pdf

Normal anatomy of the ankle and hindfoot: an anatomic and
MR imaging correlation
Poster No.:
C-1228
Congress:
ECR 2016
Type:
Educational Exhibit
Authors:
Y. Martínez Paredes , D. Abellán Rivero , M. Saez Soto , A.
1
2
1
1
1
3
cepero , M. C. Gutierrez Ramirez , J. D. D. Berná Mestre ,
1
1
M. Moreno Cascales , M. A. fernandez-villacañas Marin ,
1 1
2
3
B. Torregrosa Sala ; Murcia/ES, el palmar/ES, El Palmar
(MURCIA)/ES
Keywords:
Anatomy, Musculoskeletal system, MR, Education, Trauma
DOI:
10.1594/ecr2016/C-1228
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Page 1 of 24
Learning objectives
The aim of this poster is to review the hindfoot normal anatomy using MR imaging and
the correlation with anatomical sections.
The complexity of this anatomical structure makes the hindfoot and the ankle a
radiological challenge.
Background
The best imaging modality to study the hindfoot and the ankle is the MR imaging
that allows high anatomical resolution. This anatomical structure is rich in details that
radiologist need to know in order to make an accurate diagnosis.
Findings and procedure details
JOINTS
DISTAL TIBIOFIBULAR JOINT
The distal tibiofibular joint is a fibrous joint formed by the distal tibia and fibula, which
may contact at the base of the syndesmosis with a small cartilage -covered area. The
sindesmotic ligamentous complex supports this joint and it is optimally visualized on
axial and coronal MR images with intermediate to low signal. This complex consists of
the anterior tibiofibular ligament (ATIFL), the posterior tibiofibular ligament (PTIFL), the
transverse ligament and the interosseous ligament.
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The ATIFL has a multifascicular aspect due to fatty tissue interposed
between fascicles and presents an oblique way from the anterior tubercle
of the distal tibia to the anterior tubercle of the distal fibula (Fig. 1). On axial
MRI is triangular-shaped and it could lead to depiction of a partly interrupted
ligament, leading to a false positive diagnosis of a ruptured ligament.
The PTIFL extends from the posterior tibial malleolus to the posterior
tubercle of the fibula and it presents a lower horizontal part known as
transvers ligament. It is multifascicular, as ATIFL, and triangular with a broad
Page 2 of 24
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base at the tibial insertion. On sagittal MRI it may simulate an intra-articular
body.
The transverse ligament is a thick, round ligament that has heterogeneous
signal. It extends horizontally between the proximal margin of the fibula
malleolar fossa and the dorso-distal rim of the tibia (Fig. 2).
The interosseous ligament is considered a distal continuation of the
interosseus membrane at the level of the tibiofibular syndesmosis. The
presence is variable; it can be absent or rather markedly present (Fig. 3).
TALOCRURAL JOINT
Talocrural joint consists of a synovial joint that is formed by the distal tibia and fibula and
the talar trochlea enclosed by this mortise. It is supported by lateral collateral ligament
complex (anterior talofibular, calcaneofibular and posterior talofibular ligaments) and
medial collateral ligaments complex (deltoid ligament) (Fig.4, 5 and 6).
The lateral collateral ligament complex:
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The anterior talofibular ligament (ATFL) is composed by two separate
bands that originate at the anterior margin of the lateral malleolus and run to
the insertionon the lateral aspecto of talar body. It is optimally visualized on
axial images (Fig. 5).
Calcaneofibular ligament originates from the anterior part of the lateral
malleolus and runs obliquely to the posterior region of the lateral calcaneal
surface. It is usually seen on axial and coronal images (Fig. 6).
Posterior talofibular ligament (PTFL) is a fan shaped and striated
ligament that originates from the malleolar fossa of lateral malleolus and
runs to insert in the posterolateral talus. Its heterogeneity should not be
misinterpreted as a tear (Fig. 4 and Fig 6).
SUBTALAR JOINT
Subtalar joint is a complex joint between the talus and calcaneus and consists of three
articulations. The head of talus with the facet of the calcaneus forms the anterior joint. The
medial facet of the talus with the middle facet at the sustentaculum tali of the calcaneus
forms the middle joint (Fig. 8). Finally, the posterior facet of the talus with posterior facet of
the calcaneus forms the posterior joint. They are supported by interosseous talocalcaneal
ligament, spring ligament complex, bifurcate and cervical ligaments.
The interosseous talocalcaneal ligament is the most medial and posterior ligament. It
originates from the calcaneal (anterior to posterior subtalar joint), and runs to its insertion
at medial talar sulcus (Fig. 9). It has intermediate to low signal on MRI.
Page 3 of 24
The spring ligament complex is composed of the ligaments between the calcaneous
and navicular bone. The most important function of this complex is the stability
of the longitudinal arch of the foot. It's subdivided in three parts: superomedial
calcaneonavicular ligament, inferoplantar longitudinal calcaneonavicular ligament and
medioplantar oblique calcaneonavicular ligament.
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The superomedial calcaneonavicular ligament originates from the
sustentaculum tali and inserts into the superomedial aspect of the navicular
bone, closed to the talonavicular joing. It is always visible on MRI, on
transverse oblique or coronal planes with indeterminate signal on T1weighted sequences and low signal on T2-weighted sequences (Fig. 10).
Sometimes discrimination between it and the posterior tibialis tendon is not
possible.
The medioplantar oblique calcaneonavicular ligament originates anterior
to the middle articular facet of the calcaneus in the coronoid fossa and
inserts into the medioplantar portion of the navicular bone, just below the
navicular tuberosity (Fig. 11). It is seen on the transverse oblique plane with
a striated appearance on T1 and T2-weighted sequences.
The inferoplantar longitudinal calcaneonavicular ligament originates in
the coronoid fossa (anterior to the medioplantar oblique calcaneonavicular
ligament) and inserts into the beak of the navicular bone. It is best seen
on coronal plane, with intermediate signal on T1-weighted sequences and
variable signal on T2-weighted sequences.
The bifurcate ligament originates form calcaneal anterior process and inserts on two
lims to navicular and cuboid (Fig. 12). It is best seen on sagittal plane, lateral to
inferoplantar longitudinal component of spring ligament.
The cervical ligament is the most anterior ligament in sinus tarsi. It originates from the
calcaneal (medial to extensor digitorum brevis) and runs to inserts into the talar neck (Fig.
13). The ligament is optimally visualized on coronal plane, and on consecutive sagittal
and axial planes too, with intermediate signal.
TENDONS
The tendons must be studied on MR images perpendicular to the tendon course in T1 and
T2-weighted sequences and they typically presents low signal on all pulse sequences.
The exception to low signal of normal tendons is the magic angle effect, the ossicles
or fibrocartilage presence. The magic angle effect is due to the ordered collagen fibers
and leads to an increased signal within the tendon in T1 and DP weighted sequences
(on short TE MR images). The maximum of this effect is present in tendons orientated
55º relative to the orientation of B0. The most frequently affected tendons is peroneus
longus tendon. Generally the magic angle effect can be avoided by plantar flexing foot in
Page 4 of 24
patient supine, imaging patient prone and correlating tendon's signal alterations on high
TE sequences.
The tendons in the ankle can be subdivided in four compartments: anterior compartment,
medial compartment, lateral compartment and posterior compartment.
ANTERIOR COMPARTMENT
The anterior compartment includes the extensor group constituted by the anterior tibialis
tendon, the extensor hallucis longus tendon and the extensor digitorum longus tendon
(Fig.14).
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Anterior tibialis tendon (ATT): The anterior tibialis muscle originates from
the lateral tibial condyle and its tendon crosses the anteromedial aspect of
the ankle and runs toward the medial border of the foot until its insertion
at the tubercle on the anteromedial aspect of the medial cuneiform and
the inferomedial aspect of the base of the first metatarsal bone. The ankle
portion is retained by the superior extensor retinaculum, close to the talar
head by the superomedial band and close to the medial cuneiform by the
inferomedial band of the inferior extensor retinaculum.
Extensor hallucis longus tendon (EHL): The extensor hallucis longus
muscle originates from the fibula and interosseous membrane. The EHL
tendon runs between the ATT and the EDL tendon to insert on the base of
the distal phalanx of the great toe.
Extensor digitorum longus tendon (EDL): the extensor digitorum
longus muscle originates from the fibula and runs laterally with the anterior
compartment tendons. Distally is divided into four slips to insert on the
second and third phalanges of the four lesser toes.
MEDIAL COMPARTMENT
The medial compartment includes the flexor group of tendons constituted by the posterior
tibialis tendon, the flexor digitorum longus tendon and the flexor hallucis longus tendon
(Fig. 14 and 15).
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Posterior tibialis tendon (PTT): The posterior tibialis muscle originates
from the proximal third of the posterior aspect of the tibia and interosseous
membrane, runs behind the medial malleolus and curves through the
tarsal tunnel. Its insertion is complex and it is subdivided into three
components. The largest component inserts at the navicular tuberosity
and the medioinferior surface of the first cuneiform. The middle component
inserts at the second and third cuneiform, the cuboid and the base of
the second, third, fourth and irregularly on the fifth metatarsal. The third
component inserts as a band on the anterior aspect of the sustentaculum
Page 5 of 24
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tali. It may be an increased T1-weigthed signal within the distal portion of the
posterior tibialis tendon in standard supine body position is usually by the
magic angle effect.
Flexor digitorum longus tendon (FDL): The FDL muscle originates from
the proximal tibial medial to the posterior tibialis tendon, runs adjacent to the
PTT and passes over the FHL at the knot of Henry, before inserting on the
second through fifth toes.
Flexor hallucis longus tendon (FHL): The FHL muscle originates from the
lower two-thirds of the fibula and the interosseous membrane. The tendon
courses trough a shallow groove in the distal tibia and then between the
medial and trigonal processes of the talus, and subsequently beneath the
sustentaculum tali. Finally, it inserts on the great toe. The FHL tendon is the
most lateral of the medial compartment tendons and normal fluid is even
more common than around the other ankle tendons.
LATERAL COMPARTMENT
The lateral compartment includes the peroneus longus and peroneus brevis tendons (Fig.
14 and 15). Their function is plantar flexion and eversion of the foot.
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Peroneus brevis tendon: The peroneus brevis muscle originates form
the distal fibula and interosseous membrane, deep to the peroneus
longus. It maintains its anterior an slightly medial position relative to the
longus as the tendons pass beneath the fibula within the retromalleolar
sulcus. It runs trhough the superior peroneal retinaculum and the inferior
peroneal retinaculum. It progresses laterally to insert on the base of the fifth
metatarsal.
Peroneus longus tendon: The peroneus longus muscle originates from the
posterolateral condyle of the tibia, the interosseous membrane and 0 0 1 44
245 casa 2 1 288 14.0 96 800x600 Normal 0 21 false false false ES JA XNONE the proximal fibula. The tendon runs through the superior peroneal
retinaculum and, distally to the inferior preoneal retinaculum, it courses
medially over the os peronei and in the peroneal groove of the cuboid to
insert on the plantar aspect of the first metatarsal and first cuneiform.
POSTERIOR COMPARTMENT
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Achilles tendon: It is the strongest tendon and the primary plantar flexor
of the foot. The tendon originates from the medial and lateral heads of the
gastrocnemius muscle and soleus muscle. It has a relatively hypovascular
region about 4 to 6 cm above its insertion, which is the site where most
injuries occur. It is characterized by not presenting a synovial sheath at
any point along its length. The Achilles tendon is seen on axial and sagittal
sequences and has low signal on T2-weighted sequences and it is slightly
heterogeneous signal on T1-weighted sequences.
Page 6 of 24
Images for this section:
Fig. 1: Axial anatomical and PD-weighted images of the distal talofibular joint that
demonstrate the anterior tibiofibular ligament (arrow).
© Department of Radiology, Clinical University Hospital Virgen de la Arrixaca; Medical
University of Murcia / Murcia 2015.
Page 7 of 24
Fig. 2: Coronal anatomical and PD-weighted images of the ankle that show the
transverse ligament (3) from the dorso-distal rim of the tibia (1) to the fibular malleolus (2).
© Department of Radiology, Clinical University Hospital Virgen de la Arrixaca; Medical
University of Murcia / Murcia 2015.
Page 8 of 24
Fig. 3: Axial anatomical, CT and PD-weighted images of the distal tibiofibular joint. The
osseous structures include are the tibia (1) and the fibula (2). The interosseous ligament
(arrow).
© Department of Radiology, Clinical University Hospital Virgen de la Arrixaca; Medical
University of Murcia / Murcia 2015.
Page 9 of 24
Fig. 4: Axial anatomical and PD weighted images of the ankle demonstrate the tibiocrural
joint. The osseous structures include the tibia (1), lateral malleolus (2) and talar dome
(3) and the ligaments are the anterior talofibular ligament (large arrow) and the deltoid
ligament (big arrow).
© Department of Radiology, Clinical University Hospital Virgen de la Arrixaca; Medical
University of Murcia / Murcia 2015.
Page 10 of 24
Fig. 5: Axial anatomical and PD- weighted images of the ankle demonstrate the tibiocrural
and subtalar joints. The osseous structures include the talus (1), the lateral malleolus (2)
and the navicular (3). The ligaments included are anterior talofibular ligament (arrow),
posterior talofibular ligament (4) and deltoid ligament (5).
© Department of Radiology, Clinical University Hospital Virgen de la Arrixaca; Medical
University of Murcia / Murcia 2015.
Page 11 of 24
Fig. 6: Coronal anatomical and PD- weighted images of the ankle demonstrate the
tibiocrural and Subtalar joints. The osseous structures include the tibia (1), the lateral
malleolus (2), the talus (3) and the calcaneus (4). The ligaments included are posterior
tibiofibular ligament (large arrow) and calcaneofibular ligament (small arrow).
© Department of Radiology, Clinical University Hospital Virgen de la Arrixaca; Medical
University of Murcia / Murcia 2015.
Page 12 of 24
Fig. 7: Coronal anatomical and PD- weighted images of the talocrural and the subtalar
joints. The osseous structures include the distal tibia (1), talar body (2) and calcaneus
(3). The ligaments includee are the tibiotalar ligament (4) and the tibiocalcaneal ligament.
© Department of Radiology, Clinical University Hospital Virgen de la Arrixaca; Medical
University of Murcia / Murcia 2015.
Page 13 of 24
Fig. 8: Anatomical and CT sagittal images of the ankle and hindfoot that show the
Talocrural joint (1), posterior Subtalar joint (2), the anterior subtalar joint and the
talocalcaneonavicular joint (4).
© Department of Radiology, Clinical University Hospital Virgen de la Arrixaca; Medical
University of Murcia / Murcia 2015.
Page 14 of 24
Fig. 9: Coronal anatomical and PD-weighted images of the talocrural and the subtalar
joints. The osseous structures include the distal tibia (1), the talar body (2) and the
calcaneus (3). The interosseous talocalcaneal ligament (arrow) originates from the
calcaneal an inserts into medial talar sulcus.
© Department of Radiology, Clinical University Hospital Virgen de la Arrixaca; Medical
University of Murcia / Murcia 2015.
Page 15 of 24
Fig. 10: Sagittal anatomical and PD-weighted images of the talocalcaneonavicular joint
include the navicular (1), the calcaneus (2), the talar head (3) and the spring ligament
(arrow).
© DDepartment of Radiology, Clinical University Hospital Virgen de la Arrixaca; Medical
University of Murcia / Murcia 2015.
Page 16 of 24
Fig. 11: Axial anatomical and DP weighted images of the talocalcaneonavicular joint
include the talar head (1), calcaneus (2), navicular (3) and spring ligament (arrow).
© Department of Radiology, Clinical University Hospital Virgen de la Arrixaca; Medical
University of Murcia / Murcia 2015.
Page 17 of 24
Fig. 12: Sagittal anatomical and PD- weighted images of the subtalar joint that include
navicular (1), calcaneus (2), talar body (3) and bifurcate ligament (arrow).
© Department of Radiology, Clinical University Hospital Virgen de la Arrixaca; Medical
University of Murcia / Murcia 2015.
Page 18 of 24
Fig. 13: Coronal anatomical and PD-weighted images of the subtalar joint that include
talus (1), calcaneus (2) and cervical ligament (arrow).
© Department of Radiology, Clinical University Hospital Virgen de la Arrixaca; Medical
University of Murcia / Murcia 2015.
Page 19 of 24
Fig. 14: Axial anatomical and PD-weighted image of the ankle demonstrate the four
compartments. The anterior compartment includes the anterior tibialis tendon (1),
extensor hallucis longus tendon (2) and the extensor digitorum longus (3). The lateral
compartment includes the peroneus brevis (4) and the peroneus longus (5) tendons. The
posterior compartment includes the Achilles tendon (6) and, in this section, the soleus
muscle. The medial compartment includes the flexor hallucis longus tendon (8), the flexor
digitorum longus tendon (9) and the posterior tibialis tendon (10).
© Department of Radiology, Clinical University Hospital Virgen de la Arrixaca; Medical
University of Murcia / Murcia 2015.
Page 20 of 24
Fig. 15: Coronal anatomical and PD-weighted images of the ankle that show the
medial and lateral compartments. The lateral compartment includes the peroneus brevis
tendon (1) and peroneus longus tendon (2). The medial compartment includes the flexor
digitorum longus tendon (3), the flexor hallucis longus tendon (4) and the posterior tibialis
tendon (5).
© Department of Radiology, Clinical University Hospital Virgen de la Arrixaca; Medical
University of Murcia / Murcia 2015.
Page 21 of 24
Fig. 16: Sagittal anatomical and PD-weighted images of the ankle that shows the
posterior compartment formed by the Achilles tendon (arrow).
© Department of Radiology, Clinical University Hospital Virgen de la Arrixaca; Medical
University of Murcia / Murcia 2015.
Page 22 of 24
Conclusion
The ankle and hindfoot are complexity anatomical structures that radiologist needs to
know in detail. Adequate knowledge of the anatomy of the ankle and hindfoot ligaments
and tendons is essential for an accurate understanding of the basic mechanisms of injury,
diagnosis and treatment of the ankle disease.
Personal information
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