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ORIGINAL ARTICLE
Year : 2019  |  Volume : 12  |  Issue : 3  |  Page : 239-249  

Magnetic resonance imaging in evaluation of traumatic and nontraumatic ankle joint and foot pathologies


Department of Radiodiagnosis, Dr. D. Y. Patil Medical College and Research Center, Dr. D. Y. Patil Vidyapeeth, Pune, Maharashtra, India

Date of Submission30-Aug-2018
Date of Acceptance16-Jan-2019
Date of Web Publication15-May-2019

Correspondence Address:
Amit Kharat
Department of Radiodiagnosis, Dr. D. Y. Patil Medical College and Research Center, Dr. D. Y. Patil Vidyapeeth, Pimpri, Pune - 411 018, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mjdrdypu.mjdrdypu_143_18

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  Abstract 


Background: The ankle joint is one of the most frequently injured joints in the body. Magnetic resonance imaging (MRI) is an emerging modality which is being used routinely for evaluation and diagnosis of pathologies of the ankle joint and foot as it can demonstrate pathologies before they become evident on other imaging modalities. Materials and Methods: We carried out a descriptive study on fifty patients over a period of 2 years to evaluate role of MRI in diagnosing various pathologies of the ankle joint and foot as demonstrated by many illustrative cases in this article. Conclusion: MRI must be the primary imaging modality of choice for optimal detection of pathologies of the tendons, ligaments, and other soft-tissue structures of the ankle joint complex and the foot.

Keywords: Ankle joint, foot, magnetic resonance imaging, nontraumatic pathologies, trauma


How to cite this article:
Kharat A, Ghosh A, Jain K, Karanjule P, Gandage SG. Magnetic resonance imaging in evaluation of traumatic and nontraumatic ankle joint and foot pathologies. Med J DY Patil Vidyapeeth 2019;12:239-49

How to cite this URL:
Kharat A, Ghosh A, Jain K, Karanjule P, Gandage SG. Magnetic resonance imaging in evaluation of traumatic and nontraumatic ankle joint and foot pathologies. Med J DY Patil Vidyapeeth [serial online] 2019 [cited 2019 Dec 15];12:239-49. Available from: http://www.mjdrdypv.org/text.asp?2019/12/3/239/258201




  Introduction Top


Magnetic resonance imaging (MRI) has revitalized the study of musculoskeletal disease in the ankle joint and foot due to quick noninvasive imaging, its high soft-tissue contrast resolution, multiplanar capabilities, lack of ionizing radiation, and ability to postcontrast imaging. MRI has the unique capability to evaluate osseous, ligamentous, tendinous, and muscular injuries about the foot and ankle, with a single imaging study before they become evident in other imaging modalities and often difficult to diagnose. Injuries to specific soft-tissue structures can be accurately assessed on MRI, allowing appropriate therapeutic intervention and rehabilitation.


  Materials and Methods Top


A descriptive study was carried out on fifty patients in the Department of Radiodiagnosis, Dr. D.Y. Patil Medical College, Hospital and Research Centre, Pimpri, Pune, over a period of 2 years. Patients from all age groups including both men and women with pain in the ankle joint and foot (rotating or twisting injuries) or without a history of trauma were included in the study. Patients with fractures/dislocations of or around the ankle joint and foot and tumorous conditions involving the foot and the ankle joint and patients with infections, amputations, and inflammatory arthritis were also included in the study. Clearance from the Ethical Committee was taken beforehand.

MRI was performed with SIEMENS 1.5 Tesla MAGNETOM AVANTO Machine. The size of the bore was 60 cm and overall length of the system was 160 cm. The MRI system used zero helium boil-off technology. A 32-channel head coil was used. The coil had 32 integrated preamplifiers and was iPAT compatible.

MRI examination of the ankle joint was performed in the axial, coronal, and sagittal planes parallel to the tabletop. MRI examination of the foot was performed in the oblique axial, oblique coronal, and oblique sagittal planes. Field of view (FOV) included the entire ankle/hindfoot up to the level of the metatarsal bases. The patient was positioned in supine position with the medial malleolus centered in the coil to evaluate the hindfoot and the ankle joint. The foot was allowed to rest in a relaxed position, generally in 10°–20° of plantar flexion and 10°–30° of external rotation. The placement of localisers were as follows. An axial localizer at the level of tibiotalar joint for obtaining sagittal images with images obtained perpendicular to transmalleolar line covering from the medial malleolar to the lateral malleolar soft tissues. A sagittal localizer for obtaining axial images with images obtained parallel to the long axis of the calcaneum covering from the posterior soft tissues to the metatarsal bases. A short-axis coronal localizer at the level of mid-metatarsals for obtaining sagittal midfoot/forefoot images with images obtained perpendicular to a best-fit transmetatarsal line covering from the medial to the lateral soft tissues or a smaller FOV for better resolution if imaging a focal area of interest. A short axis (coronal) at the level of mid-metatarsals for obtaining long-axis axial images with images obtained parallel to a best-fit transmetatarsal line covering from the dorsal to the plantar soft tissues. A sagittal localizer (at the level of second or third metatarsal) for obtaining short-axis coronal images of the forefoot with images obtained perpendicular to a line parallel to second or third metatarsals which cover from the naviculocuneiform articulation through the toes.


  Results Top


The results are shown in [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]; [Graph 1], [Graph 2], [Graph 3], [Graph 4], [Graph 5], [Graph 6], [Graph 7], [Graph 8]; and [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14], [Figure 15]. The blue arrows in [Figure 1] and [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14], [Figure 15], indicate the location of the lesions.
Table 1: Distribution of age of study participants in the study

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Table 2: Gender distribution of study participants

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Table 3: Duration of the lesion among the study participant

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Table 4: Site of the tendon pathologies among the study participants (n=50)

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Table 5: Site of the ligamentous pathologies among the study participants (n=50)

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Table 6: Magnetic resonance imaging findings - tendon lesions among the study participants (n=50)

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Table 7: Magnetic resonance imaging findings - ligament pathologies among the study participants (n=50)

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Table 8: Classification of pathologies of Achilles tendon based on its anatomical location (n=9)

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Figure 1: In a 50-year-old male patient who presented with pain and swelling of the left ankle associated with discharging sinus, past history revealed history of trauma and blackish discoloration of skin for which amputation of forefoot was performed. Coronal T2-weighted (a) image and short-tau inversion recovery image in sagittal plane (b) multiple serpiginous areas of altered signal intensity with associated marrow edema and soft-tissue edema

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Figure 2: In a 41-year-old male diabetic patient who came with complaints of pain and swelling of the left foot and had difficulty in walking, short-tau inversion recovery images in sagittal (a) and coronal (b) planes showed severe joint deformities, bone marrow edema, synovial effusion, and soft-tissue edema

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Figure 3: In a 60-year-old male patient who came with complaints of right foot swelling and multiple discharging sinuses with foul-smelling pus discharge, PDFS (a) and T1-weighted (b) images in sagittal plane showed characteristic dot-in-circle sign with associated bone marrow edema and soft-tissue edema

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Figure 4: In a 45-year-old female patient presented with left heel pain, PDFS (a) and T1-weighted (b) images in sagittal plane showed thickened plantar fascia at its calcaneal insertion with perifascial edema and associated contusion at the calcaneus

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Figure 5: In a 45-year-old female patient who came with gradual progressively increasing swelling of the right foot and ankle and had complaints of difficulty in walking and ulcerations of the foot, T1-weighted (a) and PDFS (b) images in sagittal plane showed multiple lobulated periarticular soft-tissue lesions appearing hypointense on T1-weighted image and heterogeneously hyperintense on PDFS image causing cortical erosions, periarticular punched out erosions with associated synovial pannus and soft-tissue edema

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Figure 6: In a 20-year-old male patient who presented with complaints of insidious onset intermittent dull-aching pain with associated swelling over the right ankle since 6 months, coronal and sagittal short-tau inversion recovery (a and b) and axial T2 (c) sequences showed multilocular lesion in the body and neck of the talus appearing hyperintense with fluid-fluid levels (marked by arrows), intralesional septa appearing hypointense and thinning, and break of overlying cortex at places with adjoining bone marrow edema. Sagittal T1 (d) reveals hypointense lesion in the talus

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Figure 7: In a 35-year-old male patient who presented with left heel pain not associated with swelling and no past history of trauma, T1-weighted image (a) in sagittal plane showed a well-defined homogeneously hyperintense lesion within the body of the calcaneus, which is nullified in PDFS image (b)

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Figure 8: In a 24-year-old male patient who presented with progressively enlarging swelling of the left foot since 7 months associated with difficulty in walking, sagittal T1-weighted (a) and PDFS (b) images showed a large lobulated mass in plantar aspect of forefoot involving the plantar fascia appearing hypointense on T1-weighted images and heterogeneously hyperintense on PDFS images with extension to intermetatarsal space

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Figure 9: In a 17-year-old male patient who presented with progressively enlarging swelling of the right foot, PDFS images in sagittal (a) and axial (b) planes showed a large lobulated well-defined homogeneously hyperintense soft-tissue lesion in posteromedial aspect of forefoot with multiple thin internal septations within

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Figure 10: In a 25-year-old female patient who presented with swelling over the dorsal aspect of the left foot, gradually increasing in size in the last 6-months, and had a prior history of road traffic accident and trauma to the left foot, coronal T2-weighted (a) and short-tau inversion recovery (b) images showed well-defined lobulated hyperintense cystic lesion in the dorsolateral aspect of the forefoot extending to the fourth and fifth intermetatarsal space with hypointense phleboliths within

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Figure 11: In a 50-year-old female patient who came with complaints of pain and difficulty in walking since 3 months with a prior history of trauma, sagittal T1-weighted (a) and PDFS (b) images showed bulky and lax preinsertional and middle free Achilles tendon with partial longitudinal tears

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Figure 12: In a 30-year-old female patient who came with pain, difficulty in walking, and twisting injury of the right ankle 10 days back, sagittal T1-weighted (a) and PDFS (b) images showed complete insertional rupture of Achilles tendon with associated fluid accumulation and thickened preinsertional portion of Achilles tendon

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Figure 13: In a 32-year-old female patient who presented with swelling of the posterior aspect of the right ankle and difficulty in walking in the last 3-months, sagittal T1-weighted (a) and PDFS (b) images showed bony prominence of the posterosuperior aspect of the calcaneal tuberosity with impingement of insertional Achilles tendon showing heterogeneous signal intensity and associated retrocalcaneal bursitis

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Figure 14: In a 30-year-old male patient who came with complaints of pain and gradual progressively increasing swelling of the right foot and a past history of trauma 3 months back, T1-weighted image in sagittal (a) and T2-weighted image in axial (b) planes showed heterogeneously hypointense lobulated mass lesion in medial aspect of forefoot causing destruction of the first and second metatarsals

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Figure 15: In a 23-year-old female patient who presented with complaints of swelling over the second toe of the right foot since 6 months and had a prior history of trauma to the second toe, coronal short-tau inversion recovery image (a), sagittal PDFS image (b) and axial (c) and coronal (d) T2-weighted images showed a fairly well-defined cylindrical lesion completely encasing the proximal phalanx of the second toe in relation to tendon of extensor digitorum longus and extending on plantar aspect between bone and flexor digitorum longus

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  Discussion Top


Totally fifty patients were referred for evaluation of the ankle joint complex and foot and examined on a 1.5T magnetic resonance (MR) system at Dr. D.Y. Patil Medical College, Pune, for a period of 24 months.

The study comprised 33 (66%) males and 17 (34%) females. The most common age groups affected were 31–40 years and 41–50 years, showing equal occurrence, followed by age groups of 21–30 years. The least affected group was <20 years of age. The most common age groups affected among male patients were 41–50 years, followed by age groups of 21–30 years and 31–40 years, showing equal occurrence. The most common age groups affected among female patients were 31–40 years, followed by age groups of 21–30 years and 41–50 years, showing equal occurrence. The least affected group was <20 years in both male and female patients. The patients most frequently came with complaints of pain and swelling of the ankle joint and foot.

Thomas et al. found that there was a stronger positive association of foot and ankle pain with age (over 45 years) among females than males.[1] Our study with 25 patients with age of more than 40 years showed a difference in the pattern from Thomas et al., with male patients more frequently complaining of pain of the ankle joint and foot.

The duration of the pathologies based on patient's clinical history was classified into acute and chronic, with majority of the patients (66%) presenting with chronic complaints. Nontraumatic cause represented the most common etiology (56%) of pathologies of the ankle joint and foot and rest (44%) were due to trauma. We subclassified nontraumatic etiologies into infective, inflammatory, and neoplastic with infective etiology (30%) being the most common. However, detailed history of the patients revealed little over one-third of the patients with nontraumatic pathologies had a prior history of trauma.

Nontraumatic pathologies

Osteomyelitis

Our study showed 15 cases of osteomyelitis, among which majority of cases were above 45 years of age and 12 of 15 cases were male patients. About 53.3% of cases had a prior history of trauma with 13.3% of cases showing foreign body with abscess formation. About 47.7% of cases had no history of trauma and included patients with diabetes, tuberculosis (TB), and mycetoma.

Foot infections among patients with diabetes account for 20% of hospital admissions and 80% of infectious amputations each year. A study conducted by Croll et al. showed that mean age of osteomyelitis in diabetic foot infections was 66 years (range: 34–82 years). The patients presented with cellulitis (70%), seropurulent discharge (67%), and neuropathy (67%).[2] Wheat (1985) found that pedal osteomyelitis is a common complication of diabetes, occurring in up to 15% of patients.[3] A study conducted by Zamyshevskaia et al. demonstrated the presence of bone marrow edema, soft-tissue swelling, extensive wound defect, or fistula attached to the bone and bone marrow edema concurrent with tenosynovitis in patients with diabetic foot syndrome.[4] We found similar findings in our study.

In a study conducted by Roug and Pierre-Jerome (2012) of 85 patients and 90 feet, 17 (18.9%) had vascular changes, and among them, 11 feet had infarct and 6 feet had necrosis.[5] In our study, we found one case of osteomyelitis with bone infarcts [Figure 1] of the lower tibia, talus calcaneum, and navicular.

Charcot osteoarthropathy is progressive, painless, degenerative arthropathy of single or multiple joints involving most commonly the peripheral joints due to underlying neurological deficits. Its prevalence ranges from 0.08% in general diabetic population to 13% in high-risk diabetic patients.[6] Jeffcoate et al. reviewed the clinical manifestations of the Charcot foot in diabetes and found most occurrence during the fifth and sixth decades, with men more frequently affected than women, and bilateral involvement in 30% of cases.[7] In our study, we found one male patient with unilateral foot and ankle joint diabetic osteomyelitis complicated by Charcot osteoarthropathy [Figure 2]. Similar findings were reported by Donegan et al. stating that Charcot foot is a complication of osteomyelitis in patients with diabetes.[6]

TB is a major health problem in a developing country like India. Although there has been a decrease in the incidence of TB, most developing countries have been facing a resurgence of the disease since 1985.[8] Approximately 20% of patients with TB present with extrapulmonary manifestations.[9] Only 1%–3% of tuberculous infections present with musculoskeletal TB. The most common form is tuberculous spondylitis (50%), and extraspinal manifestations are the least common with the reported frequency of peripheral arthritis 60%, osteomyelitis 38%, and tenosynovitis and bursitis 2%.[10],[11],[12],[13],[14]

In our study, we found three cases (20%) of TB of the ankle joint and foot among all the infective pathologies. The most common manifestations were osteomyelitis, bone destruction, tenosynovitis, and retrocalcaneal bursitis.

Sobel and Levitz found in their study that TB of the foot is rare and posttraumatic TB even rarer with only a few cases reported worldwide. In order of decreasing frequency, TB involves the calcaneum, talus, first metatarsal, navicular, first, and second cuneiform followed by other bones of the foot.[15] In our study, we found one case of posttraumatic TB of the foot. The most commonly involved bone by TB was calcaneus.

Czechowski et al. described the MR appearance of mycetoma as small low-signal intensity lesions on T1-weighted and T2-weighted MRI images which were due to susceptibility from the metabolic products within the grains.[16] Sarris et al. described the dot-in-circle sign as the unique pathological feature of mycetoma.[17] In our study, we found one case showing characteristic dot-in-circle sign which pathognomonic of mycetoma [Figure 3].

Inflammatory pathologies

In our study, we found eight cases of inflammatory arthritis of the ankle joint and foot with a mean age of 50 years and female predominance. The most common manifestations were tenosynovitis predominantly involving the flexor tendons, subtalar joint arthritis, and synovial pannus. In a study of 25 patients by Lee et al., the mean age of the patients was 57.8 years and showed male predominance with predominant involvement of the flexor tendons and subtalar joint.[18]

In our study, we found two cases of plantar fasciitis [Figure 4] in female patients with a mean age of 50 years. Both the cases showed thickened plantar fascia, perifascial edema and bone marrow abnormality in the calcaneus. One case showed deep signal intensity along with thickened fascia. In a study of 25 patients with plantar fasciitis by Grasel et al., the mean age of the patients was 49 years and showed female predominance. They found superficial signal intensity in 76% of cases, deep signal intensity in 52%, interfascial signal intensity in 52%, thickened fascia in 24%, and bone marrow abnormality in 56% of cases.[19]

In our study, we found two cases of gout [Figure 5] in one male and one female patient with a mean age of 55 years. One case showed monoarticular involvement. The predominant findings included osseous erosions and destruction, periarticular soft-tissue tophi, punched out cortical erosions, synovial pannus, reactive marrow edema, and bursitis. Similar findings were observed in a study conducted by Barnes and Helms (2012).[20]

Neoplastic pathologies

In our study, we found one case of primary aneurysmal bone cyst (ABC) of the talus [Figure 6] in a 20-year-old male patient. ABC is a locally aggressive nonneoplastic tumor-like lesion of bone with cystic cavities containing blood. It represents 1% of all primary bone tumors collectively.[21] This tumor has a predilection for metaphyseal regions of the long bones (femur – 22%, tibia – 17%, and humerus – 10%), and spine (12%) and pelvis (9%).[22] The tumor shows peak incidence in the second decade and is more common in the female population. Primary ABC of the talus is extremely rare with only a few cases reported in the literature. In a study of 57 ABCs by Levy et al., only five ABCs were secondary to fracture or other bone trauma.[23] In our study, we found that the patient had a history of prior trauma.

In our study, we found one case of calcaneal interosseous lipoma [Figure 7] in a 35-year-old male patient. Interosseous lipoma is a common lipogenous benign lesion of bone and found in the calcaneus in 10%–15% of cases. They represent 2% of all bone tumors. It shows peak incidence between the fourth and fifth decades. They are predominantly metaphyseal lesion found frequently in the lower limbs in 71% of cases.[24],[25],[26]

In our study, we found one case of unilateral plantar fibroma [Figure 8] in a 24-year-old male patient. Plantar fibromatosis or Ledderhose disease is a rare foot disorder of unknown etiology characterized by local proliferation of abnormal fibrosis in the plantar fascia. Slowly growing nodules are found most often in the central and medial portions of the plantar fascia showing local aggression and progressively replace the normal plantar aponeurosis. It can occur at any age group with the greatest prevalence at middle age and beyond. Males are most frequently affected than females. It can be associated with other forms of fibromatosis, such as Dupuytren's disease in the hand, Peyronie's disease, or knuckle pads. Bilateral involvement may be seen in 25% of cases.[27]

In our study, we found one case of plantar neurofibroma [Figure 9] in a 17-year-old-male patient. Plexiform neurofibroma is a benign nerve which results from aberrant growth of the cells of the nerve sheath. It typically occurs in neurofibromatosis (NF) and considered the hallmark for NF type I. It shows a predilection for larger peripheral nerves of the face, neck, and extremities. These are unencapsulated and may infiltrate surrounding muscle fibers and adipose tissue. Predisposing factors may be due to increased growth rates occurring during childhood or hormonal changes, such as puberty or pregnancy. Trauma may be an inciting factor, but there is a doubtful association.[28]

In our study, we found one case of hemangioma [Figure 10] in a 25-year-old female patient who had a prior history of road traffic accident. Hemangiomas represent abnormal proliferations of blood vessels, making up 7% of all benign soft-tissue tumors. These lesions are mostly small and asymptomatic. They are most commonly congenital; however, 20% of cases can be linked to trauma. Approximately 90% of cases occur before the age of 30 years with low incidence seen in older adults. The most common site is in the subcutaneous adipose tissue but may also be found in the muscles. The most common location is in the thigh (36%) followed by the calf (17%).[29]

Traumatic pathologies

In our study, we found anterior talofibular ligament to be most commonly injured (18%) followed by calcaneofibular ligament (8%) and posterior talofibular ligament (6%). The deltoid ligament complex was least commonly injured.

Injuries to the ankle joint are the most common injuries in sports and recreational activity. These injuries most commonly occur in young people. Injuries to the ligaments of the ankle joint complex are called low ankle sprains. High ankle sprains include injuries of tibiofibular ligament or the syndesmosis. Inversion sprains resulting in injury of the lateral ligaments of the ankle joint complex are most common. High ankle sprains usually occur due to an eversion injury combined with fractures or lesions of the deltoid ligament complex. Isolated injury of the syndesmosis occurs only in 3% of cases.

Anterior talofibular ligament due to its vulnerable position during plantar flexion is the most commonly ruptured ligament in lateral ankle sprain. The second most common injury is a combination of rupture of the anterior talofibular ligament and the calcaneofibular ligament seen in 20%–25% of the cases. The posterior talofibular ligament being a very strong ligament is rarely injured except in severe ankle trauma.[30] We found similar findings in our study with anterior talofibular ligament being most commonly injured or injured in combination with calcaneofibular ligament. We found only one case of complete rupture of all three lateral ligaments of the ankle joint complex which was seen in a case of severe ankle trauma with comminuted fracture of the neck of the talus.

In a study conducted by Taga et al. and van Dijk found that osteochondral lesions of the talar dome were seen in 89% and 66% of acute ankle injuries.[31],[32]

Grana (1991) found that chondral lesions were seen in 80% and osteochondral lesions were seen in 6.5% of acute ankle joint injuries.[33]

In our study, we found two cases of osteochondritis dissecans of the superomedial aspect of the talar dome associated with injuries of lateral ankle ligament complex.

The talus is the third most commonly affected anatomical site of osteochondritis dissecans after the knee and the elbow joints.[34],[45] Osteochondritis dissecans of the talus has an incidence of 0.09% and a prevalence of 0.002/100,000 person/year. It is most common in the second decade of life.[36],[37],[38]

In our study, we found that the deltoid ligament complex was least (2%) injured. The deltoid ligamentous complex is the strongest ligament of the ankle joint serving as the primary stabilizer of the axially loaded ankle. It accounts for only 5% of all ankle sprains. Forced eversion and pronation of the ankle is the most classical mechanism of injury, most often resulting in a medial malleolus avulsion fracture. These often result in mechanical instability.[39]

In our study, the mean age of patients with Achilles tendon injuries to be 40.8 years and showed male predominance. A study conducted by Maffulli et al. found that Achilles tendon injuries are approximately 10 times more common in runners than in age-matched controls.[40] Ham and Maughan observed that the peak age of occurrence of injuries to Achilles tendon was between 30 and 40 years. In our study, we found similar findings.[41] In our study, we found that the most common location of the Achilles tendinopathy to be preinsertional and middle free tendon (main body) with only one case showing insertional tendinopathy [Figure 11] and [Figure 12]. Similar findings were noted by Maffulli who found 55%–65% of injuries to be in the midportion of the tendon and 20%–25% to be at the insertion of the tendon.[42] Insertional tendinopathy is often associated with a prominent calcaneal tuberosity (Haglund's deformity) and calcification at the insertion site.[43]

In our study, we found two cases of Haglund's deformity [Figure 13] with insertional tendinopathy and calcification at insertion site.

The Achilles tendon despite being the strongest and thickest tendon is the most commonly ruptured occurring in healthy, active young to middle-aged population with a mean age ranging from 37 to 43.5 years and male predilection with male: female ratio ranging from 5.5:1 to 30:1.[44],[45]

The most common site for ruptures is of the midsubstance Achilles 3–6 cm proximal to the site of insertion on the calcaneus.[46]

Insertional ruptures usually present with insertional tendinopathies.[47] In our study, we found that most common anatomical site for the Achilles tendon rupture to be middle free tendon (main body) and preinsertional tendon. Most of the tendons had tendinopathies and intrasubstance calcifications. In our study, insertional rupture of the Achilles tendon was associated with insertional tendinopathy, findings similar to Kannus and Józsa.

In our study, we found one case of monoarticular pigmented villonodular synovitis (PVNS) [Figure 14] in a male patient aged 30 years. PVNS is a disorder causing proliferation of synovium affecting the synovial linings of joints, tendon sheaths, and bursae. There are two forms of this disease based on the extent of synovial involvement and localized and diffuse form. Both of these may be intra-articular or extra-articular.[48] PVNS is predominantly monoarticular and most commonly involves the knee and to a lesser extent wrist and ankle.[49] The incidence of PVNS affecting ankle is about 2.5%.[50]

The incidence of PVNS is estimated to be two cases per 1 million persons. It most commonly occurs in patients between 20 and 50 years of age.[51],[52]

In our study, we found one case of giant cell tumor of tendon sheath [Figure 15] in a female patient aged 23 years. Giant cell tumor of tendon sheath is most commonly seen in individuals between 30 and 50 years with slight female predilection.[53],[54] It is a type of extra-articular PVNS. It may be localized type which is seen in fingers and toes and diffuse type which is seen in large joints.

The etiology of PVNS is unknown with a likelihood of sequelae to trauma being hypothesized. In 44%–53% of patients with PVNS, there was a history of trauma.[55] In our study, we observed that both the cases of PVNS and giant cell tumor of tendon sheath had a history of prior trauma.

In a study was conducted by Saltzman et al. on 639 patients, they found that primary osteoarthritis of the ankle joint was only 7.2%. Ankle osteoarthritis secondary to trauma was the most common cause, accounting for 70% of cases. Osteoarthritis secondary to inflammatory cause accounted for 12% of cases.[56] In our study, we found two cases of posttraumatic osteoarthritis of the ankle joint and one case of inflammatory arthritis.


  Conclusion Top


MRI is the primary imaging modality of choice due to its excellent soft-tissue contrast for optimal detection of pathologies of the tendons, ligaments, and other soft-tissue structures of the ankle joint complex and the foot. It holds an advantage over conventional radiography and computed tomography for early detection and assessment of osseous abnormalities. However, both the former modalities may provide additional information, which may act as an adjunct along with MRI to reach a most probable diagnosis.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14], [Figure 15]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]



 

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