Normal MRI of the ankle and hindfoot

Normal MRI of the ankle and hindfoot

Normal MRI of the ankle and hindfoot


Introduction

This e-Anatomy module is dedicated to the anatomy of the ankle and hindfoot, showing the normal MRI appearance of the ligaments, tendons, muscles, retinacula, synovial bursae and sheaths, tarsal bones, and plantar aponeurosis.

The main indications for ankle magnetic resonance imaging (MRI) scan are:

  • Evaluation of occult fractures or bone marrow edema when initial radiographs are negative but clinical suspicion remains high, especially in cases of persistent pain after acute trauma.
  • Assessment of ligamentous and tendon injuries, including grading of syndesmotic, anterior tibiofibular, and deltoid ligament injuries, which is particularly important for treatment planning in athletes. 
  • Evaluation of chronic ankle pain with normal or nonspecific radiographs, including suspected impingement syndromes and exclusion of other soft tissue or osseous pathology. MRI is particularly valuable for detecting and characterizing tendon disorders (such as tendinosis, tenosynovitis, and tendon ruptures), ligament tears, and chronic instability, as well as for identifying occult or stress fractures, osteochondral lesions, and bone marrow edema that may be missed on initial imaging. MRI is also indicated especially when there is suspicion for conditions such as tarsal coalition, impingement syndromes, compressive neuropathies (e.g., tarsal tunnel syndrome), or synovial disorders.

Material and methods

This MRI of the ankle and hindfoot was performed on a healthy 48-year-old male patient using a Siemens 3T MRI.

The main imaging planes used for magnetic resonance imaging of the ankle were axial, coronal, and sagittal planes. Each plane serves distinct purposes in evaluating ankle anatomy and pathology:

  • Axial plane: This plane is optimal for assessing the anterior and posterior tibiofibular ligaments, anterior and posterior talofibular ligaments, and provides an overview of the deltoid ligament. It is also essential for evaluating the tendons, neurovascular bundles, and the syndesmosis. Axial imaging is particularly useful for visualizing ligament injuries and tendon pathology, especially when combined with fat-suppressed or STIR sequences to reduce magic angle effects and improve diagnostic sensitivity for tendon abnormalities.
  • Sagittal plane: Sagittal imaging provides optimal views of the Achilles tendon, plantar fascia, and the spring ligament. It is also useful for assessing the tibiotalar and subtalar joints, as well as the alignment and integrity of the hindfoot and midfoot structures.
  • Coronal plane: The coronal plane is best for visualizing the full length of the deltoid ligament, including its tibiospring, tibiocalcaneal, and posterior tibiotalar components. It is also valuable for assessing the lateral collateral ligaments, spring ligament, and the relationship between the talus and calcaneus. Coronal images are crucial for evaluating joint spaces, cartilage, and osseous structures.

The sequences used for ankle MRI are as follows:

  • T1-weighted sequences: for anatomical detail and assessment of bone marrow, as they provide high contrast between fat and other tissues, allowing for evaluation of bone, tendons, and ligaments. 
  • Fat-suppressed proton density-weighted sequences: detecting fluid, edema, and inflammation, making them highly sensitive for identifying ligamentous injuries, tendon pathology, and bone marrow abnormalities. 

The anatomical structures were labeled by Antoine Micheau MD (Radiologist, Montpellier – France), following the Terminologia Anatomica 2.

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