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Ankle MRI Approach

Introduction
Contents
Introduction The purpose of this article is to provide a practical approach to interpreting ankle MRIs. Sequences Pathologic diagnoses are not listed in this article. The images are all generally normal ankle MRI images detailing specific points about the examination. The protocol section which lists the Checklist sequences involved is only one way to image the ankle. There are a number of different sequences that make up an ankle protocol which are usually institution dependent. Detailed Anatomy Lisfranc ligament Achilles Tendon Deltoid: Deep Deltoid: Superficial Calcaneofibular Ligament Distal Ant Tibiofibular Lig Anterior Talofibular Ligament Posterior Talofibular Ligament Spring Ligament

Sequences
Sag T1 Sag T2 FSE SPIR (or fat sat) Ax T2 FSE SPIR (or fat sat) Cor T2 SPIR (or fat sat) Cor T1/PD FSE

Another Protocol: Sag T1 Sag T2 fat saturation Ax T2 fat saturation Cor T2 fat saturation Cor T1 cartilage sequence (TE = 30, cartilage sequences have a longer TE than T1)

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Another Ankle MRI protocol. The top left image is a sagittal T1 weighted image (with a longer TE so it is actually a proton density (PD)). The top middle image is a coronal proton density weighted image. The top right image is an axial high resolution T2 weighted image which has the same slice thickness as the other sequence but the matrix is doubled to 512 in one direction. The bottom left image is an axial T2 fat saturated image. The bottom middle image is a sagittal T2 weighted fat saturated image.

Checklist
1. tibiotalar joint including talar dome (T1W for subchondral signal change and T2W) 2. subtalar joints - posterior, middle, anterior facets (T1 & T2) 3. midfoot: calcaneocuboid joint, talonavicular joint, Lisfranc ligament 4. interosseous membrane (high signal or thickening indicated injury - axial images) 5. Ligaments (at least axial and coronal proton density) Lateral Ligaments: - distal anterior tibiofibular ligament - "D" shaped fibula on axial plane - distal posterior tibiofibular ligament - "D" shaped fibula on axial plane - anterior talofibular ligament (ATFL) - "C" shaped/concave fibula on axial plane - posterior talofibular ligament (PTFL) - "C" shaped/concave fibula on axial plane - calcaneofibular ligament (CFL) - normally not as black as anterior talofibular ligament Medial Ligaments: - deltoid ligament: deep: - normally heterogenous, if loses hetergeneity this is bad superficial: - spring ligament - travels under the talar head medial ankle

6. Tendons: Posterior Tendons:

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- Achilles tendon - normally concave or flat anteriorly on axials. Normally <6mm thick - flexor digitorum longus tendon - tibialis posterior tendon: allowed to have a small bit of fluid around it at the level of the medial malleolus, anymore and it is abnormal. If the fluid is circumferential or if it is > 3mm thick then it is abnormal. The normal tibialis posterior tendon should be only 2-3 times the size of the flexor digitorum tendon in the axial plane. - flexor hallicus longus (FHL) can have fluid around it as well Anterior Tendons: - anterior tibialis tendon - extensor digitorum longus tendon 7. Sinus tarsi - fat should remain preserve (FSE and T1 bright) 8. Plantar fascia - medial band is more commonly affected than lateral band - if thickness of the medial band is >5 mm or if high T2 signal (edema) this is abnormal 9. assess tarsal tunnel (look for masses such as ganglions or synovial cysts 10. check the base of the 5th metatarsal for a fracture on the axial PDs

Detailed Ligament Anatomy

Remember that the anterior talofibular ligament (ATFL) is the commonest injured ligament in the foot. The calcaneofibular ligament (CFL) is the second commonest injured ligament. The third commonest is the distal anterior tibiofibular ligament.

Lisfranc ligament

Axial T1W image assessing the normal Lisfranc ligament between the medial base of the second metatarsal and the lateral side of the 1st (or medial) cuneiform.

Achilles Tendon

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Axial T1W image assessing the normal Achilles tendon (red). Normally the Achilles tendon is concave or flat on axial imaging. If it is convex or if it is >6 mm it is abnormal. Incidental accessory soleus muscle (green)

Deltoid ligament: Deep portion

Coronal (left) and axial (right) T1W images assessing the deep portion of the deltoid ligament.

Deltoid ligament: Superficial portion

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Coronal (left) and axial (right) T1W images assessing the superficial portion of the deltoid ligament.

Calcaneofibular Ligament

Coronal (left) and axial (right) T1W images assessing the normal calcaneofibular ligament.

Distal Anterior Tibiofibular Ligament

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Coronal (left) and axial (right) T1W images assessing the distal anterior tibiofibular ligament which is thickened but intact due to a previous injury in this patient.

Distal Posterior Tibiofibular Ligament

Coronal (left) and axial (right) T1W images assessing the normal assessing the distal posterior tibiofibular ligament.

Anterior Talofibular Ligament

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Coronal (left) and axial (right) T1W images assessing the normal normal anterior talofibular ligament.

Posterior Talofibular Ligament

Coronal (left) and axial (right) T1W images assessing the normal posterior talofibular ligament. This ligament is normally less dark than the anterior talofibular ligament.

Spring Ligament

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Coronal (left) and axial (right) T1W images assessing the normal spring ligament.

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