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   Table of Contents      
ORIGINAL ARTICLE
Year : 2021  |  Volume : 7  |  Issue : 1  |  Page : 77-85

High-Resolution 3-Tesla MRI in the Evaluation of Ankle and Hindfoot Pain: A Pictorial Review


Department of Radiology, Maulana Azad Medical College and Lok Nayak Hospital, New Delhi, India

Date of Submission13-Mar-2021
Date of Decision22-Mar-2021
Date of Acceptance02-Apr-2021
Date of Web Publication28-Apr-2021

Correspondence Address:
MBBS, DNB Radiology Surabhi Gupta
Senior Resident, Department of Radiology, Maulana Azad Medical College and Lok Nayak Hospital, Jawaharlal Nehru Marg, New Delhi 110002
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mamcjms.mamcjms_24_21

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  Abstract 


Ankle joint is affected by a large gamut of pathologies ranging from traumatic to nontraumatic in origin. Although ankle radiographs continue to serve as the initial investigation of choice, magnetic resonance imaging (MRI), owing to its superior soft tissue resolution and noninvasive nature is the most important investigative tool to evaluate ankle and hindfoot pain. MRI allows excellent assessment of soft tissue structures like ligaments, tendons, fascia, neurovascular bundle, and cartilage. MRI can also be used in detection of osseous injuries like bone contusions, stress and insufficiency fractures, osteonecrosis, osteochondral defects, and transient bone marrow edema. In this pictorial essay, we aim to study the normal anatomy of ankle joint as well as demonstrate a spectrum of common pathologies affecting the ankle joint with their salient imaging features on MRI.

Keywords: Ankle, hindfoot, magnetic resonance imaging


How to cite this article:
Kachari ER, Singh S, Gupta S, Kumar J. High-Resolution 3-Tesla MRI in the Evaluation of Ankle and Hindfoot Pain: A Pictorial Review. MAMC J Med Sci 2021;7:77-85

How to cite this URL:
Kachari ER, Singh S, Gupta S, Kumar J. High-Resolution 3-Tesla MRI in the Evaluation of Ankle and Hindfoot Pain: A Pictorial Review. MAMC J Med Sci [serial online] 2021 [cited 2021 Oct 24];7:77-85. Available from: https://www.mamcjms.in/text.asp?2021/7/1/77/314884




  Introduction Top


Ankle and hindfoot pain can be due to a myriad of conditions including both traumatic causes such as fractures, tendon or ligamentous injuries and nontraumatic causes such as osteomyelitis, impingement syndromes, entrapment neuropathies, plantar fasciitis, etc. However, most of these conditions present with nonspecific and overlapping signs and symptoms. Therefore, imaging plays a pivotal role in the diagnosis and management of ankle and hindfoot pain.

Various imaging modalities can be used for the diagnosis of ankle and hindfoot pain such as plain radiographs, ultrasonography, computed tomography, and magnetic resonance imaging (MRI). Imaging of the ankle and foot usually begins with plain radiographs. However, plain radiographs are nonspecific and have low sensitivity in the detection of soft tissue injuries, while ultrasonography is operator dependent. Computed tomography is useful in the detection of bone pathologies but has limited role in soft tissue injuries. MRI with its excellent soft tissue contrast resolution, noninvasive nature, and multiplanar capability with no radiation hazard, has now assumed center stage in the evaluation of ankle and hindfoot pain.


  Normal anatomy Top


Ankle joint is made of two joints − the true ankle joint (between tibia medially, fibula laterally, and talus inferiorly) and the subtalar joint (between talus superiorly and calcaneum inferiorly). Three ligamentous groups provide support to the ankle joint, namely,[1] the syndesmotic ligament complex which is made of anterior and posterior tibiofibular and interosseous ligaments [Figure 1]A–C; the lateral ligament complex composed of anterior talofibular (ATFL), posterior talofibular ligament (PTFL), and the calcaneofibular ligament (CFL) [Figure 2]A–D; and the medial ligament/deltoid ligament complex composed of deep tibiotalar ligament (TiTL) and superficial tibiocalcaneal, tibiospring (TiSL), and tibionavicular ligament (TiNL) [Figure 3]A–D. The various tendons around the ankle joint can be arranged in four major groups: the flexors on the medial side include tibialis posterior, flexor digitorum longus, and flexor hallucis longus tendon; the extensors on the anterior side include tibialis anterior, extensor hallucis longus tendon, and extensor digitorum longus tendon; the peroneal tendons on the lateral side include peroneus longus and peroneus brevis tendon; and posteriorly the Achilles and plantaris tendon [Figure 4].
Figure 1 (A and B) Axial T2W images of the ankle show the normal anterior inferior tibiofibular (black arrow with white outline) and posterior inferior tibiofibular (white arrow with black outline) ligaments. (C) Coronal T1W image shows the normal interosseous ligament (red arrow) between tibia (T) and fibula (F) − normal syndesmotic ligament complex

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Figure 2 Axial T2W (A) and T2W fat saturated (B) images of the left ankle show the normal anterior talofibular (ATFL) (black arrow with white outline) and posterior talofibular ligament (PTFL) (white arrow with black outline). Coronal STIR (C) and axial T2W fat saturated (D) images show the normal calcaneofibular ligament deep to the peroneal tendons (red arrow) − normal lateral ligament complex

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Figure 3 (A and B) Coronal T1W images of the right ankle show the normal tibiotalar ligament (TiTL) having a striated appearance (black arrow with white outline) and the normal tibiocalcaneal ligament (TiCL) (white arrow with black outline). (C) Coronal STIR image shows the normal tibiospring ligament (TiSL) (red arrow) merging with the fibers of the spring ligament (yellow arrow). (D) Axial T2W image shows the normal tibionavicular ligament (TiNL) (white arrowhead) − normal medial (deltoid) ligament complex

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Figure 4 Axial T2W image of the ankle showing the normal extensor tendons (yellow arrows), flexor tendons (red arrows), peroneal tendons (blue arrows), and posterior compartment tendons (green arrows) AT, Achilles tendon; EDL, extensor digitorum longus; EHL, extensor hallucis longus; FDL, flexor digitorum longus; FHL, flexor hallucis longus; PB, peroneus brevis; PL, peroneus longus; PT, plantaris tendon; TA, tibialis anterior; TP, tibialis posterior.

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  Ligament abnormalities Top


Ligament injuries around the ankle joint are commonly seen and can involve both the lateral ligament complex and/or medial ligament complex. Out of these, the lateral ligament complex injuries are more frequent and constitute nearly 75% of all sports-related injuries.[2]

Among the ligaments constituting the lateral ligament complex, ATFL is the most commonly injured ligament.[3]

The high frequency of ATFL tears can be attributed to its biomechanics. Most ATFL tears occur in forced plantar flexion with inversion of foot when it assumes a more vertical orientation and is strained; moreover, there is absence of the stabilizing effect of CFL in this position, exposing the ATFL to injuries.[4]

Calcaneofibular ligament is the second most commonly injured lateral ligament[5] and most injuries are seen in conjunction with tears of ATFL or other ligaments. PTFL is the least commonly injured ligament, isolated injuries are rare and most PTFL tears occur in presence of ATFL, CFL tears with extreme ankle dislocation.

Medial ligament complex/deltoid ligament injuries occur infrequently in isolation and are mostly associated with other ligament injures and medial malleolar fractures.[6] There is a higher rate of injury in the superficial deltoid compared to the deep deltoid component. The strongest ligaments are the posterior deep TiTL and TiSL, whereas the weakest component is the TiNL.

Injuries can be acute, which on MRI are seen as ligaments with replacement of normal hypointense signal by hyperintense signal on T2-weighted (T2W)/proton density (PD) images; ill-defined, fuzzy margins; irregular contours; discontinuous/lax fibers/wavy fibers; and ankle joint effusion and surrounding soft tissue edema. There can also be loss of normal striations owing to edema and hemorrhage.

Acute ligament injuries can be graded as:[1]
  1. Interstitial tears: hyperintense signal within the ligament on T2W and PD images.
  2. Partial tears: partial discontinuity of ligaments involving one surface [Figures 5]A and B; [Figure 6]
    Figure 5 Axial T2W (A) and T2W fat saturated (B) MR images of the right ankle showing thickening of the anterior talofibular ligament with intrasubstance high signal intensity (black arrow with white outline) and fluid in the anterolateral recess − partial tear of anterior talofibular ligament

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    Figure 6 Axial T2W fat saturated (A) and coronal STIR (B) MR images show wavy contour of the calcaneofibular ligament (white arrow with black outline) seen deep to the peroneal tendons with surrounding fluid. Extensive edema is seen in the adjacent subcutaneous tissue − partial tear of calcaneofibular ligament

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    A and B; [Figure 7]
    Figure 7 Coronal T1W (A) and STIR (B) images of the right ankle reveal diffuse thickening of the tibiocalcaneal ligament with amorphous signal intensity (white arrow) and surrounding heterogeneity − partial tear of tibiocalcaneal ligament

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    A and B].
  3. Complete tears: discontinuity involving the entire thickness of ligament with retraction and fluid filling the gap [Figure 8]A and B.
    Figure 8 Axial T2W (A) and T2W fat saturated (B) MR images of the right ankle show complete nonvisualization of the anterior talofibular ligament with fluid in the anterolateral recess (black arrow with white outline) − complete tear of anterior talofibular ligament

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Chronic ligament injuries on MRI show either a thin, hypoplastic or a thick, hyperplastic ligament with irregular contours and resolution of edema and joint effusion.


  Tendon abnormalities Top


Tendon abnormalities/injuries can be broadly categorized into six categories: tendinosis, peritendinitis, tenosynovitis, entrapment, rupture, and dislocation.[3]

On MRI, tendinosis is seen as increased signal in the substance of the tendon on T1-weighted (T1W) images and high signal on corresponding T2W images. Chronic mechanical irritation of tendon sheath and peritenon result in their inflammation known as tenosynovitis [Figure 9]A and B and peritendinitis, respectively. On MRI, it is seen as fluid accumulation (hypointense on T1W and hyperintense on T2W images) surrounding the entire circumference of the tendon, synovial proliferation, and scarring of the tendon sheath. Excessive synovial proliferation and scarring around the tendon, manifesting as low to intermediate signal intensity soft tissue around tendon on magnetic resonance (MR) images can cause entrapment or rupture of the tendon. Acute partial tears show incomplete disruption in continuity of the tendon fibers with increased signal within the tendon on T2W/proton density fat saturated (PDFS) sequences. Chronic tears show low signal intensity on T2W sequences owing to scarring and fibrosis. Complete tears show complete disruption of tendon fibers with fluid filled gap. MRI is also useful to assess the condition of tendon remnants as well as degree of retraction in such cases.
Figure 9 (A) Sagittal STIR image of the right ankle shows fluid collection along the tendon sheath of flexor hallucis longus tendon inferior to the navicular bone (white arrow with black outline). (B) Coronal STIR image shows fluid collection along the tendon sheath of flexor hallucis longus tendon inferior to the navicular at the knot of Henry (black arrow with white outline) − flexor hallucis longus tendon tenosynovitis

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  Achilles tendon Top


Injuries of Achilles tendon can be noninsertional or insertional. Acute and chronic tendinosis, peritendinitis, tears 2 to 6 cm above its calcaneal insertion are included in the former group.[7] Insertional Achilles tendinosis [Figure 10]A–C and tears within 2 cm of its calcaneal insertion are included in the latter group.
Figure 10 (A) Sagittal T1W image of the left ankle shows a separated bony spur in the posterosuperior aspect of calcaneum (black arrow with white outline) with thickening of distal Achilles tendon. Axial T2W (B) and coronal T1W (C) images show bulky distal end of Achilles tendon with intratendinous portion of the bony spur (white arrow with black outline) − insertional tendinopathy of Achilles tendon

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Achilles tendinosis can present as fusiform thickening of the Achilles tendon on sagittal images, with loss of normal concavity of anterior tendon margin on axial images and areas of increased signal within the tendon on T2W/short tau inversion recovery (STIR) sequences [Figure 11]A and B. In Achilles peritendinitis, the tendon itself appears normal with edema in the pre-Achilles tendon fat pad manifesting as ill-defined areas of altered signal intensity.[3]
Figure 11 (A) Sagittal STIR image of the right ankle shows bulky distal end of Achilles tendon with linear hyperintensities within its fibers (short white arrow) and fluid in Kager fat pad (black arrow with white outline). (B) Axial T2W fat saturated image shows thickening of distal Achilles tendon with intrasubstance high signal intensity (white arrow with black outline) − Achilles tendinosis

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Tear of Achilles tendon is common with ankle injuries. In complete tear, there is retraction of tendoachilles fibers with a fluid-filled gap between the proximal and distal ends of the tendon, along with extensive fraying of the tendon edges [Figure 12]A and B. MRI accurately detects complete tear as well measures the width of the diastasis between the ends of the torn tendon. Partial tear of the Achilles tendon manifests as increase in the diameter of the tendon; change in signal intensity with horizontally oriented areas of increased signal intensity which extend to the tendon surface and the paratenon.
Figure 12 (A) Sagittal STIR image of the left ankle shows complete rupture of distal Achilles tendon with retraction of proximal part (which is very high up) and surrounding edema (white arrow with black outline). (B) Axial T2W fat saturated image shows absence of tendoachilles fibers in posterior aspect of ankle with fluid and heterogeneity in the area (black arrow with white outline) − complete rupture of Achilles tendon

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  Haglund syndrome Top


Haglund syndrome is a common cause of posterior ankle pain. It consists of Haglund deformity, inflammation of superficial bursa, retrocalcaneal bursitis, and Achilles tendinosis along with calcaneal bone marrow edema in some cases.[8] Haglund deformity is defined as a bony projection on the posterosuperior aspect of the calcaneal tuberosity which can be seen on the lateral view radiographs of ankle. On MRI, Haglund deformity presents as a “bony bump” along the posterior superior corner of the calcaneal tuberosity best appreciated on sagittal T1W images; T2W sequence show excessive fluid in retrocalcaneal bursa, retro-Achilles bursa, and increased signal or partial tear of Achilles tendon at its insertion site, completing the constellation of findings in Haglund syndrome [Figure 13]A and B.
Figure 13 (A) Lateral radiographic view of the right ankle shows hypertrophy of the posterosuperior aspect of calcaneum (white arrow). (B) Sagittal STIR image in the same case shows bony prominence of posterosuperior aspect of calcaneal tuberosity/Haglund deformity (white arrow) with thickening and linear hyperintensities in distal tendoachilles (white arrowhead). Fluid in the retrocalcaneal bursa (black arrow with white outline) and edema in the calcaneum is also seen − Haglund syndrome

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  Impingement syndrome Top


Ankle impingement is defined as entrapment of an anatomical structure which causes pain and restricted motion of the ankle, and results from repetitive or acute forced plantar flexion of foot. In posterior ankle impingement syndrome, the posterior talus and adjacent soft tissues are compressed between the tibia and calcaneus. Osseous causes of impingement include prominent os trigonum, Stieda process, and prominent downsloping of posterior tibial articular surface whereas soft tissue causes include synovitis of the flexor hallucis longus tendon sheath, thickened posterior intermalleolar ligament, and posterior synovial recess of the subtalar and tibiotalar joints.[2]

Among these, the most common causes of posterior impingement syndrome are os trigonum (accessory ossicle of the lateral tubercle of talus) and Stieda process (an elongated lateral tubercle of talus). MR findings can reveal an os trigonum, a Stieda process causing impingement on the flexor hallucis longus tendon, bone marrow edema in the lateral talar tubercle, and os trigonum and tenosynovitis of flexor hallucis longus (FHL) tendon. Inflammatory changes and fluid can be in the posterior recess of subtalar and tibiotalar joints [Figure 14]A–C.
Figure 14 Sagittal T1W (A) and STIR (B) images of the left ankle show a Stieda process (white arrowhead) causing impingement of the flexor hallucis longus tendon (white arrow with black outline) with loculated collection along the tendon sheath of flexor hallucis longus tendon (black arrow with white outline). (C) Axial T2W fat saturated image shows fluid along the flexor hallucis longus tendon posterior to the talus (red arrow) − posterior impingement syndrome

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  Plantar fasciitis Top


Plantar fasciitis refers to the inflammation and microtears of plantar fascia due to repetitive mechanical stress and trauma. The normal plantar fascia is usually seen as a thin linear hypointense structure with thickness ∼3.22 mm ± 0.53 mm on sagittal and coronal MR images with slight expansion at its calcaneal end.[2] In plantar fasciitis, the plantar fascia shows fusiform thickening (up to 7–8 mm) along with intermediate signal intensity on T1W and PD images and hyperintense signal on T2W and STIR images within it. These changes are most marked near its calcaneal end. Perifascial edema, noted as poorly circumscribed areas of high signal intensity in the soft tissues, deep or superficial (or both) to the plantar fascia, are best appreciated on sagittal STIR images [Figure 15]A–C. Other MR findings of plantar fasciitis include increased intrafascial signal intensity, bone marrow edema in the calcaneus, and calcaneal spurs.[9]
Figure 15 Sagittal T1W (A) and STIR (B) images of the left ankle show thickening of the proximal part of plantar fascia with intrasubstance high signal intensity (red arrow). (C) Coronal STIR image shows similar findings with perifascial edema which has high signal intensity (white arrow with black outline). Edema in the calcaneum is also seen − plantar fasciitis

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  Plantar fibromatosis (Ledderhose disease) Top


Plantar fibromatosis is a rare, benign, hyperproliferative disorder of the plantar aponeurosis.[10] On MRI, plantar fibromatosis is usually seen as an ill-defined, infiltrative mass involving the deep aponeurosis along the plantar muscles on medial aspect of foot. It is of low signal intensity on T1W and low to intermediate signal on T2W images owing to the presence of collagen tissue [Figure 16]A–C. Lesions with less collagen and more cellularity can have high signal intensity on T2W images with marked enhancement in 50% cases.[11]
Figure 16 Sagittal T1W (A) and STIR (B) images of the left ankle show a well-defined lobulated lesion adjacent to the plantar fascia, appearing hypointense on T1W and hyperintense on STIR images with hypointense foci within (white arrow with black outline). (C) Sagittal postcontrast image shows avid enhancement of the lesion with few areas of low signal within − plantar fibromatosis

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  Ankle tuberculosis Top


Extrapulmonary tuberculosis (TB) is seen to affect 20% of patients with TB and musculoskeletal TB accounts for only 1% to 3% of extrapulmonary tuberculous infections.[12] TB of foot and ankle joint is very uncommon. Initial ankle radiograph reveals reduction of joint space and juxta-articular osteopenia with subarticular osseous erosions while the advanced cases show extensive joint destruction with sclerosis and fibrous ankylosis.

On MRI, most cases of ankle joint TB show synovial thickening, intraosseous and soft tissue abscess/phlegmon formation with joint effusion commonly affecting the subtalar joint. On postcontrast sequences there is thin peripheral enhancement of abscesses [Figure 17]A–D. The most commonly affected bone is talus with bone involvement in the form of signal alteration of bone marrow (appearing hypointense on T1W and hyperintense on T2W images) and areas of lytic bone destruction.[13]
Figure 17 Sagittal T1W (A) and axial T2W fat saturated (B) images of the left ankle show a well-demarcated lesion in the cuboid appearing hypointense on both T1W and T2W images (white arrow with black outline) suggestive of sequestrum. A hyperintense rim (on T2W) is seen around the lesion. (C) Postcontrast axial image shows rim enhancement due to granulation tissue (black arrow with white outline). (D) Coronal STIR image shows a linear fluid-filled structure extending from the bone to the skin surface suggestive of sinus formation (red arrow). Soft tissue edema is also seen − ankle tuberculosis

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  Complex regional pain syndrome Top


Complex regional pain syndrome (CRPS; previously known as Sudeck atrophy or reflex sympathetic dystrophy) is a pain disorder of the extremities which develops unpredictably and is divided into two types. Type I CRPS does not have an associated peripheral nerve injury, whereas type II CRPS is associated with a peripheral nerve injury and therefore has a specific pain distribution.[14] Plain X-ray findings are nonspecific and consist of soft tissue swelling and diffuse osteopenia. In early stages, MRI findings in type I CRPS include soft tissue changes with bone marrow edema [Figure 18]A–C. Late stages show muscle atrophy on MRI.
Figure 18 STIR sagittal (A) and coronal (B) images of the right ankle show diffuse bone marrow edema in talus and calcaneum appearing as hyperintense areas (white arrow with black outline). (C) Coronal postcontrast image shows mild thickening of skin and subcutaneous tissue with enhancement (black arrow with white outline) − complex regional pain syndrome (CRPS)

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  Sinus tarsi syndrome Top


Sinus tarsi is a tunnel, located in the lateral aspect of foot between the neck of the talus and anterosuperior surface of calcaneum which contains fat, neurovascular bundles, roots of inferior extensor retinaculum, and two ligaments − cervical ligament and interosseous talocalcaneal ligament. Sinus tarsi syndrome is associated with abnormalities of one or more structures in the tarsal sinus that lead to pain and instability of the hindfoot. The most characteristic finding in sinus tarsi syndrome is obliteration of normal sinus tarsi fat, which is replaced by inflammatory tissue (hypointense on T1W and hyperintense on T2W images) or fibrous tissue (hypointense on both T1W and T2W images).[15] There can be associated tears of the cervical and interosseous talocalcaneal ligaments [Figure 19]A–C]. Advanced stages may show degenerative arthritis.
Figure 19 Sagittal T1W (A) and STIR (B) images of the right ankle show diffuse infiltration of the tarsal sinus fat with proliferative tissue, appearing hypointense on T1W (white arrow with black outline) and hyperintense on STIR with thickening and irregularity of the cervical and interosseous talocalcaneal ligaments (red arrows). (C) Coronal STIR image shows thickening of the cervical and interosseous talocalcaneal ligaments (red arrows) with heterogeneity in sinus tarsi, marrow edema in talus (black arrow with white outline) and surrounding soft tissue edema − sinus tarsi syndrome

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  Pigmented villonodular synovitis Top


It is defined as benign proliferation of synovium associated with hemosiderin deposition. It can involve the joints, bursae, or tendon sheaths. In ankle joint, it usually affects the tendon sheaths of flexor and peroneal tendons. On imaging, pigmented villonodular synovitis is seen as diffuse or focal, villous and nodular hypertrophy of synovial membrane with secondary pressure erosions on the adjacent bones. Owing to the paramagnetic properties of hemosiderin, the synovial thickening shows intermediate to low signal on T1W and predominantly low signal on T2W images with blooming on gradient echo sequences [Figure 20]A–D. Enhancement of synovium is common after contrast administration.[16]
Figure 20 Sagittal T1W (A) and axial T2W (B) images of the left ankle show a well-defined lesion arising from the synovium around the ankle joint appearing hypointense on both T1W and T2W images (white arrow with black outline). (C) Sagittal postcontrast image shows intense postcontrast enhancement of the lesion (black arrow with white outline) with low signal foci within. (D) Photomicrograph with Giemsa (400×) shows papillaroid cohesive clusters of mononuclear cells and scattered multinucleated giant cells in a hemorrhagic background − pigmented villonodular synovitis

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  Conclusion Top


MRI is an excellent imaging modality in the evaluation of ankle and hindfoot pain. MRI with its exquisite soft tissue contrast resolution, can demonstrate a large spectrum of pathologies around the ankle joint affecting the various soft tissue structures like ligaments, tendons, muscles, synovium, vascular tissue, and cartilage. MRI can also aid in early detection of few osseous abnormalities seen in the bones constituting the ankle joint.

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  References Top

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Botha SH. Reflex sympathetic dystrophy/complex regional pain syndrome, type 1. S Afr J Radiol 2004;8:38-40  Back to cited text no. 14
    
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14], [Figure 15], [Figure 16], [Figure 17], [Figure 18], [Figure 19], [Figure 20]



 

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  In this article
Abstract
Introduction
Normal anatomy
Ligament abnorma...
Tendon abnormalities
Achilles tendon
Haglund syndrome
Impingement syndrome
Plantar fasciitis
Plantar fibromat...
Ankle tuberculosis
Complex regional...
Sinus tarsi syndrome
Pigmented villon...
Conclusion
References
Article Figures

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