A small amount of fluid around the tendon therefore can be normal. This probably represents a mild strain (grade 1). In this case there is a lot of edema in the navicular bone. https://doi.org/10.1016/j.rcl.2008.10.001. Usually this is best appreciated on fatsat images. Once you have studied the bones, scan the joints for effusion. The two most common injuries are tendinopathy and rupture. Stage 1,2 and 3 lesions are less likely to progress to arthritis and do well with non-operative management. It has a transverse orientation and is best seen on axial images. In this patient there is very subtle edema in the distal fibula. Most tendons in the ankle joint have a tenosynovial layer. 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. However when you compare the findings with the normal patient on the left, you will detect the big accessory soleus muscle. A is showing low grade injury of the deep deltoid ligament. Sometimes the fracture line is not seen on MR. Prognosis of these lesions depends on stability, location, and size of the lesion.Imaging has an essential role in the diagnosis, staging, and management of osteochondral lesions. The pathogenesis of these disorders is different, but the clinical presentation and imaging features are not always distinctive. Most of the time the ATFL is injured as well. Both patients have had an eversion injury, with stretching of the deltoid ligament. The capsule thickening can be posttraumatic or postoperative. Since they have a normal signal intensity, they are easily missed. By continuing you agree to the use of cookies. 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 image shows an extreme case of insertion tendinopathy of the Achilles tendon. The orientation of the tendons along the medial and lateral malleolus can cause the 'magic angle artifact' to occur. Both describe a joint defect which involves the articular cartilage and the underlying subchondral bone. The image on the right shows fiber discontinuity making it a full thickness or grade 3 tear. Treatment Both non-surgical and surgical treatment can be used for the management of osteochondral injuries of the ankle joint. On the image in the middle there is a deltoid ligament injury with separation of the periosteum or "periosteal stripping". Membrana interossei, which runs all the way up to the fibular head. Osteochondral injury staging system for MRI attempts to grade the stability and severity of osteochondral injury and is used to plan management. This is edema due to a ligamentous avulsion injury. Edema is present in the bed of the defect (asterisk). The lateral ligaments also show edema and thickening. The images show tendinopathy of the PTT, aswell as injury to the spring ligament. There is also a fracture of the malleolus tertius (blue arrow). 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. 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). 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. Note that the periosteum and flexor retinaculum are also thickened. On the fatsat images, you may think that there is only some edema in the subcutaneous fatty tissue. This joint permits much of the up (dorsiflexion) and down (plantarflexion) motion of the foot and ankle. 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 anterior syndesmosis is also thickened but shows low signal. On the image on the right there is thickening of the deltoid ligament with a low signal intensity as a result of chronic injury. The peroneus longus tendon migrates forward into the peroneus brevis tendon tear, thereby preventing healing (figure). There is subtle thickening of the cortex and some infiltration of the subperiosteum. 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. In both studies magnetic resonance imaging (MRI) was performed prior to open reduction and internal fixation (ORIF). Background: The incidence of osteochondral lesions (OCLs) in association with displaced ankle fractures has only been examined in two previous studies. They typically are associated with a history of trauma; however, nontraumatic etiologies have been described. Noncontrast MR imaging is the standard of care imaging modality for diagnosing and classifying osteochondral lesions… Another example of Achilles tendinopathy. The CFL runs from the distal fibula to the lateral side of the calcaneus and is best appreciated on coronal images. The os trigonum is present in the normal population in about 5-15%. Then continue reading. Posterior tibial tendon injury in young patients is mainly due to trauma or overuse. 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 this article a systematic approach is presented on how to describe a standard MRI of the ankle. 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). Some examples of accessory muscles. The tendons will show relatively hyperintense signal at 55* to B0), simulating pathology like tendinopathy or partial tears. 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). They are associated with a prominent calcaneal tubercle. This patient has edema in the calcaneus as a result of a stress fracture. On the right a patient who developed postoperative fibrosis after resection of a Haglund exostosis. This part is prone to rupture because the blood flow in this area is poor, which also can impair its ability to heal. There is also some joint effusion in the talocalcaneal joint. Stress fractures of the calcaneus are a frequently unrecognized source of heel pain. This was the cause of continuing impingement. Plantar fasciitis, the most common cause of heel pain in the athlete, is a low-grade inflammation involving the plantar aponeurosis and the perifascial structures. Too much fluid is indicative of bursitis. Radiography Patients with an acute ankle injury with hemarthrosis or substantial tenderness first undergo weightbearing plain radiography … Isolated injury of the anterior syndesmosis can be seen in low grade exorotation injuries. This can be challenging, because the actual tear cannot be seen, only the architectural deformation. When there is a break, tear, separation, or disruption of the cartilage that could be referred to as an osteochondral lesion. 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 patient on the right has edema in the medial talus. Compression of the os trigonum and surrounding soft tissues between the tibia and the calcaneus during plantar flexion can be a cause of posterior impingement. This patient had anterior ankle pain due to impingement by the thickened capsule. MRI is the best imaging modality which helps to visualize the cartilage and the bone lesions as well as bone edema. Ligaments: check the syndesmosis, the lateral and medial ligaments. A fluid-filled break in the articular surface (arrowhead) is present, and there is fluid at the anterior interface of the fragment (arrow). It is a result of repetitive impaction of the fibrotic tissue on the bone during dorsal flexion. Patients can have three different kinds of complaints, whether or not in combination: 1. It is thought that it is caused by a chemical shift artifact when subcortical fatty marrow is exposed to joint fluid. The left image shows a normal fluid accumulation in the tibiotalar joint, talocalcaneal joint en retrocalcaneal bursa. 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. Here we see three patients with ATFL injury. 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. The extensor tendons are rarely injured. 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). Osteochondral defect is mainly used when a patient is older or when a particular trauma is thought to be the cause of the defect. This is scar formation as a result of prior injury. On the axial image, the edema is localised around the insertion site of the posterior syndesmosis. 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. Therefore it is best just to describe a tendon abnormality as tendinopathy without trying to further specifying the abnormality. As the foot undergoes dorsiflexion, the peroneus brevis tendon is repeatedly compressed between the peroneus longus tendon and the lateral malleolus, predisposing to tear. OCD usually causes pain during and after sports. Isolated injury of the CFL is uncommon. 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. Stress fractures are easy to miss on MR alone and this could lead to a wrong diagnosis like for instance osteomyelitis. The posterior tibial tendon is the most commonly injured tendon. On sagital images the achilles tendon should be a straight line without any fluid around it and no focal thickening. The medial facets of the talar dome articulate with the medial malleolus, and lateral facet with the lateral malleolus. Accessory FHL or FDL are associated with tarsal tunnel syndrome. This injury usually results from overuse, especially in runners. In B - the anterior syndesmosis is thickened with edema, indicating partial tearing or grade 2 injury. The Achilles tendon is the largest and strongest tendon in the human body. Split tears of the peroneus longus are less common. On the non fatsat images however, there is obvious thickened fibrotic tissue on the anterior side. The plantar fascia is a thick aponeurosis which supports the arch on the plantar side of the foot. Accessory muscles are frequently seen around the ankle joint. Copyright © 2008 Elsevier Inc. All rights reserved. This term covers a wide spectrum of pathologies including (sub)chondral contusion, osteochondritis dissecans, osteochondral fracture and osteoarthritis resulting from longstanding disease. Much of this bone is covered with cartilage. by Kiley D. Perrich et al. Capsular thickenig and soft tissue abnormalities are usually better seen on non-fatsat images. In addition to the standard planes, a oblique scan is sometimes included oriented perpendicular to the peroneus and tibialis posterior tendons. This condition is also known as osteochondritis dissecans (OCD) of the talus or a talar osteochondral lesion (OCL). 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