other common causes of painful hindfoot - o'mara for ... · ballet dancers & soccer...

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Other Common Causes of Painful HindfootKate O’Mara, DO

April 21, 2015

Financial DisclosuresNothing to disclose.

Objectives

Explore differential diagnosis for hindfoot pain Consider etiologies beyond ligament/tendon injury

Recognize imaging findings typical of impingement syndromes

Heel pain

Other hindfoot pain

Painful Hindfoot

Impingement Syndromes Anterior Anterolateral

Anteromedial Posteromedial

Posterior Talocalcaneal & calcaneofibular

Heel Pain Plantar fasciitis Plantar fibromatosis

Bursitis Haglund deformity/syndrome

Calcaneal stress fracture

Os trigonum Syndrome

Osteochondral Lesions Tarsal Coalition Sinus Tarsi Syndrome Tarsal Tunnel Syndrome Baxter’s neuropathy Synovial Disorders Multifocal bone marrow edema

Ankle Impingement Syndromes

Pathologic conditions resulting in chronic, painful restriction to movement

Secondary to soft-tissue or osseous abnormalities

Typically related to an ankle sprain

Classified according to its anatomic relationship to the tibiotalar joint

Ankle Impingement Syndromes

Anterolateral

Anterior

Anteromedial

Posteromedial

Posterior

Talocalcaneal & Calcaneofibular

Lateral hindfoot

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Anterior Impingement Syndrome Ballet dancers & soccer players

Progressive symptoms due to impingement of hypertrophied soft tissue & bony spurs Anterior tibiotalar spurs within joint capsule

Repeated dorsiflexion (ballet - plié)

Direct trauma from ball impact (soccer – ball strike)

Microfractured trabecular bone, periosteal hemorrhage, anterior chondral margin trauma result in new bone formation

Effusion

Hypertrophied synovium with impingement, irregular capsular thickening

Marrow edema uncommon

Anterior Impingement Syndrome

Lateral drawing of ankle shows typical location of spur formation (orange) at anterior ankle projecting from anterior tibia and anterior talus. This spur results in decreased angle between tibia and talus, measuring less than 60°.

AJR. 2010;195: 595-604.

Anterior Impingement• 25-year-old man• Opposing tibiotalar

osteophytes • OCD distal tibia &

lateral talar dome

AJR. 2010;195: 595-604.

Anterior Impingement

T1:spurs projecting from dorsal talar neck (arrow) and from anterior distal tibia (arrowhead).

STIR: concavity along dorsal talar neck (arrow) that accommodates tibial osteophyte. Talar neck marrow edema and intraarticular soft-tissue scarring (arrowhead)

Anterolateral Impingement

Typically young athletes with minor trauma (inversion)

Recurrent subclinical instability & microtrauma with hemorrhage, localized reactive synovial hyperplasia, scarring

Eversion & dorsiflexion cause symptoms of impingement

May form reactive hyalinized connective tissue mass: “meniscoid lesion”

May be associated with distal/accessory fascicle of anterior inferior tibiofibular ligament (normal variant)

Treatment: arthroscopic resection of hypertrophic synovium & scar tissue


• Typical location ofsynovitis

• Anterolateral recessbetween anteriortibiofibular (arrows) and anterior talofibularligaments (arrowheads)

AJR. 2010;195: 595-604.

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• Accessory ligament or distal fascicle of anteroinferior tibiofibular ligament(white arrow)

• Normal variant• Can cause

impingement whenthickened

• Black arrows = anteriortibiofibular ligament

• Arrowheads = anterior talofibular ligament

AJR. 2010;195: 595-604.

Anterolateral Impingement Imaging

Ultrasound nodular, mixed echogenic, synovitic mass

Bone spurs

Anterior talofibular ligament injury

MRI Thickened anterior talofibular ligament

Lateral gutter fullness

MR Arthrogram Capsule adheres to tibia and fibula – scarring & synovitis


• Low-signal-intensity meniscoid-shaped mass(arrow)

• Extends from thickenedanterior talofibularligament (arrowhead) intolateral gutter

AJR. 2010;195: 595-604.Axial T2

Anteromedial Impingement

Rare complication of inversion trauma

Microtrauma & healing initiates synovial, ligamentous, capsular thickening in anteromedial compartment

Compressed during dorsiflexion & inversion

MR Arthrography Anteromedial capsular thickening

Abnormal soft tissue anterior to the deltoid ligament & medial malleolus

Anteromedial Impingement• 24-year-old woman• Synovitis (arrow) in

anteromedial gutter deep to superficial anterior deltoid fibers

• Synovitis extendsposteriorly between flexordigitorum longus andposterior tibial tendons(arrowhead), suggestingconcomitant posteromedial impingement

AJR. 2010;195: 595-604.Axial PD


• Synovitis in anteromedialgutter (arrow)

• Outlined by joint fluid

AJR. 2010;195: 595-604.Coronal FS PD

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• 51-year-old man• Remote ankle sprain• Thickening and

ossification of deep (arrows) and superficial (arrowhead) deltoidligament fibers

AJR. 2010;195: 595-604.Coronal FS PD

Posteromedial Impingement

Following severe inversion injury with ATF ligament injury

Allows compression of posteromedial structures between medial wall of talus & medial malleolus Joint capsule

Posterior deltoid ligament

Posteromedial flexor tendons

Forms thickened, disorganized fibrous tissue

Accessory medial talar tubercle may contribute

Treatment Injection: steroid & local anesthetic

Surgical resection

Posteromedial Impingement

MRI Loss of normal fat striations in posterior deltoid ligament

Posteromedial synovitis

Thickening & abnormal signal posteromedial joint capsule May displace/surround adjacent tendons

US Thickening posteromedial capsule

Posteromedial synovial hypertrophy

Displacement/entrapment of adjacent tendons

Posteromedial Impingement• Marked scarring and loss of

normal architecture of deep deltoid ligament (arrows)

• Medial displacement ofposterior tibial tendon (arrowhead)

• Obliteration of fat planesbetween posterior tibial tendon and scarred ligament

• M = medial malleolus.

AJR. 2010;195: 595-604.Axial T2

Posterior impingement

Posterior ankle pain with plantar flexion Compression of talus & soft tissues between posterior tibia

& calcaneus

AKA os trigonum syndrome, talar compression syndrome, posterior block

Os-trigonum most common cause


Posterior talar process is bifid Smaller medial process

Groove for flexor hallucis longus tendon

Larger lateral process If elongated: Steida process

Failure of fusion (14-25%): os trigonum (3 articular surfaces)

JAAOS, Oct 2005,vol. 13 no. 6 365-371

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Soft tissue impingement Posterior capsule

Posterior talofibular, posterior intermalleolar & tibiofibular ligaments Posterior intermalleolar ligament

– anatomic variant – extendsobliquely from posterior medial malleolus to posterior margin of fibular malleolar fossa

Radsource.us

Chronic repetitive stress in plantar flexion

Ballet dancers: en pointe

Soccer players: ball strike

Posterior impingement Imaging Lateral x-ray (plantar flexion)

impingement of os trigonum/lateral tubercle between calcaneus & posterior tibia

US Nodular, hypoechoic thickening of posterolateral joint

capsule

MRI Posterolateral capsule thickening & synovitis

Bone marrow edema

Os trigonum/lateral tubercle fragmentation

Fluid along flexor hallucis tendon sheath

Posterior Impingement

• 27-year-old woman• Prominent Stieda process

(black arrow)• Posterior osteophyte (white

arrow) along distal tibia

AJR. 2010;195: 595-604.


Sagittal T1: low-signal-intensity os trigonum (arrow) and adjacent low-signal soft-tissue abnormality (arrowheads)

27-year-old female ballet dancer with posterior impingement and os trigonum.

STIR: opposing talar and os trigonum marrow edema (arrows), adjacent soft-tissue edema, and joint effusion (star)

AJR. 2010;195: 595-604.


Low-signal-intensity soft-tissue scar posterior to talus (arrow)

AJR. 2010;195: 595-604.

T1 STIR

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Posterior Impingement – Os trigonum

Posterior Impingement, FHL tenosynovitis

Posterior impingement Management

Conservative initially

Ultrasound guided anesthetic/steroid injection

Surgical excision – osseous & soft tissue elements

Talocalcaneal & Calcaneofibular Impingements

Extra articular soft-tissue and osseous impingements

Lateral to the ankle joint

Sequelae of flatfoot deformity & hindfoot valgus Posterior tibial tendon (PTT) deficiency

Rheumatologic disorders

Diabetes

Calcaneal fractures

Congenital flatfoot

Calcaneal osteotomy is often necessary to correct hindfoot valgus and lateral hindfoot impingement

Lateral extra articular talocalcaneal & subfibular hindfoot impingements

Normal hindfoot valgus (<6°) and no lateral impingement

Progressive hindfoot valgus, abnormal contact between lateral talus and calcaneus (red) occurs first and results in talocalcaneal impingement

Subsequent abnormal contact between both lateral talus and calcaneus (red) and calcaneus and fibula (orange) subsequently develop and produce combined talocalcaneal and subfibular impingementAJR. 2010;195: 595-604.

Talocalcaneal and calcaneofibular impingement

• 66-year-old woman• Pes planus and hindfoot

valgus• STIR: marrow edema of

opposing lateral talarprocess (solid arrow) and calcaneus (open arrow)

AJR. 2010;195: 595-604.

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Sag T1: edema and scarring (arrowheads) surrounding thickened, entrapped calcaneofibular ligament (arrow)


AJR. 2010;195: 595-604.

• Edema and scarringsurrounding thickened, entrappedcalcaneofibular ligament (arrow)

• Hindfoot valgusangle, formed byintersection of linealong medialcalcaneal wall andline parallel to longaxis of tibia, isincreased (30°).


AJR. 2010;195: 595-604.

Coronal FSPD

• 61-year-old woman withsevere hindfoot valgus

• Contact betweencalcaneus and fibula withopposing marrow edemaand subchondral cysts(arrows)


AJR. 2010;195: 595-604.

STIR

• Coronal PD: neocalcaneal facet (solid arrow) articulating with distal fibula.

• Lateral subluxation of calcaneus and subchondral changes in posterior subtalar facet (arrowheads)

• Peroneal tendons (open arrow) are minimallylaterally subluxed


AJR. 2010;195: 595-604.

Lateral Hindfoot Impingement

• Characteristic bone marrow edemaat the inferior apex of the lateral talar process (asterisk) as well asat the subjacent angle of Gissane(arrowhead)

http://radsource.us/lateral-hindfoot-impingement/#sthash.OQ8j95vE.dpuf

FST2

Heel pain (calcaneodynia) Plantar fasciitis/ tear Calcaneal stress fracture/ insufficiency avulsion fractures Tarsal tunnel syndrome Baxter’s nerve impingement Bursitis Achilles

Tendinosis, Insertional tendinosis Tendon tear Peritendinitis & Paratendinitis

Haglund Deformity & Syndrome Sever Disease (calcaneal apophysitis) Os Trigonum Syndrome

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Plantar fasciitis

Most common cause of inferior heel pain Inflammation usually related to repetitive trauma

Microtears near its origin Runners, obese patients

Inflammatory arthropathies (enthesopathy) Reactive arthritis, ankylosing spondylitis, psoriatic arthritis

MRI Intermediate signal (should be low) – intrafascial edema Thickening 6-10mm (normally 2-4mm) – fusiform Marrow edema calcaneal tuberosity Surrounding hyperintense T2 (edema)

Heel spur on X-ray not diagnostic

Plantar fasciitis

AJR 2013;200: 845-855

Plantar Fasciitis Plantar Fascia Tear

Sports related (running, jumping)

Chronic plantar fasciitis after corticosteroid injections

Usually proximal, near calcaneal attachment Associated with tear of flexor digitorum brevis muscle

MRI Partial/complete disruption, edema & hemorrhage

Perifascial fluid

Plantar Fascia Tear Plantar Fascia Tear

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Plantar Fascia Tear Plantar Fibromatosis

Benign fibroproliferative disorder, unclear etiology

M.C. medial portion central fascial band

One or more palpable nodules

MRI Nodules along plantar fascia

Low T1, intermediate to high T2/STIR

Enhancement varies (based on cellularity)

Deeper lesions often solitary, aggressive, high recurrence following excision

Plantar Fibromatosis

T1T2FS T1FS post

Plantar Fibromatosis

T1 T2FS T1FS+

Plantar fibromatosis

T1 T2FS T1FS post

Bursitis

Retrocalcaneal bursa (subachilles bursa) Between posterosuperior calcaneus and Achilles tendon

insertion

Should measure < 1-2mm AP

Superficial Achilles bursa (retro-Achilles bursa, subcutaneous calcaneal bursa) Between tendon and skin

Adventitial (acquired)

Bursitis: edema without mass effect on skin

Webmd.com

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Retrocalcaneal bursitis

With or without Achilles tendinosis

Repetitive trauma (runners)

Conservative treatment, sometimes corticosteroids

X-ray: obliteration of normal retrocalcaneal fat pad

MRI: enlarged bursa >7mm long, 11mm trans, 1mm AP considered abnormal


Radiology blogspot

Haglund Deformity & Syndrome

Deformity: prominent bony projection of calcaneus Superior, posterior aspect of calcaneal tuberosity

Associated with wearing low-back shoes

Syndrome: mechanically induced inflammation Inflammation of superficial bursa

Achilles tendinosis


Bony prominence

Haglund Deformity - XR

Enlarged calcaneal tuberosity Draw parallel pitch lines

along superior & inferior calcaneus

Calcaneal tuberosity enlarged if extends above superior pitch line

Syndrome: loss of radiolucent retrocalcaneal recess (indicates bursitis)

AJR. 2013;200: 845-855.

Radiopaedia

Haglund Syndrome

Bony prominence (T1)

Excessive fluid retrocalcaneal bursa

Fluid in retro-Achilles bursa

Bone marrow edema in calcaneal tuberosity

Achilles insertional tendinosis

AJR. 2013;200: 845-855.

Calcaneal stress fracture 2nd most common site of fatigue stress fracture (after

metatarsals) Insufficiency fractures (RA, neurologic disorders, DM) Repetitive trauma (jumping) Posterosuperior or posterior calcaneus

Oriented vertically (perpendicular to long axis of calcaneus)

X-ray: variable sclerotic band MRI:

band-like low T1, high T2 in intramedullary space, extends to cortex

Extensive surrounding edema, hemorrhage

Periosteal callus – hypointense line parallel to cortex

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• 24 year old militaryrecruit

• Fracture line (arrow) and intense surrounding marrow edema

• Associated retrocalcaneal bursitis(arrowhead)

radsource.us/plantar-fasciitis/#sthash.1gxQs12n.dpuf

T2 fat sat

Calcaneal Stress Fracture

• 43-year-old woman

• Vertical fracture line outlined by bone marrow edema

American Journal of Roentgenology. 2011;197: W720-W729.

STIR

Sever Disease (calcaneal apophysitis)

Skeletally immature

Traction: at site of Achilles tendon insertion

X-ray nonspecific Increased density, fragmentation of apophysis (also seen in

healthy kids)

MRI Edema in calcaneal apophysis, may extend to calcaneal

tuberosity

Sever Disease (calcaneal apophysitis)

Orthocarolina.comMypacs.net/case 154930

Calcaneal Insufficiency Avulsion (CIA) Fractures

Avulsion fracture involving posterior 1/3 of calcaneus

Same plane as fatigue type calcaneal fracture

No significant force

Displaced 10-30 mm, often rotated

Mean time from diagnosis of diabetes mellitus to CIA fracture: 20 years

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Calcaneal tuberosity avulsion fracture. Weerakkody et al. Radiopaedia

Calcaneal Insufficiency Avulsion (CIA) Fractures

Calcaneal Insufficiency Avulsion (CIA) Fractures Osteochondral Lesions (OCL)

Post-traumatic injury of articular (hyaline) cartilage and underlying subchondral bone

Common locations (in order of frequency) Femoral condyles

Capitellum of elbow

Talar dome

Patella

Talar dome OCL Medial more common than lateral

Deeper

Greater surface area

Radiopaedia

Small OCD talar dome OCD talus

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OCD Talus OCD Talus

Stable v Unstable OCL

Unstable Hyperintense T2 signal (equal to joint fluid) between

detached osteochondral fragment and parent bone

Cystic change at donor site

Extensive bone marrow edema

Collapse of articular surface

Arthrogram may help delineate, if necessary

Treatment

Stable Nonweightbearing cast immobilization

Progressive weightbearing over 3-4 months

Unstable Surgery: remove subchondral fragment & Debris

Microfracture of remnant bone to promote growth of new fibrocartilage

Internal fixation (fragment > 7.5mm)

Osteochondral allografts or autografts

OATS (osteochondral autograft transfer system)

Heal with type II collagen instead of fibrocartilage

OCL Differential Diagnosis

AVN – Avascular Necrosis Significant bone marrow edema

Spares articular surface

End stage OCL and AVN can result in collapse of articular surface

OA – Osteoarthritis Changes involve both sides of joint

Eburnation

Osteophytes

OCL may result in OA

AVN Talar dome

Radiopaedia.

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Osteoid Osteoma Talus Tarsal Coalition

Congenital connection between 2 or more bones Bony, cartilaginous, or fibrous

Prevent normal joint motion

Subtalar coalition

Calcaneonavicular coalition

Coalitions cause abnormal bone overgrowth Osseous coalition: continuous bony bar

Nonosseous coalition: bony overgrowth with irregular cleft

Tarsal Coalition –Radiographic features Subtalar coalition (best seen on Harris view)

C-sign (lateral) – continuity of inferomedial talus and ST Also seen in flat foot deformity

Dysmorphic Sustentaculum Tali – inferior border rounded, enlarged

Talar beak – articular surface flares superiorly to accommodate increased motion at talonavicular joint Talar osteophyte – proximal to joint and arcs over joint Talar ridge – normal attachment ankle joint capsule, proximal

Absent Middle Facet sign

Calcaneonavicular coalition Anteater sign (lateral) – Elongated anterior process of calcaneus Elongated Navicular sign (AP) – Reverse anteater – elongated

lateral navicular

C-sign, talar beak

Subtalar coalition: CT/MRI

Osseous: bony continuity across middle subtalar facet

Nonosseous: fibrous or cartilaginous coalition Narrow, obliquely oriented, undulating contour

Subchondral cysts

Bone marrow edema

Enlarged ST, rounded contour inferiorly

Peroneal or flexor tendon tenosynovitis

Subtalar (talocalcaneal) coalition

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Talocalcaneal coalition Talocalcaneal coalition (fibrocartilagenous)

Calcaneonavicular Coalition –CT/MRI

Sagittal: elongated anterior calcaneal process with blunted tip

Axial: Abnormal shape anterior calcaneus and lateral navicular

Subchondral cysts & bone marrow edema anterior calcaneus

Calcaneonavicular Coalition

• T1: elongated & broadened anterior process of calcaneus (arrowhead)

• Irregular articulation(arrow) with the navicular: "anteater's nose".

• STIR: bony hypertrophy& subarticular marrow edema (asterisks) at the abnormalcalcaneonavicular articulation

T1: slightly widened mediolateral dimension of the navicular (black arrow)• tapers laterally and

articulates (white arrow) with the enlarged anterior process of the calcaneus (arrowhead)

http://radsource.us/tarsal-coalition

Calcaneonavicular coalition Calcaneonavicular coalition

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Sinus Tarsi Syndrome

Lateral pain, perceived hindfoot instability

Subtalar region, anterior to posterior subtalar joint

Normally fat-filled

Talocalcaneal (Interosseous) Ligament Cervical ligament: anterior

Best seen on Coronal: vertical course

Interosseous talocalcaneal ligament: posterior & medial Coronal: oblique orientation inferior talus to superior calcaneus

Inferior extensor retinaculum (superficial)

Tarsal sinus ligamentous system

1. Cervical ligament2. Medial root IER3. Interosseous

talocalcaneal ligament

4. Intermediate root5. Lateral root of the

inferior extensorretinaculum.

AF = anterior facetMF = medial facetPF = posterior facet

Normal appearance (cadaver)

normal course of the cervical ligament (1), interosseous talocalcaneal ligament (3), and the medial (2) and intermediate (4) roots of the inferior extensor retinaculum


Etiology: Trauma (70%)

Inflammation (RA, gout, Ank spond)

Foot deformities (pes cavus/planus)

MRI: replacement of normal fat signal Inflammatory infiltrate, fibrosis

Low T1, high T2

Ligaments obscured or ruptured

High association with lateral ligament disruption Calcaneofibular ligament

Differential diagnosis: Lateral hindfoot impingement

Sinus tarsi syndrome

T1: absence of fat signal at the sinus

radsource.us/lateral-hindfoot-impingement

52 year-old male with ankle pain and swelling

STIR: edema throughout the sinus tarsi with subcortical bone marrow edema along the talus and calcaneus at marginsof the sinus (arrows)


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Tarsal tunnel syndrome

Entrapment neuropathy of posterior tibial nerve or of its branches within the tarsal tunnel Usually unilateral

Clinical presentation Pain & paresthesia in the toes, sole, or heel

Physical exam: Tinel sign (distal paresthesias produced by percussion over the affected portion of nerve)

Electromyography and nerve conduction studies are useful in confirming the diagnosis

Tarsal tunnel anatomy Fibro-osseous canal , medial ankle

Boundaries

Roof: flexor retinaculum

Floor - medial surfaces of talus & calcaneus

Contents (from anterior to posterior)

Tibialis posterior tendon

Flexor digitorum longus tendon

Neurovascular bundle

Posterior tibial artery & vein

Posterior tibial nerve

Flexor hallucis longus tendon

A mnemonic to remember the order is: Tom, Dick and Very Nervous Harry

Divided by fibrous septae joining the retinaculum to calcaneus, forming four separate compartments - one for each of the tendons and one for the neurovascular bundle

Tarsal Tunnel Anatomy Tarsal tunnel syndrome

• Compression of posterior tibial nerve between medial surface of ankle and overlying flexor retinaculum

• Pain, sensory deficits, and muscle weakness

• MRI: mechanical causes of compression

• tenosynovitis

• neural tumors

• ganglion cysts

• posttraumatic fibrosis

• accessory muscle - flexor digitorum accessorius longus (FDAL)

Tarsal tunnel syndrome: flexor digitorum accessorius longus (FDAL)

radsource.us/tarsal-tunnel-syndrome

Tarsal Tunnel Syndrome: ganglion cyst


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Tarsal tunnel syndrome: Schwannoma


Tarsal tunnel syndrome: Varicosities


Baxter's neuropathy

Nerve entrapment syndrome : compression of the inferior calcaneal nerve 1st branch of the lateral plantar nerve - courses through

tarsal tunnel

Clinical presentation heel pain (plantar medial foot and anterior/medial

calcaneus)

paresthesia with motor weakness of the abductor digiti minimi muscle

no associated cutaneous sensory deficit

Baxter’s neuropathy - MRI

Acute phase of muscle denervation Decreased T1, increased T2FS signal intensity

Increased extracellular water content

Decreased muscle fiber volumes

Chronic phase of muscle denervation Amyotrophy or fatty degeneration

Abductor digiti minimi muscle

Less commonly: flexor digitorum brevis & quadratus plantae muscles

Baxter’s Nerve Impingement

• Fattydegeneration of the abductor digiti minimi muscle

Baxter’s neuropathy - chronic

October 2009 Radiology, 253, 160-166.

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Synovial Disorders

PVNS – Pigmented Villonodular Synovitis

Synovial chondromatosis

Synovitis

PVNS

Proliferative disorder of synovium

Joints, tendon sheaths, bursae

Hemorrhage results in hemosiderin deposition

MRI variable: intermediate/low T1, low and high T2, blooming artifact GRE

Diffuse form involves joints (knee > hip > ankle)

Focal form: tendon sheath (GCTTS giant cell tumor of tendon sheath)

PVNS Ankle FHL Giant Cell Tumor Tendon Sheath

FHL GCTTS post Gad Synovial chondromatosis

Synovial metaplasia

Benign, monoarticular

Lining cells produce cartilage nodules

May or may not ossify

Treatment: synovectomy

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T1 T2FS

Mass-like signal distending ankle joint

MyPACS.net: Radiology Teaching Files > Case 8494317


Multifocal Bone Marrow Edema

High turnover - children <15 years Multiple foci of high T2 signal in several ankle/foot bones

Asymptomatic, self limiting

Altered gait Strenuous exercise Bone impaction/bone contusions

Trabecular microfractures, edema, hemorrhage

Immobilization – patchy, subcortical, subchondral CRPS – Complex Regional Pain Syndrome

Skin edema & thickening

Patchy, subcortical edema pattern

High Turnover

• 12-year-old girl

• Sagittal STIR image shows multiple foci ofincreased bone marrow signal

• Associated withincreased sports-related activity

AJR. 2011;197: W720-W729.

Immobilization

MR image obtained after 6 weeks of bracing shows talar osteochondral lesion (arrow, reason for bracing)

Extensive bone marrow edema in multiple bones related to disuse osteoporosis

Radiopaedia

CPRS• Soft tissue edema

and enhancement, skin thickening

• Muscle atrophy inlater stages

• Patchy bonemarrow edemasignal (particularlysubcortical, periarticular)

Radiopaedia

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Calcaneal Vascular Grooves

• At critical angle of Gissane

• Common • May be quite extensive

American Journal of Roentgenology. 2011;197: W720-W729.

STIR

Painful Hindfoot

Impingement Syndromes Anterior Anterolateral

Anteromedial Posteromedial

Posterior Talocalcaneal & calcaneofibular

Heel Pain Plantar fasciitis Plantar fibromatosis

Bursitis Haglund deformity/syndrome


Os trigonum Syndrome

Osteochondral Lesions Tarsal Coalition Sinus Tarsi Syndrome Tarsal Tunnel Syndrome Baxter’s neuropathy Synovial Disorders Multifocal bone marrow edema

Objectives

Explore differential diagnosis for hindfoot pain Consider etiologies beyond ligament/tendon injury

Recognize imaging findings typical of impingement syndromes

Heel pain

Other hindfoot pain

References

Current Concepts in Imaging Diabetic Pedal Osteomyelitis. Donovan. Radiol Clin N Am 46 (2008) 1105-1124.

Osteochondral Lesions About the Ankle. Naran. Radiol Clin N Am 46 (2008) 995-1002

Ankle Impingement Syndromes. Hopper. Radiol Clin N Am 46(2008) 957-971

Imaging of Tarsal Coalition. Crim. Radiol Clin N Am 46(2008) 1017-1026

Imaging of Soft Tissue Lesions of the Foot & Ankle. Bancroft. Radiol Clin N Am 46(2008) 1093-1104

Current Concepts in Imaging Diabetic Pedal Osteomyelitis. Donovan. Radiol Clin N Am 46(2008) 1105-1124

References

Sinus Tarsi Syndrome. MRI Clin No Amer. Vol 2, Num 1 (1994) 59-66.

Tarsal Tunnel Syndrome. MRI Clin No Amer. Vol 2, Num 1 (1994) 67-78

MRI of Plantar Fasciitis & Other Causes of Heel Pain. MRI Clin No Amer. Vol 2, Num 1 (1994) 97-108

Tumors of the Ankle & Foot. MRI Clin No Amer. Vol 2, Num 1 (1994) 139-154

Sonography & MRI of Selected Benign Masses in the Foot & Ankle. Pham. AJR 2003;180:99-107

MRI of Ankle and Lateral Hindfoot Impingement Syndromes. AJR 2010; 195:595-604

Bone Marrow Edema Patterns in Ankle & Hindfoot: Distinguishing MRI Features. Rios. AJR 2011;197:W720-W729

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References

Calcaneal insufficiency avulsion fractures in patients with diabetes mellitus. Radiology 1991 Sep;180(3):725-9.

MRI of Heel Pain. AJR 2013; 200:845-855

MR imaging of the tarsal tunnel and related spaces: normal and abnormal findings with anatomic correlation. AJR. 1990;155: 323-328.

Avascular Necrosis of the Talus: A Pictorial Essay. RSNA. 2005;25:399-410.

Diabetic Foot & Ankle 2012, 3: 18754 -http://dx.doi.org/10.3402/dfa.v3i0.18754

Imaging of the Foot & Ankle. 3rd Ed. Berquist. LWW. 2011.

Diabetes

Pedal osteomyelitis

Charcot joint

Calcaneal insufficiency avulsion fractures

Skin Callus

Develop at pressure points Normal: 1st/5th metatarsal head, heel

Hallux valgus: medial to 1st metatarsal

Rocker-bottom: beneath cuboid

MRI: focal prominence in subcutaneous fat Low T1, low to intermediate T2

May enhance

Adjacent fat normal (helps distinguish from infection)

Adventitial bursa Thin, flat fluid collection

Adjacent to callus

Skin Callus

• Focal hypointense area in subcutaneous fat in the midfoot in both sequences (arrows) • No accompanying soft tissue changes, consistent with callus• Subchondral marrow edema at intertarsal joints is a result of neuroarthropathy

T1 T2FS

Diabetic Foot & Ankle 2012, 3: 18754 - http://dx.doi.org/10.3402/dfa.v3i0.18754

Ulceration & Sinus Tract

Callus breakdown

Focal skin interruption, “heaped up” margins, soft tissue defect

T2 bright, intense peripheral enhancement (granulation tissue)

Sinus tract (“tram track” enhancement) leads to bony prominence

Plantar ulcer with cuboid osteomyelitis

Radiology Assistant/Diabetic Foot MRI

23

Sinus tract – no osteo

Radiology Assistant/Diabetic Foot MRI

Soft tissue swelling, cellulitis, abscess

Edema & cellulitis: fat reticulation with intermediate T1 & high T2 signal Cellulitis enhances, edema does not

Phlegmon: ill-defined low T1, intermediate to high T2 (not as bright as fluid) Vague enhancement

Abscess: fluid signal collection Peripheral rim enhancement

Cellulitis, fistula and associated osteomyelitis and septic arthritis

T1 T2FS

T1+G

T1+G

• High T2 signal and significant skin enhancement = cellulitis (arrowheads).• Deep ulcer in the medial portion of the first toe • Fistula (white arrow) traversing the distal phalanx• Abnormal signal of the proximal and distal phalanges due to osteomyelitis & septic arthritis (black arrow)


Gangrene

Clinical diagnosis – imaging usually unnecessary

Dry – noninfected, devitalized tissue

Wet – superimposed infection

MRI – delineate areas of soft tissue devascularization Nonenhancing area

Sharp demarcation from viable tissue

Reactive hyperemia/enhancement of periphery

Wet gangrene – look for soft tissue gas GRE most sensitive - blooming

Gas gangrene

• Widespread low-signal-intensity foci demonstrating blooming artifact (arrowheads) alongthe dorsum of the foot indicating soft-tissue gas

• Fluid collections (white arrows), with peripheral enhancement (black arrows) • Subcutaneous tissue, fascial and muscular enhancement (asterisk) are present

T1 T2FS

T1+G T1+G


Osteomyelitis

Confluent low T1 signal, high T2

High T2 signal without low T1 – reactive edema (may enhance)

Periosteal reaction: circumferential high T2, enhances

Adjacent soft tissue findings (ulcer, sinus tract, cellulitis, abscess, foreign body)

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Osteomyelitis3 phase bone scan• Increased activity blood

flow, blood pool, delayed phases distal 1st MT

• Consistent withosteomyelitis.

MRI• Confluent hypointense

T1, hyperintense T2 • Indicate presence of

osteomyelitis in the first metatarsal head (white arrows)


Septic arthritis

Contiguous spread from adjacent soft tissue infection Ankle & subtalar joints in hindfoot related to ulceration at

malleoli or calcaneus

Complex joint effusion, thick synovial enhancement

Soft tissue & subchondral marrow edema, marginal erosions

Confluent low T1 - osteomyelitis

Septic Arthritis

• XR: focal soft tissue swelling, demineralization (arrows) inperiarticular region in distalinterphalangeal joint of the first toe.

• T2FS: ulcer and sinus tract (thinwhite arrow) extending to the joint space.

• T1, T1+G: synovial enhancement(arrowhead) and abnormal intramedullary signal (thick whitearrow) that is extending from thejoint surface, consistent with septicarthritis and accompanyingosteomyelitis


Septic tenosynovitis

Spread from adjacent ulceration Peroneals – lateral malleolus ulcer

Achilles (peritenonitis) – calcaneal ulcer

Tiny fluid collection around the posterior tibial tendon that demonstrates contrast enhancement (arrows). The tendon is closely related with to the deep ulcer in subcutaneous tissue (arrowheads).

T2T1+G

Septic tenosynovitis


Neuropathic arthropathy

Acute stage may mimic osteomyelitis MRI: soft tissue edema, fluid collections, effusions, marrow

changes, enhancement

Subacute stage (coalescense): bone resorption

Chronic, consolidation stage: debris, destruction, dislocation, density (x-ray) MR: deformity, osseous fragmentation, joint effusions

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Chronic neuropathic osteoarthropathy• XR: fragmentation &

subluxation (arrowheads) at the midfoot with dorsal soft tissue swelling

• MRI: extensive midfoot bone marrow edema

• Multiple midfoot fluid collections

• Diffuse bone marrow enhancement and associated periarticular subchondral cysts suggestive for neuroarthropathy only

• No associated ulcer,sinus tract or abscess formation. Clinical evaluation revealed no signs of infection.

Diabetic Foot & Ankle 2012, 3: 18754

Osteomyelitis v Charcot

Osteomyelitis

Contiguous spread of infection from skin ulceration

Distal to Lisfranc’s joint, calcaneus, malleoli

Charcot

Articular disease

Lisfranc’s joint, metatarsophalangeal joints

Neuropathic arthropathy with superimposed infection

Diffuse marrow changes (periarticular in Charcot joint without infection)

Positive “Ghost sign” = superimposed infection Bones “disappear” on T1

“Appear” & become more distinct on T2 and post-contrast images

Negative ghost sign = neuropathic foot Bones are truly dissolved and destroyed

Ghost Sign = Osteomyelitis

Ghost Sign• Poor definition of the margins of a bone on T1-weighted

images, which become clear after contrast administration• Indicative of neuro-osteoarthropathy with superimposed

osteomyelitisRadiology Assistant

Masses - benign

Plantar fibromatosis

Peripheral nerve sheath tumors

Lipomas

Glomus tumors

Ganglion cysts

Abscess

Epidermal Inclusion Cysts

Subcutaneous Granuloma Annulare

Masses - malignant

MFH – Malignant Fibrous Histiocytoma Common soft tissue sarcoma Spreads from calf Infiltrating, rapid growth Nonspecific MRI appearance

Synovial Sarcoma Cells resemble synovial membrane, only 5% intraarticular 2/3 lower extremity Slow growing, infiltrative Lobulated, with cysts/necrosis, fluid levels

Liposarcoma nonspecific

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MFH

Radiopaedia.org

Synovial sarcoma

other common causes of painful hindfoot - o'mara for ... · ballet dancers & soccer...

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