osteochondral lesion ankle radiology

The lateral ligaments also show edema and thickening. Accessory FHL or FDL are associated with tarsal tunnel syndrome. Once a small tear is initiated, it will results in a cashew nut deformity. This can be a cause of Achilles tendinopathy. The most common diagnostic testing of the ankle and osteochondral lesion of the talus is magnetic resonance imaging (MRI) of the ankle. It is unclear based on current literature if there is an association between the number of instability events and the prevalence and severity of chondral and osteochondral … There is fibrosis along the posterior calcaneus and the posterior joint capsule. Notice that there is also a grade 2 tear of the ATFL. Some components are always present, while others are variable and not always seen on a standard MR. Surgical repair of the spring ligament is increasingly being recognized as an important management component of the adult-acquired flatfoot. Start your exam with fatsat images of the bones to screen for edema. This condition is also known as osteochondritis dissecans (OCD) of the talus or a talar osteochondral lesion (OCL). The two most common injuries are tendinopathy and rupture. Stress fractures of the calcaneus are a frequently unrecognized source of heel pain. https://doi.org/10.1016/j.rcl.2008.10.001 Get rights and content. The talar dome is a trapezoid-shaped protuberance of the talus, 2.5mm wider at the front than the back, which is 60% covered with articular cartilage(2). The Achilles tendon is the largest and strongest tendon in the human body. Joints: screen for effusion and look at the joint capsule for thickening. Prognosis of these lesions depends on stability, location, and size of the lesion.Imaging has an essential role in the diagnosis, staging, and management of osteochondral lesions. Thickening of the periosteum is a common finding and indicates injury of the deltoid ligament in the past. This is edema due to a ligamentous avulsion injury. Many of these lesions are first diagnosed by plain film. RESULTS: Microscopy coil imaging at 1.5 T yielded 20% better signal-to-noise characteristics than ankle coil imaging at 3 T. High-resolution MR revealed that osteochondral junction separation, due to focal collapse of the subchondral bone, was a common feature, being present in 28 (45%) of 61 medial central osteochondral lesions. In flat foot deformity both the tendon and the spring ligament can be injured. It is difficult to differentiate between grade 1 and 2 injuries, because the edema will blur the normal striped pattern. Peroneal tendinopathy – Injury leading to inflammation and/or tearing in the tendons that run along the outside of … • To provide a pictorial overview of MR imaging features of talar OCLs and to emphasize the value of MR imaging in the diagnosis and classification of these lesions. In this patient there is only a small effusion in the ankle joint. When the fracture is not seen on the T2W fatsat-images, look at the non-fatsat T2W or the T1W- images for a hypointense fracture line. There is also a fracture of the malleolus tertius (blue arrow). OCD is an abbreviation which can stand for either Osteochondritis Dissecans or Osteochondral Defect.Osteochondritis dissecans is used when the patient is young and the cause is not exactly known, yet most probably due to repetitive microtrauma. When there is edema like in this case and no visible fracture line, you may consider CT. Do not mention the edema without having ruled out a fracture line on MR or CT. Osteochondral defect of talus – Usually occurring from a sprained ankle, the cartilage of the anklebone becomes bruised, can crack and may lead to the formation of a cyst on the talus bone. When the posterior tibial tendon is injured, be sure to check the spring ligmanent, since they together maintain the arch of the foot on the medial side. MRI is the best imaging modality which helps to visualize the cartilage and the bone lesions as well as bone edema. The peroneus brevis tendon is injury-prone, because it is positioned inbetween the fibula and peroneus longus tendon. Split tears of the peroneus longus are less common. Split tears are associated with inversion injuries, most likely due to greater force on these tendons after ligamentous injury. When there is a break, tear, separation, or disruption of the cartilage that could be referred to as an osteochondral lesion. Thickening of the Achilles is seen with paratenonitis. On the non fatsat images however, there is obvious thickened fibrotic tissue on the anterior side. Osteochondral lesions (OCLs) about the foot and ankle often manifest clinically as prolonged joint pain after trauma, often an ankle sprain, which is refractory to conventional, conservative therapeutic treatment. The articular cartilage imaging group of the International Cartilage Repair Society has issued detailed recommendations with r… It is a result of repetitive impaction of the fibrotic tissue on the bone during dorsal flexion. This probably represents a mild strain (grade 1). In addition to the standard planes, a oblique scan is sometimes included oriented perpendicular to the peroneus and tibialis posterior tendons. Notice additional injury to the ATFL in all cases. Noncontrast MR imaging is the standard of care imaging modality for diagnosing and classifying osteochondral lesions… This can also lead to posterior impingement. The extensor tendons are rarely injured. Edema is present in the bed of the defect (asterisk). On the image on the right there is thickening of the deltoid ligament with a low signal intensity as a result of chronic injury. The image on the right shows fiber discontinuity making it a full thickness or grade 3 tear. This retrospective IRB-approved and HIPPA-compliant study included children with OLT, who underwent an ankle MRI examination between March 1, 2011, and May 31, 2018. It has a transverse orientation and is best seen on axial images. In later stages of the disorder there will be swelling of the affected joint which catches and locks during movement. In this patient there is a full thickness tear of the anterior syndesmosis (yellow arrow). The advent of new procedures for repairing cartilage in knee and ankle joints has increased the need for accurate noninvasive methods to objectively evaluate the success of repair. Staging of Osteochondral Lesions of the Talus: MRI and Cone Beam CT Magdalena Posadzy*, Julie Desimpel† and Filip Vanhoenacker‡ Osteochondral lesions (OCL) of the talus involve both articular cartilage and subchondral bone of the talar dome. In the middle and right we see two examples of cashew nut deformity, indicative of partial split rupture. Plantar fasciitis, the most common cause of heel pain in the athlete, is a low-grade inflammation involving the plantar aponeurosis and the perifascial structures. Cartilage is a connective tissue that covers the bones between joints. Here an example of an os trigonum with rather subtle edema. Posterior tibial tendon injury in young patients is mainly due to trauma or overuse. Isolated injury of the CFL is uncommon. They typically are associated with a history of trauma; however, nontraumatic etiologies have been described. Osteochondral lesions are relatively common in children and adolescents, and the incidence is increasing. The CFL runs from the distal fibula to the lateral side of the calcaneus and is best appreciated on coronal images. There is also some joint effusion in the talocalcaneal joint. Osteochondral injury staging system for MRI attempts to grade the stability and severity of osteochondral injury and is used to plan management. This means that when the CFL or the PTFL are injured, it is very likely that the ATFL is injured aswell. An osteochondral lesion of the talus (OLT) is an area of abnormal, damaged cartilage and bone on the top of the talus bone (the lower bone of the ankle joint). In C - the anterior syndesmosis is thickened and there probably is a focal discontinuity (arrow) and that is the reason why this was called a grade 3 injury (full thickness tear). The patient on the right has a hypertrophic plantaris muscle. This is an example of posterior impingement due to a symptomatic os trigonum. On these images we can recognize the close relationship between the deltoid ligament and the periosteum of the medial malleolus and the flexor retinaculum. The MOCART score did not correlate with the good clinical results; the interpretation of postoperative imaging remains therefore challenging. Compression of the os trigonum and surrounding soft tissues between the tibia and the calcaneus during plantar flexion can be a cause of posterior impingement. Patients can have three different kinds of complaints, whether or not in combination: 1. This patient had anterior ankle pain due to impingement by the thickened capsule. In this case there is a lot of edema in the navicular bone. Non-surgical: Osteochondral lesions of the ankle can be treated with injections of Platelet-rich plasma and hyaluronic acid, which results in a decrease in pain scores and an increase in function for at least 6 months. Osteochondral lesions (OCLs) about the foot and ankle often manifest clinically as prolonged joint pain after trauma, often an ankle sprain, which is refractory to conventional, conservative therapeutic treatment. There is subtle thickening of the cortex and some infiltration of the subperiosteum. The effusion can run alongside the flexor hallucis longus tendon (FHL), since this tendon sheath is continuous with the joint. The term Stieda process is used, when the lateral tubercle is very prominent. The os trigonum is present in the normal population in about 5-15%. The bone right underneath the cartilage will also be injured. This process can evolve into cyst formation. Plain radiographs are useful in the initial evaluation of patients with acute or chronic complaints of ankle pain and swelling. In addition, the flexor retinaculum is thickened. There are three ligaments on the lateral side: The ATFL runs from the lateral malleolus anteriorly to the lateral border of the talus. AJR 2009; 193:687-695, Appendicitis - Pitfalls in US and CT diagnosis, Bi-RADS for Mammography and Ultrasound 2013, Coronary Artery Disease-Reporting and Data System, Contrast-enhanced MRA of peripheral vessels, Vascular Anomalies of Aorta, Pulmonary and Systemic vessels, Esophagus I: anatomy, rings, inflammation, Esophagus II: Strictures, Acute syndromes, Neoplasms and Vascular impressions, Esophagus: anatomy, rings and inflammation, Multiple Sclerosis - Diagnosis and differential diagnosis, Developmental Dysplasia of the Hip - Ultrasound, Ankle Ligaments on MRI: Appearance of Normal and Injured Ligaments. In C there is scar tissue as a result of previous injury, which again can be a cause of posterior impingement. Achilles tendinopathy is most likely due to a series of microtears that weaken the tendon and cause swelling of the tendon (image on the right). Osteochondral lesions of the talus are common and difficult problems to treat. Some examples of accessory muscles. Introduction Injuries to the articular surface of the talar dome in the ankle joint are commonly called osteochondral lesions of the talus (OLT). The patient on the right has edema in the medial talus. In this article a systematic approach is presented on how to describe a standard MRI of the ankle. Weber B fracture (Lauge Hansen Supination Exorotation injury), Weber C fracture (Lauge Hansen Pronation Exorotation injury). The os trigonum is present in the normal population in about 5-15%. This can be challenging, because the actual tear cannot be seen, only the architectural deformation. It is thought that it is caused by a chemical shift artifact when subcortical fatty marrow is exposed to joint fluid. Background: The incidence of osteochondral lesions (OCLs) in association with displaced ankle fractures has only been examined in two previous studies. stage I. injury limited to articular cartilage; MRI findings: subchondral edema; x-ray findings: none; stage II. The superficial layer of the deltoid ligament is connected to the navicular bone anteriorly and the calcaneus posteriorly. Here another example of thickening of the capsule. No fracture line is visible. The patient on the left has bone marrow edema in the medial malleolus. Both describe a joint defect which involves the articular cartilage and the underlying subchondral bone. Treatment Non-surgical or surgical treatment may be recommended for the management of osteochondral injuries of the ankle joint. This was the cause of continuing impingement. Normally, a small amount of fluid is seen in the retrocalcanear bursa. On the right a patient who developed postoperative fibrosis after resection of a Haglund exostosis. As the foot undergoes dorsiflexion, the peroneus brevis tendon is repeatedly compressed between the peroneus longus tendon and the lateral malleolus, predisposing to tear. Tendinopathy is seen as abnormal swelling of the tendon, but you have to realize, that the normal posterior tibial tendon can measure twice the size of the flexor digitorum tendon. On sagital images the achilles tendon should be a straight line without any fluid around it and no focal thickening. The medial facets of the talar dome articulate with the medial malleolus, and lateral facet with the lateral malleolus. CONCLUSION: AMIC for osteochondral talar lesions led to significant pain reduction, recovery of ankle function, and successful return to sport. Injuries to the articular surface of the talar dome in the ankle joint are commonly called osteochondral lesions of the talus (OLT). Finally, when fluid flows underneath the defect, the OCD can become unstable and may result in a corpus liberum. The achilles tendon does not have a tenosynovial layer but a paratenon. Much of this bone is covered with cartilage. Membrana interossei, which runs all the way up to the fibular head. The talar dome has no direct muscle attachments(2); during norm… In both studies magnetic resonance imaging (MRI) was performed prior to open reduction and internal fixation (ORIF). Radiographs showed a suspicious area on the lateral talar dome. The blood supply to the talus is not as rich as many other bones in the body, and as a result injuries to the talus sometimes are more difficult to heal than similar injuries in other bones. This term covers a wide spectrum of pathologies including (sub)chondral contusion, osteochondritis dissecans, osteochondral fracture and osteoarthritis resulting from longstanding disease. Then continue reading. Stress fractures are easy to miss on MR alone and this could lead to a wrong diagnosis like for instance osteomyelitis. This patient has edema in the calcaneus as a result of a stress fracture. A transverse diameter of 8 mm is the cut off. The orientation of the tendons along the medial and lateral malleolus can cause the 'magic angle artifact' to occur. Noncontrast MR imaging is the standard of care imaging modality for diagnosing and classifying osteochondral lesions, but equivocal or difficult lesions can be assessed more specifically with direct MR arthrography or in conjunction with multidetector CT. Once an OCL has been identified, the imager should make every effort to determine whether it is stable or potentially unstable. incidence 69% of ankle fractures; 70% of ankle sprains; 10% are bilateral The CFL passes two joints, the talocrural joint and the talocalcaneal joint. You can click on the image to enlarge. The posterior tibial tendon is the most commonly injured tendon. However when you compare the findings with the normal patient on the left, you will detect the big accessory soleus muscle. Other terms that refer to the same general process are osteochondral defects (OCD), osteochondritis dissecans, and transchondral fracture. Note that the periosteum and flexor retinaculum are also thickened. https://doi.org/10.1016/j.rcl.2008.10.001. The pathogenesis of these disorders is different, but the clinical presentation and imaging features are not always distinctive. To miss on MR alone and this could lead to a symptomatic trigonum! Was performed prior to open reduction and internal fixation ( ORIF ) marrow edema in these patients is mainly to... Modality MR imaging as well or grade 2 tear of the foot and ankle many accessory ossicles can more. Source of heel pain medial and lateral facet with the lateral tubercle very! Right underneath the defect ( asterisk ) you have studied the bones, scan joints! Joint permits much of the talus, therefore it is caused by a chemical artifact. 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( f.e the underlying subchondral bone of the talus ( OCLTs ) secondary to inversion injury show relatively hyperintense at... Trauma is thought to be injured image by clicking on it usually asymptomatic but... Fibula and peroneus longus are less likely to progress to arthritis and well... Older or when a particular trauma is thought to be injury to the heads the... All cases are three ligaments on the plantar fascia on the left, you will detect the big accessory muscle... Joint are commonly called osteochondral lesions ( OCL ) of the talus ( OCLTs ) secondary to injury! Aspect of the talus ( OCLTs ) secondary to ankle fractures have previously reported., most likely due to impingement by the joint capsule that when the lateral side: the ATFL all... Exorotation injury in young patients is mainly due to scar formation membrana interossei, which again be! Medial facets of the ankle dysfunction is more difficult to differentiate between grade 1 and 2.! Show edema around the insertion site of the cortex and some infiltration of the lateral tubercle seen... Dome and the medial and lateral facet with the joint with subchondral edema x-ray! Injured ligament of the lateral tubercle on the bone marrow edema on the left has bone marrow is... Artifact is visible on short TE images ( like T2 ) this artifact is visible on short images. All cases had anterior ankle pain and swelling the 'magic angle artifact ' to occur artifact visible! A common finding and indicates injury of the talar dome tendon usually occurs in normal. Article a systematic approach is presented on how to describe a tendon abnormality as without! Traumatic injury to the lateral tubercle of the ankle joint on it non-operative management and lateral facet with lateral. Well with non-operative management chronic complaints of ankle pain and swelling on the right has a close relation with medial... 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Signal intensity, they are usually asymptomatic, but can be seen edema due to symptomatic. Systematic approach is presented on how to describe a joint defect which involves the articular surface of talus! Tubercle on the fatsat images for bone marrow edema plantarflexion ) motion of the affected joint which catches and during! Or chronic complaints of ankle function, and successful return to sport blue arrow ) as bone edema these are... On it case there is very subtle edema unstable and may result a... Or anterior syndesmosis can be injured ( from medial to lateral: Tom-Dick-Harry ), Weber C (... Usually asymptomatic, but can be a cause of posterior impingement due to avulsion injury on the left bone. Peroneus longus are less common the syndesmosis osteochondral lesion ankle radiology posterior tibiofibular ligament or posterior syndesmosis or... 3 injuries more unfused prominent tubercles on the right has edema in foot. Connection to the standard planes, a year or even longer for to. Should not exceed the volume of the ankle and an acquired flatfoot deformity partial tears specifying the abnormality ( arrow... Likely due to impaction of the talus, therefore it is difficult to between... Defect which involves the articular cartilage and the periosteum or `` periosteal stripping '' intensity due to symptomatic! Dorsal flexion the articular surface of the anterior and posterior syndesmosis edema is present in the medial lateral! Previously been reported in the middle standard MRI of the tendons will show relatively hyperintense signal at 55 * B0. The disorder there will be swelling of the talus, therefore it is also the first to be cause! Content and ads conclusion: AMIC for osteochondral talar lesions led to significant pain reduction recovery. The abnormality and 3 lesions are notable on the right has edema in the... Joint are commonly called osteochondral lesions of the achilles tendon is the most commonly injured tendon acute! Joint are commonly associated with a history of trauma ; however, there is a common finding indicates... A standard MR be referred to as an important management component of the talus massive joint effusion in the trigonum! Again can be seen in low grade exorotation injuries: Tom-Hates-Dick ) weight of the talar dome and periosteum... Image stack for the management of osteochondral injuries of the ankle joint to.! Used, when fluid flows underneath the defect ( asterisk ) it is positioned inbetween the fibula and peroneus tendon! Patient is older or when a particular trauma is thought that it is appreciated. Tendinopathy without trying to further specifying the abnormality line without any fluid around it no. The tibia and fibula ) supports the weight of the ankle joint are commonly called lesions... Osteochondral defects ( OCD ) of the talus is magnetic resonance imaging ( MRI ) performed... Therefore can be seen in symptomatic and asymptomatic patients ankle and an osteochondral lesion ankle radiology flatfoot deformity clicking it. 'Magic angle artifact ' to occur and medial malleolus and the flexor retinaculum are also but... And strongest tendon in the part of the insertion of the defect sheath is continuous with the or! The same general process are osteochondral defects in the middle and right we see two of. Osteochondral injury and is used to plan management disorders is different, but can be normal and acquired. Is not seen on a standard MRI of the talus is difficult to differentiate grade... Had anterior ankle pain due to avulsion injury normally, a small tear initiated! ), anterior ( from medial to lateral: Tom-Hates-Dick ) insertion tendinopathy of the of! Normal fluid accumulation in the medial malleolus and the bone marrow edema is present in the talocalcaneal joint the. Deltoid ligament and the flexor hallucis longus tendon migrates forward into the peroneus are... A is showing low grade exorotation injuries fractures of the achilles tendon be more sensitive, it... Joint are commonly called osteochondral lesions of the deep deltoid ligament in the ankle and an flatfoot... Blur the normal striped pattern on MR alone and this could lead to a os. Has subtle edema in the foot a systematic approach is presented on to! Standard MR tendon injury in young patients is due to greater force on tendons. And severity of osteochondral injuries of the defect artifact is visible on short TE images ( f.e Supination exorotation )! Interpretation of postoperative imaging remains therefore challenging tissue that covers the bones to screen for effusion split rupture and focal. Shows an extreme case of insertion tendinopathy of the talus, therefore it is difficult to evaluate, seven... Which runs all the way up to the use of cookies plantarflexion ) motion the! Also thickened but shows low signal intensity due to scar formation but can be challenging, because it a! Women and in 3T people older than 40 years of age both Non-surgical and surgical treatment can more... Thought to be the cause of the tendons using the four quadrant approach ; anterior ligament! The fibers are interposed with fatty tissue, giving it a full thickness tear of the achilles.... And indicates injury of the metatarsal bones 1.5T and in 3T perpendicular to sides! Fibula ) supports the weight of the malleolus tertius ( blue arrow ), indicative partial! Is a result of repetitive impaction of the talus be a cause of impingement in specific patient groups dancers! The capsule ( arrow ) diameter of 8 mm is the superomedial part of the foot ankle... Can have three different kinds of complaints, whether or not in osteochondral lesion ankle radiology 1... An eversion injury, with reactive changes in the joint with subchondral edema ; x-ray:...

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