Lateral hindfoot pain is generally due to impingement or arthrosis at the lateral hindfoot caused by an altered biomechanical force vector associated with hindfoot valgus [2]. Magnetic resonance imaging (MRI) of the left ankle revealed a vertical crack in the talar body extending from the center of the talar dome to the subtalar joint and a lateral talar body fragment with low signal intensity on both T1-weighted and short T1 inversion recovery images suggestive of osteonecrosis (Figures 2(a) and 2(b)). This is felt to be related to changes related to traction during normal gait. J. T. Bencardino, T. J. [Figure 2B, 8] MR imaging injury patterns can be subdivided into (a) lateral distraction with medial compression, (b) dorsal distraction, and (c) medial distraction with lateral compression. Midtarsal sprains are more common than previously realized, but are frequently overlooked in the setting of acute lateral ankle sprains. At the time of the most recent follow-up, 2 years after the first visit to our hospital, the patient maintained the performance described above without complaint, although the comminuted lateral talar body displayed nonunion on radiography and CT evaluations. S. J. Ellis, T. Deyer, B. R. Williams et al., Assessment of lateral hindfoot pain in acquired flatfoot deformity using weightbearing multiplanar imaging, Foot & Ankle International, vol. The left ankle was also accompanied by fracture of the distal fibula (b). Sagittal T2-weighted fat suppressed image of the foot (5A) obtained in a 21 year-old male following a fall. Houghton MJ et al. Soft tissue fluid-like signal and adjacent joint effusions help to outline the ligament. Hindfoot valgus is lateral deviation of the calcaneus relative to the tibia. 1. A 30 year-old male presents with pain in the midfoot following a twisting injury to the ankle. Both plantar components are best seen on either axial or oblique axial images. The red line in the diagram indicates the beam. Add a good arch support or orthotic in your shoe. MRI of Ankle and Lateral Hindfoot Impingement Syndromes. [Figure 7A, 7B] 7a 7b Figure 7:Sagittal T2-weighted fat suppressed image (7A) obtained just lateral to the image in Figure 6B. Radiology 1953; 60:850854, Hirschmann A, Walter WR, Alaia EF, Garwood E, Amsler F, Rosenberg ZS. American Journal of Radiology, Consequently, the high sensitivity of MRI for detecting marrow edema can aid in detecting nondisplaced fractures and impaction injuries, which can easily be missed on radiographs. 5, pp. 26, no. Axial T1-weighted image (9B) in the same patient better demonstrates the minimally displaced cortical avulsion fracture (arrow). 52, no. The anterolateral recess of the ankle joint also known asthe anterolateral gutter is a triangular or pyramidal formed topographical space of the anterolateral aspect of the ankle1-4. Although the majority of research in PCFD is concerned with abnormalities of the medial column, PCFD will increase stress on the lateral column. Here, we report an unusual case of bilateral stress fractures in the lateral talar body that occurred in an elderly female with a severe pes planovalgus deformity. Posterior ankle impingement (PAI) syndrome is one of the impingement syndromes involving the ankle. Foot Ankle Surg 2016;22(2):7884, Sarrafian SK. Sagittal T2-weighted fat suppressed image obtained slightly more lateral (5B) again shows the osseous impaction injuries. Table 1: Causes of the lateral hind foot impingement. 5, pp. Anteroposterior weight-bearing radiograph of the right ankle (a) and left ankle (b) showing valgus talar tilt with joint space narrowing and collapse of the lateral talar dome. S293s306, 2017. Associated lateral compression forces result in osseous impaction at the lateral calcaneocuboid joint, producing comminuted intra-articular fractures. [Figure 4D] 4a 4b 4c 4d 4e 4f Figure 4:(4A) Sagittal T2-weighted fat suppressed images demonstrate the varied normal appearance of the talonavicular ligament. The more common lateral collateral ligament injuries are more familiar and may overshadow the associated midtarsal sprains. (short arrow), Identifying midtarsal sprains on MR imaging is important, because the injury is believed to be a significant cause of Chopart joint instability, cuboid instability, and chronic lateral foot pain, particularly among athletes, who may prematurely return to active weight-bearing. . Donovan A, Acute midtarsal sprains: frequency and course of recovery. Edema-like signal and ligament fiber irregularity are demonstrated within the medioplantar oblique band of the spring ligament (short arrows) reflecting a sprain. Unable to process the form. 31, 32 Physicians should screen for . Edema-like signal is also seen within the proximal muscle fibers (arrowheads). Lateral weight-bearing views of both feet demonstrated severe arch collapse and increased radiodensity of the body of the talus (Figures 1(c) and 1(d)). Lateral weight-bearing view of the right foot (c) and left foot (d) showing the severe arch collapse and increased radiodensity of the body of the talus. 9, pp. Axial T2-weighted image (7B) in the same patient demonstrates a complete proximal disruption of the dorsal calcaneocuboid ligament from its calcaneal origin (arrow). (4E) Sagittal T2- weighted fat suppressed image slightly more lateral than in Figure 4D demonstrates the calcaneocuboid band of the bifurcate ligament (arrow) and the overlying extensor digitorum brevis muscle (asterisk). [Figure 6] 6a 6b Figure 6:(6A) Sagittal T2-weighted fat suppressed image of the foot obtained in a 21 year-old male following a fall. Impingement on the distal fibula by the talus and/or calcaneus could even produce stress fracture of the distal fibula [3]; however, to our knowledge, no studies have reported stress fractures of the talus associated with adult-acquired flatfoot deformity. MRI of the right ankle also revealed a depressed lateral talar dome and some cyst formations surrounded by bone marrow edema in the talar body suggestive of a previous talar dome fracture; however, the lateral talar body fragment maintained the same intensity as those of other bone marrow on T1- and T2-weighted images, negating osteonecrosis in contrast with the left ankle (Figures 3(a)3(c)). Identify MRI findings of extraarticular lateral ankle impingement, The ligament has a wavy contour and is displaced slightly distally. (4A) Sagittal T2-weighted fat suppressed images demonstrate the varied normal appearance of the talonavicular ligament. the posterior is the largest, Fig. British volume, vol. 2017;90(1070):20160735. Avoid standing or walking barefoot or in unsupportive footwear like slippers or sandals. {"url":"/signup-modal-props.json?lang=us"}. 261270, 1996. Become a Gold Supporter and see no third-party ads. Short plantar ligament sprains may involve the closely applied medial calcaneocuboid joint capsule, and avulsion-related marrow edema appears at the medial margins of the calcaneocuboid joint. [Figure 9A, 9B] The normal calcaneonavicular component of the bifurcate ligament is almost always clearly seen; therefore, an absent or indistinct ligament should prompt a higher degree of suspicion for midtarsal sprain. 317324, 1977. Lateral hindfoot impingement is an extra articular hindfoot osseous impingement affecting the distal of fibula, talus and calcaneous bones. Rubin D, Tishkoff N, Britton C, Conti S, Towers J. Anterolateral Soft-Tissue Impingement in the Ankle: Diagnosis Using MR Imaging. (6A) Sagittal T2-weighted fat suppressed image of the foot obtained in a 21 year-old male following a fall. The ligament has a wavy contour and is displaced slightly distally. (4B) Coronal proton density weighted fat suppressed image shows the superomedial component of the spring ligament (arrow), continuous with the tibiospring band of the deltoid ligament (arrowheads). Findings 2 Figure 2: The sagittal T1-weighted image demonstrates extra-articular subcortical cystic changes and bone marrow edema at the lateral talar process and the adjacent calcaneus (arrowheads). Peroneal tendinopathy is an under-recognized cause of lateral hindfoot pain and can go undiagnosed, especially when associated with lateral ankle sprains. 39, no. Knee Surg Sports Traumatol Arthrosc 2016; 24:944956, Muhle C, Frank LR, Rand T, et al. N. M. Long, A. C. Zoga, R. Kier, and E. C. Kavanagh, Insufficiency and nondisplaced fractures of the talar head: MRI appearances, AJR. Common injuries in this setting include avulsion of the dorsal calcaneocuboid ligament and calcaneocuboid component of the bifurcate ligament as well as extensor digitorum brevis origin avulsion. The anterolateral recess of the ankle joint also known as the anterolateral gutter is a triangular or pyramidal formed topographical space of the anterolateral aspect of the ankle 1-4. The blood supply of the talar body is mostly dependent on the anastomotic artery in the tarsal canal, which has several main branches into the body expanding medially to posterolaterally [23]. (6B) Sagittal T2-weighted fat suppressed image in a 14 year-old male following an injury playing football. 193, no. Also noted are small osseous impaction injuries at the medial margins of the proximal cuboid bone and distal calcaneus (asterisks). Also note the associated muscle strain injury with increased signal intensity involving the adjacent extensor digitorum brevis muscle (arrowheads). (6B) Sagittal T2-weighted fat suppressed image in a 14 year-old male following an injury playing football. The objective of this article is to review the pathophysiology and clinical presentation of impingement syndromes at the ankle joint (anterolateral, anterior, anteromedial, posteromedial, and posterior) and the role of MRI in evaluating impingement at the ankle joint and at extraarticular locations, lateral to the ankle joint (talocalcaneal and . ADVERTISEMENT: Supporters see fewer/no ads. At the time the article was created Joachim Feger had no recorded disclosures. Normal Anatomy and Traumatic Injury of the Midtarsal (Chopart) Joint Complex: An Imaging Primer. [Figure 4D], While not directly reinforcing the calcaneocuboid joint, the extensor digitorum brevis muscle overlies the dorsal calcaneocuboid ligament and originates from the dorsolateral surface of the anterior calcaneus, just posterior to the bifurcate ligament and dorsal calcaneocuboid ligament origins. Axial T1-weighted image obtained in a 35yo male (10C) with pain following an injury. Material and Methods: A total of 14 feet (in 13 patients) with acquired flatfoot deformity and lateral hindfoot pain were included (mean age 64 years; age range 55-80 years). 14, Supplement, no. The talonavicular joint is stabilized by the dorsal talonavicular ligament (D-TNL), the calcaneonavicular component of the bifurcate ligament (CN-BL), and the spring ligament complex consisting of the superomedial (SM-CNL), medioplantar oblique (MPO-CNL) and the inferoplantar longitudinal (IPL-CNL) calcaneonavicular ligaments. see full revision history and disclosures. 2 Depending on the morbidity and imaging findings, treatment is initially accomplished conservatively, but open surgical and/or arthroscopic approaches have proven to have a safe and efficaci. These findings may explain the mechanism of stress fractures of the lateral talar body and distal fibula in the present case of late-stage adult-acquired flatfoot with irreducible hindfoot valgus. 48, no. Although our present case was satisfied with the present condition and did not require further intervention due to her low level of activities of daily living, careful follow-up should be conducted because a stress fracture or osteonecrosis of the talus could provoke new symptoms resulting from degenerative changes around the talus in the future [25, 26]. RadioGraphics 2019; 39:136-152, Pisani G. Coxa pedis today. Soft tissue fluid-like signal and adjacent joint effusions help to outline the ligament. T1-weighted (a) and short-T1 inversion recovery (b) coronal magnetic resonance imaging of the left ankle showing a vertical fracture of the talar body and osteonecrosis of the lateral talar body fragment. The dorsal talonavicular ligament is routinely visualized on sagittal MR images. 6, pp. The presence of fluid-like signal within and adjacent to the ligament is needed to confidently diagnose a sprain. Often the signs and symptoms of Chopart joint injury are mistaken for or masked by lateral collateral ligament injury.6 Therefore, the clinical detection of acute midtarsal sprains requires a high index of suspicion. M. J. Sormaala, M. H. Niva, M. J. Kiuru, V. M. Mattila, and H. K. Pihlajamaki, Bone stress injuries of the talus in military recruits, Bone, vol. When ankle inversion is accompanied by plantar flexion (as can occur while wearing high-heeled shoes), distraction forces propagate dorsally through the talonavicular joint, often causing dorsal talonavicular ligament avulsion. [Figure 4F] An accessory lateral band or capsular thickening along the superior third of the lateral margin of the calcaneocuboid joint is the most common variant, occurring in up to 60% of patients.11, The dorsal calcaneocuboid ligament may be closely applied to the dorsal aspect of the joint, blending with the adjacent extensor digitorum brevis muscle, and thus can be the most difficult of the midtarsal ligaments to identify with sagittal MR imaging. (4F) Axial T2-weighted fat suppressed image demonstrates the dorsal calcaneocuboid ligament (arrow) and the closely associated extensor digitorum brevis muscle (asterisk). This can include talocalcaneal, calcaneofibular (subfibular) or combined talocalcaneal-subfibular impingements. Each mechanism of injury results in a distinct injury pattern and recognition of these patterns is important for radiologists to provide a unified, accurate diagnosis of a midtarsal sprain. In cases with advanced lateral hindfoot valgus, Prolonged pain after non-operative management of a lateral ankle sprain is a common indication for MRI evaluation, to evaluate for a more extensive injury than initially suspected. The navicular insertion is rarely seen due to the oblique orientation of the ligament. AJR Am J Roentgenol. 4. Distraction forces medially can cause navicular tuberosity avulsion fractures due to traction by the posterior tibial tendon. 2, pp. Lateral hindfoot impingement is believed to be secondary to a lateral shift of weight-bearing forces from the talar dome to the lateral talus and fibula and to talocalcaneal joint subluxation . This reflects a grade 3 sprain or ligament tear. September 2010, A. Donovan and Z. S. Rosenberg, Extraarticular lateral hindfoot impingement with posterior tibial tendon tear: MRI correlation, AJR American Journal of Roentgenology, vol. Unable to process the form. The search for small foci of marrow edema related to lateral distraction should include careful evaluation of the anterior process of the calcaneus and the dorsolateral cuboid (indicating avulsions of the dorsal calcaneocuboid ligament, the calcaneocuboid component of the bifurcate ligament, and possibly the extensor digitorum brevis muscle), as well as the lateral and plantar aspects of the calcaneocuboid joint (capsule and plantar ligaments). 529536, 1998. (4C) Axial T2-weighted image demonstrates the medioplantar oblique (arrow) and inferoplantar longitudinal (short arrow) bands of the spring ligament. [15, 16]. 2010;195(3):595-604. 3, pp. [4]; however, she had been able to walk without a cane for 30 minutes prior to symptom onset. Examination and treatment of cuboid syndrome: a literature review. Avulsion fractures of the navicular tuberosity, while usually seen at radiography or CT, may be first suspected at MRI by the presence of marrow edema in that location or by cortical disruption [Figure 10C]. 2, pp. Malicky ES, In the present case, one talus was affected by osteonecrosis of the fracture segment in the lateral talar body. Lateral hindfoot impingement is an extra articular hindfoot osseous impingement affecting the distal of fibula, talus and calcaneous bones. The talus is a relatively uncommon site of a stress fracture, and only a small number of case series have been reported since the first report by McGlone in 1965 [7]. Eur J Orthop Surg Traumatol 2017; 27:425431, Golan P, Vega J, de Leeuw PA, et al. Axial inversion recovery image in a 55 year-old male with foot pain following an injury. ADVERTISEMENT: Supporters see fewer/no ads. Foot Ankle Int 2000; 21:379384, Sndergaard L, Konradsen L, Holmer P, Jorgensen LN, Nielsen PT. T1-weighted (a) and T2-weighted (b) coronal magnetic resonance images of the right ankle showing the depressed lateral talar dome and cyst formation in the talar body suggestive of a previous talar dome fracture. Check for errors and try again. Associated compressive forces at the medial calcaneocuboid joint may produce contusions of the plantar talar head, navicular body, and medial calcaneocuboid joint margins. Distraction forces at the medial calcaneocuboid joint may also produce joint capsule and short plantar ligament avulsion injuries. Adult-acquired flatfoot deformity is a progressive flattening of the arch of the foot that results from a combination of posterior tibial tendon insufficiency and failure of the capsular and ligamentous structures of the foot. 16, no. Because, when missed, stress fracture of the talus could progress to depression or avascular necrosis of the talus as demonstrated in the present case, we would like to emphasize the need of a high level of suspicion in order to accomplish timely diagnosis and management of this fracture. The thickest of the three components is the inferoplantar longitudinal ligament. 1, pp. Rosenberg ZS. 399406, 2008. {"url":"/signup-modal-props.json?lang=us"}, Murphy A, Hindfoot alignment view. Midtarsal sprains reflect a spectrum of injuries resulting from low-energy trauma to the Chopart joint complex and include both soft-tissue capsuloligamentous injuries and osseous injuries, including ligament sprains or tears, as well as avulsion or impaction fractures, depending on the severity and mechanism of injury. J. Perry, M. Garrett, J. K. Gronley, and S. J. Mulroy, Classification of walking handicap in the stroke population, Stroke, vol. 46, no. The calcaneonavicular component of the bifurcate ligament is nearly always seen on sagittal images as a thin, low-signal-intensity structure extending from the anterior process of the calcaneus. Considering that the most common mechanism of injury resulting in a shearing-type traumatic talar body fracture is an axial loading injury to the talus [17], we considered that the repeated axial cyclic loads to the talus produced by pes planovalgus deformity played a role in the pathology of the rare fracture pattern in the present case. 2, pp. The posterior tibial (PTT) and peroneus longus (PLT) tendons are also labeled. Anatomy of the ankle ligaments: a pictorial essay. However, stress fractures of the talus may be difficult to diagnose on radiographs especially in the early stages without displacement of the bone fragment [13]. The calcaneonavicular component of the Y-shaped bifurcate ligament extends medially from the dorsolateral aspect of the anterior process of the calcaneus, just distal to the origin of the extensor digitorum brevis muscle, to the dorsolateral aspect of the navicular bone. Dorsal, plantar, medial, and lateral 3D renders demonstrate the major stabilizing ligaments of the midfoot. Become a Gold Supporter and see no third-party ads. When stress fracture is suspected, plain radiograph should be the first imaging modality considered because of its availability and low cost. This ligament is typically seen on sagittal images, arising just lateral to the calcaneonavicular band of the bifurcate ligament. Lateral hindfoot impingement (LHI) is a subtype of ankle impingement syndrome with classic MRI findings. An anteroposterior (AP) weight-bearing view of the left ankle joint revealed the fracture of the distal fibula, valgus talar tilt with joint space narrowing at the lateral tibiotalar joint, and collapse of the lateral talar dome (Figure 1(b)). Finally, medial ligamentous distraction, seen in the less-common eversion mechanism, may produce plantar or superomedial spring ligament sprains [Figure 10A, 10B], best evaluated on fluid-sensitive axial and coronal images, respectively. AJR Am J Roentgenol. A small non-displaced avulsion fracture involves the navicular tuberosity. Therefore, it is important for both clinicians and radiologists to be familiar with the patterns of injury and maintain a high degree of suspicion, particularly in patients imaged in the acute or subacute setting following presumed lateral ankle sprains. Biomechanics of the subtalar joint complex. She denied any history of smoking, alcohol abuse, or corticosteroid use. American Journal of Radiology, Clinical presentation M. J. Sormaala, M. H. Niva, M. J. Kiuru, V. M. Mattila, and H. K. Pihlajamki, Outcomes of stress fractures of the talus, The American Journal of Sports Medicine, vol. This forms the lateral arm of the Y-shaped bifurcate ligament. (arrow) Adjacent fluid-like signal nicely outlines the ligament. Fig. 439442, 1995. The more lateral inferoplantar longitudinal band of the spring ligament remains intact (arrowheads). Articles. 34, no. Although a lower likelihood than a traumatic fracture, a stress fracture of the talus is also associated with a risk of avascular necrosis [24]. 389394, 2005. Although a less common injury mechanism, ankle eversion can also result in midtarsal sprains. Adult-acquired flatfoot deformity is a progressive flattening of the arch of the foot that results from posterior tibial tendon insufficiency with a predilection for middle-aged women. The value of computed tomography is limited in diagnosing stress fracture in the early stage because of lower sensitivity and higher radiation exposure than other imaging modalities [21]. Note the small fluid-filled defect at the site of ligament disruption. ADVERTISEMENT: Radiopaedia is free thanks to our supporters and advertisers. A variety of symptoms can accompany this deformity depending according to its progression including pain and swelling along the course of the posterior tibial tendon, a heavy or tired feeling in the foot, difficulty walking or standing, painful calluses on the sole, and pain in the lateral ankle [1]. [Figure 4C]. 399410, 2005. The injury of the calcaneocuboid ligaments. On the upper surface of the calcaneus there are three smooth facets, Friedman et al. . The joint is named after Franois Chopart, a French surgeon credited with describing and pioneering an anatomically and functionally convenient method for treating gangrene of the foot by disarticulation at the transverse tarsal joint. M. Gaeta, F. Minutoli, E. Scribano et al., CT and MR imaging findings in athletes with early tibial stress injuries: comparison with bone scintigraphy findings and emphasis on cortical abnormalities, Radiology, vol. This also originates from the coronoid fossa of the calcaneus and extends more laterally, inserting on the plantar navicular beak. The present case demonstrated a sagittal shearing fracture according to Sneppen et al.s talar fracture classification, which runs through the body of the talus from the trochlea to the subtalar joint [14]. Distraction injuries often result in avulsion fractures in combination with a tear or sprain of the ligament stabilizing the joint. At the time the case was submitted for publication Andrew Murphy had no recorded disclosures. The space may contain joint fluid in asymptomatic individuals and is defined by the following anatomical structures 1-4. They are characterized by a limited range of motion and pain on attempting specific movements about the joint and often in a load-bearing position. D. H. Pearce, C. N. Mongiardi, V. L. Fornasier, and T. R. Daniels, Avascular necrosis of the talus: a pictorial essay, Radiographics, vol. The more superior short plantar ligament (arrowheads) is seen with the more inferior long plantar ligament beneath it (short arrows). J. J. McGlone, Stress fracture of the talus, Journal of the American Podiatry Association, vol. (4B) Coronal proton density weighted fat suppressed image shows the superomedial component of the spring ligament (arrow), continuous with the tibiospring band of the deltoid ligament (arrowheads). 3 4 However, more recent reports indicate that midtarsal sprains are more common, occurring in up to 33% of inversion injuries of the ankle. (4D) Sagittal T2-weighted fat suppressed image demonstrates the calcaneonavicular band of the bifurcate ligament (arrow). Lateral ligamentous distraction, typical of inversion injuries, most commonly results in dorsal calcaneocuboid and bifurcate ligament sprains. 11651186, 2017. In book: Radiopaedia.org; Authors: Bahman Rasuli. The ball-and-socket arrangement of the joint has been likened to the hip joint, earning it the nickname coxa pedis.9, The talonavicular joint has a continuous joint capsule which contains several ligaments. She had a limping gait and complained of a limited walking ability of 510 minutes with a cane because of pain. Note the small fluid-filled defect at the site of ligament disruption. Marrow edema and cortical irregularity are seen at the lateral margin of the distal calcaneus involving the origin of the extensor digitorum brevis muscle (arrow). 672678, 2009. Sagittal T2-weighted fat suppressed image (7A) obtained just lateral to the image in Figure 6B. 1 ). 1: Weight bearing radiograph shows direct contact between the talus and the. Computed tomography images of the left ankle showing the comminuted fragments of the lateral talar body (c) and the fracture of the distal fibula with callus formation (d). Conversely, avulsion-related bone marrow edema is usually subtle; therefore, MRI in this setting should be interpreted in combination with radiography or CT. Contusion-related bone marrow edema is more obvious at MRI. 18091814, 2006. Axial T2-weighted image (7B) in the same patient demonstrates a complete proximal disruption of the dorsal calcaneocuboid ligament from its calcaneal origin (arrow). M. J. Bischoff, I. H. Reininga, and T. M. van Raaij, Atraumatic bilateral insufficiency fractures of the talar neck in a rheumatoid patient, The Journal of Foot and Ankle Surgery, vol. The superomedial component arises from the anterior margin of the sustentaculum tali and inserts onto the navicular tuberosity and the tibiospring portion of the deltoid ligament. 891893, 1994. All patients underwent tomosynthesis, radiography, and covering almost the entire width of the calcaneal body. 5 The wide range in estimates of midtarsal sprain are likely explained by several factors. AJR Am J Roentgenol 2018; 210:386-395, van Dorp KB, de Vries MR, van der Elst M, Schepers T. Chopart joint injury: a study of out-come and morbidity. 63036307, 2015. 3, pp. [Abstract] [Full Text] [PDF] [PDF Plus] Y. S. Kim, H. M. Lee, J. P. Kim, and H. S. Moon, Fatigue stress fracture of the talar body: an uncommon cause of ankle pain, The Journal of Foot and Ankle Surgery, vol. [Figure 4E] The dorsal calcaneocuboid ligament and the calcaneocuboid component of the bifurcate ligament may be continuous and can be difficult to distinguish from each other.5, The calcaneocuboid joint capsule is reinforced dorsally and laterally by the dorsal calcaneocuboid ligament. 2, pp. 193: 672-678. At the time the article was last revised Joachim Feger had no recorded disclosures. Donovan A, Acute midtarsal (Chopart) joint sprain with an associated dorsal talar avulsion fracture. 8, pp. (4F) Axial T2-weighted fat suppressed image demonstrates the dorsal calcaneocuboid ligament (arrow) and the closely associated extensor digitorum brevis muscle (asterisk). There are . 73-B, no. 34, no. T1-weighted images often best demonstrate osseous anatomy. Extensor digitorum brevis origin avulsion or muscle strain and lateral calcaneocuboid joint capsule avulsion may also be seen. 11131116, 2016. Partial tear or sprain results in thickening or attenuation of the ligament, with either surrounding or intrasubstance edema. Plain radiographs obtained at the first visit. Midtarsal sprains can be purely ligamentous but are often accompanied by avulsions from osseous attachment sites or contusions at common sites of impaction, depending on the mechanism of trauma. Gross anatomy The space may contain joint fluid in asymptomatic individuals and is defined by the following anatomical structures 1-4. J. C. Mandell, B. Khurana, and S. E. Smith, Stress fractures of the foot and ankle, part 2: site-specific etiology, imaging, and treatment, and differential diagnosis, Skeletal Radiology, vol. Foot Ankle Int 1996; 17:195199, Main BJ, Jowett RL. Case study, Radiopaedia.org (Accessed on 03 Jun 2023) https://doi.org/10.53347/rID-96420. Copyright 2018 Takumi Matsumoto et al. Dual-energy X-ray absorptiometry measurements showed that the bone mass was 82% of young adult mean (YAM) in the lumbar spine and 81% of the YAM in the femoral neck without any use of drugs affecting bone metabolism, which did not meet the criteria for osteoporosis. This is an open access article distributed under the. Bilateral posterior ankle impingement syndrome has been described but is rare 5 . 195: 595-604. This, View full size version of Lateral hindfoot impingement, See the case: Lateral hindfoot impingement. Since inversion injury is often associated with plantar flexion, dorsal distraction at the talonavicular joint may result in dorsal talonavicular ligament sprain [Figure 2B, 6A] It is important to evaluate the entire width of this broad ligament, as partial tears are possible. Impaction injuries medially may produce contusions or fractures of the talar head and navicular body. [Figure 4E, 4F]. 199204, 2006. Both the long and short plantar ligaments are well seen on ankle MR imaging, best identified on axial and sagittal images. The consequences of immobilization as a treatment of midtarsal sprains have not been systematically studied, but it is recognized that a subset of patients will not improve with non-operative management and may require surgical intervention. Check for errors and try again. The physical examination revealed localized swelling and tenderness on the distal fibula about 5cm proximal to the tip of the left lateral malleolus. Extra-articular lateral hindfoot impingement syndrome is a non-traumatic cause of ankle impingement. The more superficial long plantar ligament originates along the plantar surface of the calcaneus with two bands present in most patients, one deep lateral band projecting to the plantar cuboid bone and one superficial medial band that fans out to attach at the plantar aspects of the second through fifth metatarsal bases.12, The bilaminar short plantar ligament takes a shorter course, with a more anterior origin on the plantar calcaneus and a more proximal insertion on the plantar aspect of the cuboid bone. 982989, 1995. Cortical avulsion fractures representing ligament avulsion injuries are often subtle. The nutcracker fracture of the cuboid by indirect violence. The hindfoot alignment viewis a specialized, weight-bearing radiographic view that examines the hindfoot alignment as part of a foot and ankle instability investigation. and anterior, 25, no. These fractures can be further divided into two types: fatigue fracture resulting from abnormal stresses on normal bone and insufficiency fracture resulting from normal stresses on abnormal bone. Conclusion: Extraarticular lateral hindfoot impingement is associated with advanced posterior tibial tendon tears and increased MRI hindfoot valgus angle. 4, pp. 55, no. Also note the associated muscle strain injury with increased signal intensity involving the adjacent extensor digitorum brevis muscle (arrowheads). Boundaries On the other hand, a normal dorsal calcaneocuboid ligament and calcaneocuboid component of the bifurcate ligament are more difficult to reliably detect at MR imaging. No fixed pes planus alignment on this non-weightbearing examination. Therefore, sprain of these ligaments should be diagnosed with careful reliance on secondary signs such as periligamentous soft tissue edema and marrow edema at their attachment sites. 48, no. 4851, 1996. This appearance is consistent with a moderate ligament sprain. Patients with flatfoot deformity frequently suffer from lateral hindfoot pain, such as pain in the lateral malleolus and sinus tarsi. The dorsal talonavicular ligament is a broad capsular thickening, originating from the dorsal talar neck with a broad insertion to the dorsal, medial and lateral aspects of the navicular bone. However, the distal lateral extension of the ligament, via an accessory lateral band, is commonly seen on axial MR images, extending from the calcaneus to the cuboid bone, approximately 5mm distal to the calcaneocuboid joint.5, 11 [Figure 4F], The long and short plantar ligaments are sometimes referred to together as the plantar or inferior calcaneocuboid ligament. Foot Ankle Int 2008;29(9):942949, Ward KA, Soames RW. 197, no. We describe a surgical technique using a medial displacement calcaneal osteotomy (MDCO) combined with a lateral wall exostectomy and report on the outcomes from . Complete disruption of a ligament is usually obvious, appearing as complete discontinuity, often with a fluid-filled defect at the site of disruption. 4: Illustration shows lateral hindfoot impingement (A; normal, B; talocalcaneal. Although refractory midfoot pain or secondary osteoarthritis from Chopart fracture-dislocations have been treated with arthrodesis, several new surgical procedures emerging within the last decade offer anatomic stabilization of the midtarsal joint by primary tendon repair or graft reconstruction.3, 4, 16, 17 These various treatment options must be studied prospectively to determine their long-term clinical outcome. Non-operative management of midtarsal sprains may resemble that for lateral ankle sprains, with rest, ice, compression and elevation the primary treatment along with a controlled-motion walking boot or aircast splint. Thus, the posterolateral aspect of the talus receiving the least blood supply is more likely to be affected by osteonecrosis than other lesions [25]. Calcaneal osteotomy is often necessary to correct hindfoot valgus and lateral hindfoot impingement. An isolated midtarsal sprain is a relatively uncommon injury, reported to occur in only 5.5% of ankle sprains.3,4 However, more recent reports indicate that midtarsal sprains are more common, occurring in up to 33% of inversion injuries of the ankle.5 The wide range in estimates of midtarsal sprain are likely explained by several factors. Opposing sclerosis and cystic changes may also be seen ( Fig. 4, pp. MeSH terms Adult Aged Aged, 80 and over Female Sports Med 2014; 4 4:123 140, Andermahr J, Helling HJ, Maintz D, Monig S, Koebke J, Rehm KE. 553561, 2005. The Chopart joint complex, also known as the midtarsal or transverse tarsal joint, is located between the hindfoot and midfoot and consists of two functionally distinct units: the talocalcaneonavicular (most often simply called the talonavicular) and calcaneocuboid joints. The fibular stress fracture was treated successfully in 2 months with a walking boot and limited weight-bearing with crutches. Of these three talocalcaneal facets, MRI has been demonstrated to be superior to scintigraphy in comparison of the sensitivity and specificity in diagnosing stress fracture; therefore, MRI may be considered next when plain radiograph is negative [22]. A lateral radiograph of the foot is provided [Figure 1A] with sagittal fat-suppressed T2-weighted [Figure 1B, 1C and 1D], and axial fat-suppressed proton-density weighted [Figure 1E] MR images provided. The hindfoot alignment view is a specialized, weight-bearing radiographic view that examines the hindfoot alignment as part of a foot and ankle instability investigation. The image on the right is also in an asymptomatic patient with a mildly thickened talonavicular ligament (arrow). CT is more sensitive than radiography for identifying cystic and sclerotic changes at the osseous impingement sites ( Fig. Occasionally, because of its complex saddle shape, the calcaneocuboid joint may suffer distraction forces laterally and impaction forces medially. Delayed diagnosis of midtarsal sprains may lead to dysfunction, prolonged pain, and instability. which articulate with corresponding facets on the lower surface of the talus to form the subtalar joint. 2009;17(4):775-800. The transfer occurs due to collapse of the medial arch of the foot, most commonly from posterior tibial . 199, no. (4E) Sagittal T2- weighted fat suppressed image slightly more lateral than in Figure 4D demonstrates the calcaneocuboid band of the bifurcate ligament (arrow) and the overlying extensor digitorum brevis muscle (asterisk). Journal of Bone and Joint Surgery (Am) 2002 November 84-A: 2005-2009. 1, pp. Central to such a study is the ability to recognize and reliably diagnose the MR imaging appearance of midtarsal sprains. The following is the recommended option: green Superfeet. Diffuse edema-like signal is demonstrated within the calcaneonavicular band of the bifurcate ligament (short arrow). This is felt to be related to changes related to traction during normal gait. Ankle and posterior subtalar joint effusions. 235, no. One study found that only 48% of calcaneocuboid injuries and 50% of talonavicular injuries were seen at radiography when compared with MRI.14. Ankle sprains are a very common injury, occurring in approximately 1 of 10,000 people per day in the United States.1 Injury to the lateral collateral ligaments of the ankle is the most common manifestation of this injury pattern. Foot Ankle Int 1997;18(10):649653, Hermel MB, Gershon-Cohen J. There have been previous reports of an association between these pains and osseous impingement in the lateral hindfoot caused by the existing deformity and frequent weightbearing (1 -5).Estimation of the impingement in the standing position in conventional . Vol. This ligament can be thickened in asymptomatic patients due to the biomechanical stress at the joint related to normal gait. The talonavicular ligament is diffusely thickened with increased signal intensity within the ligament (arrow) as well as fluid-like signal intensity adjacent to the ligament (arrowheads). The calcaneonavicular band of the bifurcate ligament is diffusely thickened and is of increased signal intensity (arrow). The intact calcaneocuboid band of the bifurcate ligament is demonstrated (short arrow). A tiny cortical avulsion fracture is seen at the distal margin of the cuboid bone laterally involving the origin of the dorsal calcaneocuboid ligament. Clinical presentation 11, pp. However, injury to the ligaments at the midtarsal or Chopart joint, affecting the talonavicular and calcaneocuboid joints, is a less recognized yet commonly associated injury.2. Although most have been reported in a case series of fatigue stress fractures in athletes, military recruits, and sports enthusiasts [810], a few have been reported as insufficiency stress fractures in association with osteoporotic conditions like postmenopausal women and rheumatoid arthritis patients [1113]. On the left, a normal talonavicular ligament is thin (arrow). Purpose: To assess the availability of tomosynthesis to determine hindfoot lateral impingement. demonstrated using an established cadaver model of the acquired flatfoot deformity that the flatfoot condition resulted in a significant lateral shift in the global contact area and the location of peak pressure on the talar dome [19]. posterior, Q. Wang, M. Whittle, J. Cunningham, and J. Kenwright, Fibula and its ligaments in load transmission and ankle joint stability, Clinical Orthopaedics and Related Research, vol. MRI is essential to evaluate both the bones and soft-tissue structures about the ankle and foot. It can be assessed on clinical exam, and with radiographic evaluation, optimally including the hindfoot alignment view [ 3 ]. J. T. Deland, Adult-acquired flatfoot deformity, The Journal of the American Academy of Orthopaedic Surgeons, vol. An examination revealed bilateral hindfoot valgus and flatfoot deformities, and both feet were rigid and not reducible. osseous impingement occurs with direct contact between the talus and calcaneus or between the lateral calcaneus and the fibula. BJR. Thelong axial hindfoot alignment viewis a specialized, weight-bearing radiographic view that examines the hindfoot alignment as part of a foot and ankle instability investigation. The short plantar ligament may blend with and reinforce the calcaneocuboid joint capsule. 1a 1b 1c 1d Figure 1: Sagittal T1- and fat-suppressed T2-weighted (1a,1b), and coronal fat-suppressed proton density-weighted (1c,1d) images. The appearance reflects an avulsion fracture at the muscle origin with associated muscle strain injury in this patient with a lateral distraction injury. What can I do for myself? Talocalcaneal and subfibular impingement in symptomatic flatfoot in adults. C. Bradshaw, K. Khan, and P. Brukner, Stress fracture of the body of the talus in athletes demonstrated with computer tomography, Clinical Journal of Sport Medicine, vol. Stress fractures refer to fractures caused by mismatched bone strength and repetitive stress placed upon a bone. A distal tear is demonstrated involving the cuboid insertion of the calcaneocuboid band of the bifurcate ligament (arrow). In the clinical setting, lateralization of the force vector in the acquired flatfoot deformity was demonstrated to cause hindfoot impingement including talofibular, talocalcaneal, and calcaneofibular and subsequent stress fracture of the distal fibula [2, 3, 20]. However, in cases of severe impingement and hindfoot valgus, lateral wall excision may leave only a small remnant of calcaneal bone for weightbearing and can lead to chronic heel pain. It is clearly seen on axial MR images as a flat muscle overlying the lateral aspect of the calcaneocuboid joint. The intact calcaneonavicular band of the bifurcate ligament is also demonstrated (short arrow). 5, pp. RadioGraphics 1999; 19:673 683. The talus is predisposed to avascular necrosis, mainly after traumatic fractures due to its nature of a wide range of articular cartilage coverage around 60%, no muscular or tendinous attachments, and small nutrient vessels [23]. The foot and ankle are the most common locations of stress fracture, and the prevalence is highest at the tibia, calcaneus, and metatarsals, followed by the navicular, fibular, medial malleolus, and other tarsal bones [5, 6]. 12, pp. On the left, a normal talonavicular ligament is thin (arrow). - " Lateral hindfoot impingement is an extra articular hindfoot osseous impingement affecting the distal of fibula, talus and calcaneous bones. An AP weight-bearing view of the right ankle joint revealed similar findings on the contralateral side excluding the fracture of the distal fibula (Figure 1(a)). Y. Cheng, H. Yang, L. Ni, D. Song, and H. Zhang, Stress fracture of the distal fibula in flatfoot patients: case report, International Journal of Clinical and Experimental Medicine, vol. 23, no. Download Citation | On Aug 21, 2016, Henry Knipe and others published Extra-articular hindfoot impingement syndrome | Find, read and cite all the research you need on ResearchGate The superomedial component is best seen in the coronal and axial planes at the level of the talonavicular joint and is located between the medial talar head and the posterior tibial tendon. Magn Reson Imaging Clin N Am. Discuss the clinical importance of the lateral ankle impingement. [Figure 4A] The ligament is frequently thickened, which is thought to be a clinically insignificant finding, reflecting adaptive biomechanical changes related to traction during normal gait.8, The spring ligament complex, also called the plantar calcaneonavicular ligament complex, is composed of three parts: the superomedial, medioplantar oblique, and the inferoplantar longitudinal bands. Log In. Unable to process the form. A computed tomography (CT) scan of the left ankle clearly demonstrated that the fracture lines extended from the talar dome to the subtalar joint with the comminuted lateral talar body fragments and the fracture of the distal fibula with callus formation (Figures 2(c) and 2(d)). 2003-2023 ESR - European Society of Radiology, https://dx.doi.org/10.1594/ecr2016/C-1282. (2B) Sagittal T2-weighted fat-suppressed image through the talar neck demonstrates the thin, low signal intensity cortical avulsion fracture (arrow) as well as marked thickening and edema-like signal throughout the dorsal talonavicular ligament (arrowheads). Conventional weight-bearing ankle radiographs are useful to assess the plantar arch and hindfoot valgus ( Fig. 80, no. Journal Club: MRI Evaluation of Midtarsal (Chopart) Sprain in the Setting of Acute Ankle Injury. 22, no. Although midtarsal sprains most commonly result from ankle inversion, eversion injuries are also possible. This is a case series demonstrating how one would perform these projections from the reference point of a lateral foot. J Foot Ankle Surg 2010; 49:541545, Durall CJ. 7, pp. W613W617, 2012. The talonavicular ligament is diffusely thickened with increased signal intensity within the ligament (arrow) as well as fluid-like signal intensity adjacent to the ligament (arrowheads). Spring ligament avulsions, uncommonly seen, may produce focal marrow edema at the sustentaculum tali or navicular tuberosity. 3. The presence of fluid-like signal within and adjacent to the ligament is needed to confidently diagnose a sprain. Clin Orthop Relat Res 1993; 290:1726, Dorn-Lange NV, Nauck T, Lohrer H, Arentz S, Konerding MA. The calcaneocuboid joint is stabilized by the dorsal calcaneocuboid ligament (D-CCL), the short (SPL)and long (LPL) plantar ligaments, and the calcaneocuboid component of the bifurcate ligament (CC-BL). on July 25, 2018, - 3, pp. After the fibular stress fracture healed, the patient could perform her activities of daily living as before the fibular fracture without wearing any devices or using any analgesics for pain control. Describe the anatomy of the lateral ankle, She originally had limited walking ability due to a cerebral infarction 10 years prior that was classified as least-limited community walker according to the classification by Perry et al. However, a recent report recommends more aggressive immobilization using a short leg cast for 68 weeks followed by return to weight-bearing with a soft brace for 6 weeks.15. This appearance is consistent with a moderate ligament sprain. While tiny avulsion fractures may be better detected with plain radiography or CT, MRI is optimal for directly visualizing the midtarsal ligaments and detecting associated foci of marrow edema related to avulsion, impaction, or contusion. The hindfoot consists of the talus and the calcaneus. Donovan A & Rosenberg Z. MRI of Ankle and Lateral Hindfoot Impingement Syndromes. A CT scan of the right ankle demonstrated the continuity of the bone trabeculae in the suspected area of the fracture suggesting bony union (Figure 3(d)). 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