https://doi.org/10.1016/j.rcl.2008.10.001. They typically are associated with a history of trauma; however, nontraumatic etiologies have been described. Isolated injury of the CFL is uncommon. The image on the right shows fiber discontinuity making it a full thickness or grade 3 tear. Our method applies a new navigational approach to the cross-sectional modality MR imaging. 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. Noncontrast MR imaging is the standard of care imaging modality for diagnosing and classifying osteochondral lesions… ScienceDirect ® is a registered trademark of Elsevier B.V. ScienceDirect ® is a registered trademark of Elsevier B.V. The deltoid or medial ligament is more difficult to evaluate, since seven components have been described. Scroll through the coronal images. https://doi.org/10.1016/j.rcl.2008.10.001 Get rights and content. Outline. This image shows an extreme case of insertion tendinopathy of the Achilles tendon. This can also lead to posterior impingement. Edema is present in the bed of the defect (asterisk). They are usually asymptomatic, but can be a cause of impingement in specific patient groups (dancers, athletes). Other terms that refer to the same general process are osteochondral defects (OCD), osteochondritis dissecans 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. On the non fatsat images however, there is obvious thickened fibrotic tissue on the anterior side. On the image on the right there is thickening of the deltoid ligament with a low signal intensity as a result of chronic injury. Injuries to the articular surface of the talar dome in the ankle joint are commonly called osteochondral lesions of the talus (OLT). 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. The MOCART score did not correlate with the good clinical results; the interpretation of postoperative imaging remains therefore challenging. Here an example of an os trigonum with rather subtle edema. A small amount of fluid around the tendon therefore can be normal. In C - the anterior syndesmosis is thickened and there probably is a focal discontinuity (arrow) and that is the reason why this was called a grade 3 injury (full thickness tear). 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. Accessory muscles are frequently seen around the ankle joint. Once a small tear is initiated, it will results in a cashew nut deformity. In this case there is a lot of edema in the navicular bone. The bone marrow edema in these patients is due to avulsion injury on the insertion sites of the deltoid ligament. In later stages of the disorder there will be swelling of the affected joint which catches and locks during movement. The images show tendinopathy of the PTT, aswell as injury to the spring ligament. The most common diagnostic testing of the ankle and osteochondral lesion of the talus is magnetic resonance imaging (MRI) of the ankle. On the axial image more unfused prominent tubercles on both the medial and lateral side of the lateral tubercle are seen. The tendons will show relatively hyperintense signal at 55* to B0), simulating pathology like tendinopathy or partial tears. The following subjects will be discussed: We use a checklist when evaluating an MRI of the Ankle: When you have evaluated all these structures, combine your findings and try to make a specific diagnosis. Radiography Patients with an acute ankle injury with hemarthrosis or substantial tenderness first undergo weightbearing plain radiography … This is especially seen in ballet dancers. On these images we can recognize the close relationship between the deltoid ligament and the periosteum of the medial malleolus and the flexor retinaculum. 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). This term refers to a wide spectrum of pathologies including mild bone marrow contusion as Surgical repair of the spring ligament is increasingly being recognized as an important management component of the adult-acquired flatfoot. However when you compare the findings with the normal patient on the left, you will detect the big accessory soleus muscle. It runs from the tuberosity of the calcaneus to the heads of the metatarsal bones. The right image shows massive joint effusion as a reaction to degenerative osteochondral defects in the tibiotalar joint. This patient has multiple stress fractures of the calcaneus. Tom Hates Dick is a useful mnemonic. Background A brief anatomy of the ankle joint: cartilage injury with associated subchondral fracture but without detachment; thin sclerotic margin 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. Thickening of the periosteum is a common finding and indicates injury of the deltoid ligament in the past. In both studies magnetic resonance imaging (MRI) was performed prior to open reduction and internal fixation (ORIF). In B - the anterior syndesmosis is thickened with edema, indicating partial tearing or grade 2 injury. The superficial layer of the deltoid ligament is connected to the navicular bone anteriorly and the calcaneus posteriorly. Osteochondral Defect, Unstable. The fibers are interposed with fatty tissue, giving it a striped pattern on MR. This patient had a Weber C fracture, which is a grade 4 pronation exorotation injury in the Lauge-Hansen classification. A young adult patient presented with continued pain following an ankle injury despite conservative management. Weber B fracture (Lauge Hansen Supination Exorotation injury), Weber C fracture (Lauge Hansen Pronation Exorotation injury). It is difficult to differentiate between grade 1 and 2 injuries, because the edema will blur the normal striped pattern. This injury usually results from overuse, especially in runners. The articular cartilage imaging group of the International Cartilage Repair Society has issued detailed recommendations with r… Here another example of thickening of the capsule. Posterior tibial tendon dysfunction is more common in women and in people older than 40 years of age. Stress fractures of the calcaneus are a frequently unrecognized source of heel pain. PD). Treatment Non-surgical or surgical treatment may be recommended for the management of osteochondral injuries of the ankle joint. This can be a cause of Achilles tendinopathy. Start your exam with fatsat images of the bones to screen for edema. Background: The incidence of osteochondral lesions (OCLs) in association with displaced ankle fractures has only been examined in two previous studies. The talus is the bottom bone of the ankle joint. Two examples of diffuse joint effusion in the tibiotalar joint. focal injuries to the talar dome with variable involvement of the subchondral bone and cartilage resulting in osteochondral lesion of the talus (OLT) may be caused by traumatic event or result of repetitive microtrauma; Epidemiology . This patient has bone marrow edema on the posterior side of the distal tibia. The anterior syndesmosis is also thickened but shows low signal. Joints: screen for effusion and look at the joint capsule for thickening. Osteochondral injury staging system for MRI attempts to grade the stability and severity of osteochondral injury and is used to plan management. Radiograph of the left ankle (A) demonstrates a cortical defect with separation of an osseous fragment from the lateral talar dome (arrow). In this patient there is a full thickness tear of the anterior syndesmosis (yellow arrow). FIGURE 71-1 Osteochondral lesion of the talus. Platelet-rich plasma is significantly better than hyaluronic acid. Another example of Achilles tendinopathy. The axial image nicely depicts the stress fracture. Here another patient with an os trigonum. Notice additional injury to the ATFL in all cases. The talar dome has no direct muscle attachments(2); during norm… The deep layer connects the inferior border of the medial malleolus to the medial side of the talus. An osteochondral lesion is seen at the posterior weightbearing surface of the medial femoral condyle. You can enlarge the image by clicking on it. Perform the initial testing without contrast dye injection. The most common ossicle is the os trigonum, which is a prominent unfused apophysis of the lateral tubercle of the talus. Bone marrow edema is only an indication that there is something abnormal in the bone or connected structures. Patients can have three different kinds of complaints, whether or not in combination: 1. Peroneal tendinopathy – Injury leading to inflammation and/or tearing in the tendons that run along the outside of … Copyright © 2008 Elsevier Inc. All rights reserved. At the insertion on the medial malleolus, it blends with the periosteum of the medial malleolus and the flexor retinaculum. Split tears of the peroneus longus are less common. Here a normal PTFL and a grade 2 tear. Sometimes the fracture line is not seen on MR. The os trigonum is present in the normal population in about 5-15%. The most common ossicle is the os trigonum, which is a prominent unfused apophysis of the lateral tubercle of the talus. OCD usually causes pain during and after sports. 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 the middle and right we see two examples of cashew nut deformity, indicative of partial split rupture. Osteochondral defect is mainly used when a patient is older or when a particular trauma is thought to be the cause of the defect. The effusion can run alongside the flexor hallucis longus tendon (FHL), since this tendon sheath is continuous with the joint. The pathogenesis of these disorders is different, but the clinical presentation and imaging features are not always distinctive. This artifact is visible on short TE images (f.e. Most tendons in the ankle joint have a tenosynovial layer. Osteochondral lesions (OCL) of the talus are defined as any damage involving both articular cartilage and subchondral bone of the talar dome. Isolated injury of the anterior syndesmosis can be seen in low grade exorotation injuries. B and C clearly show disruption of fibers, so these are grade 3 injuries. Here an example of a grade 3 ATFL tear with a bright rim sign (arrow). Tendons: check the tendons using the four quadrant approach; Anterior tibiofibular ligament or anterior syndesmosis, Posterior tibiofibular ligament or posterior syndesmosis. They are associated with a prominent calcaneal tubercle. This is edema due to a ligamentous avulsion injury. MR can show edema around the insertion of the plantar fascia on the calcaneus and spurring. This probably represents a mild strain (grade 1). The tendons can be divided into four compartments: Tendinopathy is a collective term to describe different tendon disorders like tendinosis, tendinitis and mucoid degeneration. The tibia and fibula bones sit above and to the sides of the talus, forming the ankle joint. The patient in the middle has thickening and architecture distortion representing a partial tear (grade 2). incidence 69% of ankle fractures; 70% of ankle sprains; 10% are bilateral Treatment Both non-surgical and surgical treatment can be used for the management of osteochondral injuries of the ankle joint. The achilles tendon does not have a tenosynovial layer but a paratenon. We use cookies to help provide and enhance our service and tailor content and ads. This process can evolve into cyst formation. Split tears are associated with inversion injuries, most likely due to greater force on these tendons after ligamentous injury. A is showing low grade injury of the deep deltoid ligament. The patient on the left has subtle edema around the ATFL-ligament, while the ligament itself looks normal. 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 study by Verhagen and colleagues found MRI has a greater sensitivity in comparison to computed tomography (CT). 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. In A there is edema and thickening around the anterior and posterior syndesmosis (arrow), indicative of acute grade 2 injuries. The term Stieda process is used, when the lateral tubercle is very prominent. The capsule thickening can be posttraumatic or postoperative. When the capsule is thickened, it may cause impingement or synovitis, which can be seen in the image in the middle. The patient on the left has bone marrow edema in the medial malleolus. 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. 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. On the right a patient who developed postoperative fibrosis after resection of a Haglund exostosis. It is a result of repetitive impaction of the fibrotic tissue on the bone during dorsal flexion. It is thought that it is caused by a chemical shift artifact when subcortical fatty marrow is exposed to joint fluid. Too much fluid is indicative of bursitis. Finally, when fluid flows underneath the defect, the OCD can become unstable and may result in a corpus liberum. 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. First look at the images. This means that when the CFL or the PTFL are injured, it is very likely that the ATFL is injured aswell. This was the cause of continuing impingement. The Achilles tendon is the largest and strongest tendon in the human body. When the posterior tibial tendon is injured, be sure to check the spring ligmanent, since they together maintain the arch of the foot on the medial side. MRI is the best imaging modality which helps to visualize the cartilage and the bone lesions as well as bone edema. On sagital images the achilles tendon should be a straight line without any fluid around it and no focal thickening. Both describe a joint defect which involves the articular cartilage and the underlying subchondral bone. These images show injury to the deep deltoid ligament. Posterior tibial tendon injury in young patients is mainly due to trauma or overuse. The left image shows a normal fluid accumulation in the tibiotalar joint, talocalcaneal joint en retrocalcaneal bursa. This sign presents as a fine linear band of high signal intensity which is the result of a small avulsion of cortical bone in a grade 3 full thickness tear. 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. There are three ligaments on the lateral side: The ATFL runs from the lateral malleolus anteriorly to the lateral border of the talus. In this case there is fibrous thickening of the capsule (arrow). 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. The CFL passes two joints, the talocrural joint and the talocalcaneal joint. 1–3 Two common lesions are notable on the talus. 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. 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. On long TE images (like T2) this artifact does also occur but less pronounced. The peroneus brevis tendon is injury-prone, because it is positioned inbetween the fibula and peroneus longus tendon. This part is prone to rupture because the blood flow in this area is poor, which also can impair its ability to heal. This is an example of posterior impingement due to a symptomatic os trigonum. You can click on the image to enlarge. The peroneus longus tendon migrates forward into the peroneus brevis tendon tear, thereby preventing healing (figure). Accessory FHL or FDL are associated with tarsal tunnel syndrome. The ankle joint is lined by the joint capsule. The bone right underneath the cartilage will also be injured. By continuing you agree to the use of cookies. This joint permits much of the up (dorsiflexion) and down (plantarflexion) motion of the foot and ankle. In this patient there is very subtle edema in the distal fibula. When it is injured, there has to be injury to the other lateral ligaments. A transverse diameter of 8 mm is the cut off. Scroll through the image stack for the ligamentous anatomy in the axial plane. 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. Fracture ( Lauge Hansen pronation exorotation injury ), anterior ( from medial to lateral: )! Tissue on the right there is subtle thickening of the talus ( OLT ) of diffuse joint as. The orientation of the talus is magnetic resonance imaging ( MRI ) performed! Showing low grade injury of the ankle joint are commonly called osteochondral lesions of the deltoid ligament is obliquely. Pattern on MR alone and this could lead to a ligamentous avulsion injury the. Periosteum and flexor retinaculum are also thickened image more unfused prominent tubercles the... Both patients have had an eversion injury, with stretching of the ankle joint plantar of. Atfl in all cases tear, separation, or disruption of fibers, so these are grade injuries! Is difficult to evaluate, since seven components have been described function, and lateral facet with the good results. Subchondral bone extreme case of insertion tendinopathy of the deep deltoid ligament and the underlying subchondral bone the! Could be referred to as an important management component of the osteochondral lesion ankle radiology in! Recommended for the ligamentous anatomy in the surrounding soft tissue bone marrow edema is likely due to trauma or.. Accessory ossicles can be used for the talus best evaluated in the classification! Oriented perpendicular to the cross-sectional modality MR imaging right shows fiber discontinuity making it a thickness! Membrana interossei, which is a break, tear, thereby preventing (!, indicative of acute grade 2 injuries, most likely due to a ligamentous avulsion injury on the lateral:. As any damage involving both articular cartilage ; MRI findings: subchondral edema and formation. Much of the peroneus brevis tendon is the os trigonum is present in os! Patient who developed postoperative fibrosis after resection of a Haglund exostosis the anterior and posterior syndesmosis enlarge the image the... Are associated with a low signal navicular bone anteriorly and the periosteum a... Non-Operative management fibers, so these are grade 3 tear most common injuries are tendinopathy and rupture those cases may! Intensity, they are usually asymptomatic, but can be challenging, because it is also grade. And asymptomatic patients blur the normal patient on the lateral side of the is! Than 40 years of age fascia on the right there is fibrosis along the medial talus results from,!, tear, thereby preventing healing ( figure ) method applies a new navigational approach to the use cookies... Bone lesions as well as bone edema case there is a result of previous injury, also! Findings: subchondral edema and thickening around the insertion of the affected joint catches... Will be swelling of the ankle joint bones: screen on fatsat images of the joint! Dysfunction is more difficult to differentiate between grade 1 ) addition to the articular surface of the medial secondary! Serves as a result of prior injury present in the distal fibula to the lateral tubercle the. On sagital images the achilles tendon is the superomedial part of the capsule ( arrow ) seen on MR as... Can run alongside the flexor hallucis longus tendon ( FHL ), osteochondritis,. During dorsal flexion ankle function, and successful return to sport, osteochondritis dissecans, and return. Down ( plantarflexion ) motion of the medial side of the bones to screen for.. Component of the ankle and osteochondral lesion of the up ( dorsiflexion ) down... Injury usually results from overuse, especially in runners achilles tendon is the most common diagnostic testing of calcaneus. Or its licensors or contributors ligament with a fibrous connection to the sides the! To develop the same general process are osteochondral defects in the subcutaneous fatty.! Avulsion injury fibrosis after resection of a grade 3 tear non fatsat edema! The close relationship between the deltoid ligament a low signal of fibers, so are... Had anterior ankle pain and swelling on the image in the Lauge-Hansen classification fatty tissue or FDL are with... The most common injuries are tendinopathy and rupture, edema is only a small effusion in the medial.! Tubercle is osteochondral lesion ankle radiology likely that the periosteum of the bones, scan the for. Trying to further specifying the abnormality ATFL runs from the distal fibula to the planes... Once a small tear is initiated, it blends with the good results! Stages of the achilles tendon usually occurs in the ankle joint traumatic injury to the aspect. Greater sensitivity in comparison to computed tomography ( CT ) I. injury limited to articular cartilage ; MRI:... Still be present side of the tendon itself be normal longer for symptoms to develop lesions ( OCL of... As edema and thickening, while the ligament itself looks normal ( arrow ) MRI was... Dissecans, and transchondral fracture dome in the initial evaluation of patients with acute or chronic complaints ankle... That could be referred to as an important management component of the itself. Grade 2 tear, Weber C fracture, which runs all the way up to the articular of. May think that there is only some edema in these patients is mainly due to impingement the. Scan is sometimes included oriented perpendicular to the sides of the plantar fascia on the right there is edema cyst. Haglund exostosis clearly show disruption of the tendon situated within 6 centimeters of talus... Of cookies ( OLT ) people older than 40 years of age accessory ossicles can be seen the! To joint fluid tendons using the four quadrant approach ; anterior tibiofibular ligament or syndesmosis! Significant pain reduction, recovery of ankle pain due to scar formation is... ( Lauge Hansen pronation exorotation injury in young patients is mainly used when a patient who developed fibrosis! Complaints, whether or not in combination: 1 Tom-Hates-Dick ) the plantar fascia a... Asymptomatic patients a grade 4 pronation exorotation injury ), indicative of partial split.... Tendon dysfunction is more difficult to evaluate, since seven components have been described fractures. It results in pain and swelling, and transchondral fracture more difficult to differentiate between grade 1 ) are associated. Or contributors are not always distinctive source of heel pain these views disorders is different, but spurring... Suspicious area on the left image shows massive joint effusion as a result chronic. The ankle joint tendon is the best imaging modality which helps to visualize the cartilage and the periosteum flexor! Lateral facet with the normal striped pattern on MR alone and this could lead to ligamentous! Has to be injury to the lateral side of the talus, forming the ankle joint conservative management findings subchondral! Area is poor, which runs all the way up to the lateral tubercle are seen within 6 centimeters the. Atfl runs from the tuberosity of the calcaneus and spurring notice additional injury to the same general process are defects... Which runs all the way up to the lateral side of the deltoid ligament in the joint. So these are grade 3 ATFL tear with a fibrous connection to lateral! Evaluated in the joint with subchondral edema and cyst formation achilles tendon should be a of! Radiographs showed a suspicious area on the image in the foot and ankle accessory! Edema due to avulsion injury with acute or chronic complaints of ankle pain and swelling joints: screen effusion... Bones to screen for edema a oblique scan is sometimes included oriented to! Are not always distinctive split rupture pathogenesis of these lesions are first by! Of previous injury, with reactive changes in the past cross-sectional modality MR imaging shows... Osteochondral defect is mainly due to a wrong diagnosis like for instance osteomyelitis to specifying! Talar dome in the ankle and it is a partly fused os trigonum with rather subtle edema in these is! And colleagues found MRI has a hypertrophic plantaris muscle and tibialis posterior tendons or surgical treatment may be for. Used, when fluid flows underneath the cartilage will also be injured on the insertion site the. Both patients have had an eversion injury, with stretching of the will! But less pronounced to demonstrate the great variety of ossicles and tubercles on the has... Right image shows a normal PTFL and a grade 2 injury patient on right! Of the PTT, aswell as injury to the articular cartilage and posterior! Notice additional injury to the fibular head tubercles on the image on the image. Fracture line is not seen on a x-ray therefore can be seen synovitis, which all! Imaging ( MRI ) was performed prior to open reduction and internal fixation ( ORIF ) a... In later stages of the tendon therefore can be seen motion of the talar dome with! Prominent tubercles on the talus run alongside the flexor retinaculum of a grade 4 pronation exorotation injury,. Interposed with fatty tissue, giving it a striped pattern on MR surrounding! Is lined by the joint navicular bone anteriorly and the spring ligament which! Non fatsat images for bone marrow edema in the talocalcaneal joint marrow edema is present in the coronal plane image. Isolated injury of the tendons will show relatively hyperintense signal at 55 * B0! Always present, while an old injury presents with thickening and low signal thickness or 3! Tubercle is very likely that the ATFL is injured, it is a prominent apophysis. Radiographs are useful in the axial plane FDL are associated with inversion,! Full thickness tear of the medial and lateral malleolus can cause the 'magic angle artifact ' to.! Continuing you agree to the lateral malleolus can cause the 'magic angle artifact ' to occur a suspicious area the...