatric foot. Normal AP (A) and lateral (B) talocalcaneal angles are 28 degrees (range 25–55 degrees) and 47 degrees (range 25–55 degrees), respectively.


Lateral talo–first metatarsal angle is 10 degrees (range 9–31 degrees).
Measured by lines along talar and first metatarsal axes.
Tibiocalcaneal angle measured by lines along the tibial and calcaneal
axes. In this case, 70 degrees; newborn 75 degrees; 6 years 65 degrees.


FIGURE 6-86 Longitudinal plantar arch angle measured by lines at the calcaneus and fifth metatarsal. Normal 150 to 170 degrees.
Suggested Reading
Vander Wilde R, Staheli LT, Chew DE, et al. Measurements on radiographs of the foot in normal infants and children. J Bone Joint Surg 1998;70A:407–415.


Pediatric Disorders: Hindfoot Abnormalities


FIGURE 6-87 Hindfoot valgus. (A)
AP radiograph showing an increased talocalcaneal angle with the long
axis of the talus directed medial to the navicular and first
metatarsal. (B) Lateral view showing an increased angle with midfoot incongruency.


FIGURE 6-88 Hindfoot varus. (A) AP radiograph showing a decreased talocalcaneal angle with metatarsus adductus. (B) Lateral radiograph showing a decreased talocalcaneal angle.


FIGURE 6-89 Hindfoot equinus. The foot is plantar flexed with tibiocalcaneal angle greater than 90 degrees (in this case, 110 degrees).
Suggested Reading
Ozonoff MB. Pediatric orthopedic radiology. Philadelphia: WB Saunders; 1992:397–460.


Pediatric Disorders: Plantar Arch Abnormalities
FIGURE 6-90 Lateral radiograph demonstrating pes planus with talo–fifth metatarsal angle greater than 175 degrees.


FIGURE 6-91 “Rocker bottom” deformity with calcaneal–fifth metatarsal angle greater than 180 degrees.
Pes cavus with increased calcaneal dorsiflexion and plantar flexion of
the metatarsals. Calcaneal–fifth metatarsal angle is less than 150
Suggested Reading
Vander Wilde R, Staheli LT, Chew DE, et al. Measurements on radiographs of the foot in normal infants and children. J Bone Joint Surg 1988;70A:407–415.


Pediatric Disorders: Forefoot Abnormalities
FIGURE 6-93 AP radiograph demonstrating metatarsus adductus with hindfoot valgus.


FIGURE 6-94 AP radiograph of a patient with skewfoot (hooked or “Z” foot).
Suggested Reading
Hubbard AM, Davidson RS, Meyer JS, et al. Magnetic resonance imaging of skewfoot. J Bone Joint Surg 1996;78A:389–397.


Pediatric Disorders: Talipes Equinovarus
FIGURE 6-95 AP (A) and lateral (B) radiographs showing hindfoot equinus, hindfoot varus, and forefoot adductus.
Suggested Reading
Hersh A. The role of surgery in treatment of clubfoot. Foot Ankle Int 1995;16:672–681.


Pediatric Disorders: Congenital Vertical Talus


FIGURE 6-96 Congenital vertical talus. (A) AP radiographs showing hindfoot valgus (lines) greater on the right. (B) Lateral radiographs showing vertically oriented tali (lines) and calcaneal plantar flexion with flatfoot deformities.
Suggested Reading
Naptiontek M. Congenital vertical talus: a critical review of 32 feet operated by peritalar reduction. J Pediatr Orthop 1995;4:179–185.


Pediatric Disorders: Pes Planovalgus


FIGURE 6-97 Pes planovalgus (flexible flatfoot). (A)
AP radiograph showing an increased talocalcaneal angle with lateral
subluxation of the navicular. The forefoot is abducted and metatarsals
parallel. (B) Lateral radiograph showing arch collapse with increased talocalcaneal angle.
Suggested Reading
Ozonoff MB. Pediatric orthopedic radiology. Philadelphia: WB Saunders; 1992:397–460.


Pediatric Disorders: Tarsal Coalitions


FIGURE 6-98 Talocalcaneal coalition. (A) Lateral radiograph showing flatfoot deformity with osseous density (arrow) in the midsubtalar joint and a prominent talar beak (open arrow). (B) Coronal CT image confirms the coalition (arrow).


FIGURE 6-99 Calcaneonavicular fibrous coalition. Lateral (A) and oblique (B) radiographs showing elongation of the anterior calcaneal process (arrow). The coalition (arrow) is best seen on the oblique view. (C) Oblique sagittal T1-weighted MR image showing low intensity between the navicular and calcaneus (arrow) consistent with fibrous tissue.
Suggested Reading
Newman SJ, Newberg AH. Congenital tarsal coalition: Multimodality evaluation with emphasis on CT and MR imaging. Radiographics 2000;20:321–332.


Pediatric Disorders: Overgrowth/Hypoplasia/Aplasia
FIGURE 6-100 Macrodactyly. AP radiographs showing increased size of the right toes.


FIGURE 6-101 Bradydactyly. AP radiograph showing generalized shortening of the second to fourth rays.
FIGURE 6-102 Polydactyly. AP radiographs showing bilateral supernumerary metatarsals and digits.
Suggested Reading
Taybi H, Lachman RS. Radiology of syndromes, metabolic disorders, and skeletal dysplasias. St. Louis: CV Mosby-Yearbook; 1996.


Pediatric Disorders: Freiberg Infraction
FIGURE 6-103 Freiberg infraction. AP radiograph showing a flattened sclerotic second metatarsal head (arrow).
Suggested Reading
Smillie IS. Freiberg’s infraction (Kohler’s second disease). J Bone Joint Surg 1957;39B:580.


Pediatric Disorders: Köhler Disease


FIGURE 6-104 Köhler disease. AP (A) and lateral (B) radiographs showing a sclerotic flattened navicular (arrow).

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