M u s c u l o s k e l e t a l I m a g i n g • R ev i ew

Walter et al.
Chopart Joint Complex

Musculoskeletal Imaging
Review

Imaging of Chopart (Midtarsal)

Joint Complex: Normal Anatomy
and Posttraumatic Findings
William R. Walter 1 OBJECTIVE. The objective of this article is to review the normal anatomy and posttrau-
Anna Hirschmann2 matic findings of the Chopart joint complex. Key imaging features of the normal ligaments
Monica Tafur 3 and patterns of ligamentous and osseous injuries are discussed.
Zehava S. Rosenberg1 CONCLUSION. Traumatic midtarsal injuries, particularly midtarsal sprain, are often
overlooked clinically and on imaging but are relatively common and typically are associated
Walter WR, Hirschmann A, Tafur M, Rosenberg ZS with inversion ankle injuries. Radiologists should be familiar with Chopart joint anatomy
and the imaging features of midtarsal injuries because early diagnosis may help optimize
clinical management.

idtarsal sprains are defined as a tion, in part because of unfamiliarity with

M
American Journal of Roentgenology

Keywords: ankle trauma, calcaneocuboid joint,
Chopart joint, midtarsal sprain, talonavicular
doi.org/10.2214/AJR.17.19310
Received November 17, 2017; accepted after revision
January 11, 2018.
1
Department of Radiology, Musculoskeletal Division,
NYU Langone Orthopedic Hospital, 301 E 17th St, 6th Fl,
New York, NY 10003. Address correspondence to
W. R. Walter (William.Walter@nyumc.org).
2
Clinic of Radiology and Nuclear Medicine, University of
Basel Hospital, Basel, Switzerland.
3
Joint Department of Medical Imaging, University of
Toronto, Toronto, ON, Canada.
AJR 2018; 211:1–10
0361–803X/18/2112–1
© American Roentgen Ray Society
spectrum of soft-tissue and osse-
ous injuries at the Chopart joint
complex involving the talocalca-
neonavicular and calcaneocuboid joints.
Typically, midtarsal sprains result from low-
energy, inversion-type ankle trauma. They
are distinct from Chopart joint fracture-dis-
locations, which result from high-energy
trauma such as motor vehicle crashes.
Midtarsal sprains may affect the support-
ing ligaments along the talocalcaneonavic-
ular and calcaneocuboid joints. The most
commonly injured ligaments are the dor-
sal calcaneocuboid, bifurcate, and dorsal ta-
lonavicular ligaments and the spring liga-
ment complex, with plantar ligament injuries
thought to be significantly less frequent [1–4].
The range of osseous injuries includes contu-
sions, avulsions, or impaction fractures of the
anterior process of the calcaneus, talar head,
cuboid bone, and navicular bone [2, 4, 5].
The true incidence of midtarsal sprains
is uncertain, with disparate values reported
in the literature ranging from 5.5% to 33%
of inversion ankle injuries [1, 6, 7], where-
as midfoot fracture-dislocations are consid-
erably less common, estimated to occur at
a frequency of 3.6/100,000 per year [8]. In
clinical and radiographic evaluations, mid-
tarsal sprains are frequently underdiagnosed
and are missed at initial evaluation in up to
41% of cases, resulting in delayed treatment
[1]. Recent estimates indicate that 22–40%
of midtarsal sprains are missed at presenta-
typical imaging findings [9, 10]. Untreated
midtarsal sprains may cause instability and
chronic pain; therefore, recognition of mid-
tarsal sprains by clinicians and radiologists
is important [9, 11].
In this article, we discuss Chopart joint
anatomy, pathomechanisms of midtarsal
sprains, clinical implications, and radio-
graphic and cross-sectional imaging findings,
with a focus on MRI. Other injuries affecting
the Chopart joint complex, such as fracture-
dislocation, will be briefly described.
Normal Anatomy and MRI of the
Chopart Joint Complex
The Chopart joint complex, also known as
the midtarsal or transverse tarsal joint, is lo-
cated between the hindfoot and midfoot and
consists of the talocalcaneonavicular and
calcaneocuboid joints. The joint complex is
named after François Chopart, born in Par-
is in 1743, who is the surgeon credited with
describing and pioneering an anatomically
and functionally expedient method for treat-
ing gangrene of the foot by disarticulation at
the transverse tarsal joint. The first descrip-
tion of this operation was published in 1792,
3 years before his death [12].
Chopart Joint Function
The talocalcaneonavicular and calcaneo-
cuboid joints are regarded as a unit despite
the distinct functions provided by each. The
talus and navicular form the proximal, flexi-

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 Walter et al.

ble part of the medial column of the foot, and
the calcaneus and cuboid form the proximal,
more rigid segment of the lateral column. The
Chopart joint complex allows the hindfoot to
pivot while the forefoot remains still with in-
version and eversion. The complex locks on
heel inversion, stabilizing the midfoot during
the push-off phase of gait [13, 14].
The Talocalcaneonavicular Joint
The talocalcaneonavicular joint, also known
as the talonavicular joint, is composed of the
talar head, the posterior surface of the navic-
ular, and the anterior process of the calcane-
us. Extracapsular ligaments of the sinus tarsi
and tarsal canal guide motion of the calcaneo-
navicular complex, a functional unit moving
around the talus. Any motion between the cal-
caneus and the talus occurs at the anterior and
posterior subtalar joints [14, 15].
Ligaments of the talonavicular joint can
be divided into ligaments of the acetabu-
lum pedis (spring ligament and calcaneona-
vicular component of bifurcate ligament), ta-
localcaneal ligaments (lateral, medial, and
American Journal of Roentgenology
The spring ligament complex—The spring
(calcaneonavicular) ligament complex is
composed of the superomedial, medioplan-
tar oblique, and inferoplantar longitudinal
components (Fig. 1). The superomedial com-
ponent is triangular or hammock-shaped,
coursing anteromedially from its origin at
the anteromedial aspect of the sustentaculum
tali and attaching at the superomedial navic-
ular tuberosity. Its inner surface is fibrocar-
tilaginous, resembling an articular surface.
Loose connective tissue is interposed be-
tween the superomedial component and the
posterior tibial tendon, allowing gliding be-
tween the two structures. The medioplantar
oblique component originates from the cor-
onoid fossa of the calcaneus, a notch in the
anterior process of the calcaneus. It courses
medially and obliquely, attaching at the me-
dioplantar navicular, just below its tuberos-
ity (Fig. 2A). The short and thick inferoplan-
tar longitudinal component originates in the
coronoid fossa, anterolateral to the medio-
plantar oblique component, extends forward,
and fans out onto the navicular beak [15, 16]
quences, and has variable signal intensity on
T2-weighted sequences [20] (Fig. 2A).
The bifurcate ligament—The bifurcate lig-
ament consists of the lateral calcaneonavic-
ular and medial calcaneocuboid ligaments,
supporting the talonavicular and calcaneocu-
boid joints (Fig. 1). It is located anterior to the
cervical ligament and the origin of the exten-
sor digitorum brevis muscle. The lateral cal-
caneonavicular ligament extends between the
intermediary tubercle of the calcaneus and the
posterosuperior aspect of the lateral margin of
the navicular (Figs. 1 and 2B). The medial
calcaneocuboid ligament extends between the
intermediary tubercle, slightly lateral to the
lateral calcaneonavicular ligament, and the
dorsum of the cuboid, inserting approximate-
ly 15 mm anterior to the calcaneocuboid joint
[15] (Figs. 1 and 2C). The lateral calcaneona-
vicular ligament was visualized in all speci-
mens and imaging planes in a cadaveric study
by Melão and colleagues [19], whereas the
medial calcaneocuboid ligament was less con-
sistently shown, best seen on coronal and sag-
ittal ankle MR images or short-axis and sag-

posterior talocalcaneal, interosseous, and
cervical ligaments), and dorsal talonavicu-
lar ligament (Fig. 1). The talocalcaneal lig-
aments will not be discussed, because they
pertain to the subtalar joint.
Ligaments of the acetabulum pedis—The
head of the talus articulates with the acetab-
ulum pedis, which is formed by the navicu-
lar anteriorly, the anterior and middle calca-
neal facets and the plantar components of
the spring ligament complex inferiorly, the
superomedial component of the spring lig-
ament complex medially, and the calcaneo-
navicular component of the bifurcate liga-
ment laterally (Fig. 1). The acetabulum pedis
adapts to talar head displacement and rota-
tion [14].
(Fig. 2A).
The superomedial component is best
shown on coronal and axial ankle MR im-
ages and on short- and long-axis midfoot
MR images [17–19]. It is an intermedi-
ate- to low-signal-intensity band on T1- and
T2-weighted MRI sequences. The medio-
plantar oblique component is best seen on
axial ankle or long-axis midfoot planes and
has a striated appearance (Fig. 2A). The me-
dioplantar oblique component is usually not
seen on a single sagittal image because of
its oblique course. The inferoplantar longi-
tudinal component is best seen on axial and
coronal ankle MR images and on long- and
short-axis midfoot images, has intermediate
to low signal intensity on T1-weighted se-
ittal foot MR images in another study [4]. On
non–fat-saturated MRI sequences, the com-
ponents are thin, low- to intermediate-signal-
intensity structures highlighted by adjacent fat
[19, 20] (Figs. 2B and 2C).
Dorsal talonavicular ligament—The dor-
sal talonavicular ligament is a capsular thick-
ening connecting the dorsal aspect of the
talar neck and the dorsal surface of the na-
vicular bone [15] (Fig. 1). It is hypointense
on T1- and T2-weighted MRI sequences and
is best visualized on sagittal MR images [19,
20] (Fig. 2D).
The Calcaneocuboid Joint
The calcaneocuboid joint is formed by
the quadrilateral facets of the calcaneus and

Fig. 1—Anatomy of Chopart joint complex.

A, Schematic drawing of supporting ligaments of Chopart joint
depicts dorsal talonavicular ligament (TN), bifurcate ligament
(calcaneonavicular and calcaneocuboid components), and
dorsal calcaneocuboid ligament (DCC; dorsal and lateral
bundles). Short and long plantar ligaments (not shown) stabilize
plantar aspect of joint.
B, Schematic drawing of spring ligament complex depicts
medioplantar oblique (MPO), inferoplantar longitudinal (IPL),
and superomedial (SM) components. (Reprinted from Magnetic
Resonance Imaging Clinics of North America, Vol. 25/edition
1, Tafur M, Rosenberg ZS, Bencardino JT. MR Imaging of the
Midfoot Including Chopart and Lisfranc Joint Complexes, Pages
95–125, Copyright 2017, with permission from Elsevier) [20].
A B

2 AJR:211, August 2018

 Chopart Joint Complex

A B
American Journal of Roentgenology

C D E
Fig. 2—MRI anatomy of Chopart joint ligaments in different patients. Insets show level (lines) of each image.
A, Axial T1-weighted image of 37-year-old man/woman. Lateral band of dorsal calcaneocuboid ligament (arrowhead) is seen adjacent to extensor digitorum brevis muscle
(asterisk). Note also inferoplantar longitudinal (short arrow) and medioplantar oblique (long arrow) components of spring ligament complex.
B and C, T1-weighted images of 26-year-old man/woman show that lateral calcaneonavicular ligament (arrowhead, B) and more laterally located medial calcaneocuboid
ligament (wavy arrow, C) form bifurcate ligament. Long plantar ligament (curved arrow, C) typically has striated appearance.
D, Fat-saturated proton density–weighted image of 51-year-old man/woman. Talonavicular ligament (arrow) reinforces talonavicular joint capsule.
E, T1-weighted image of 44-year-old man/woman. Short plantar ligament (arrow) typically has striated appearance.

cuboid bone. The calcaneus articular sur-
face is saddle-shaped, forming a groove di-
rected inferomedially. At its posteromedial
end is the calcaneal coronoid fossa, which
articulates with the beak of the cuboid. The
posterior surface of the cuboid is also sad-
dle-shaped, with the cuboid beak lodging in
the calcaneal coronoid fossa during forefoot
flexion and adduction [15]. Four ligaments
connect the calcaneus and cuboid: the me-
dial calcaneocuboid ligament (component of
bifurcate, described in the previous section),
the dorsal calcaneocuboid ligament, and the
plantar calcaneocuboid ligaments (Fig. 1).
The dorsal calcaneocuboid ligament—
The dorsal calcaneocuboid ligament, also
called the dorsolateral calcaneocuboid lig-
ament, has been described as a thin, broad
band between the superolateral aspect of the
anterior process of the calcaneus, lateral to
the medial calcaneocuboid component of the
bifurcate ligament, and the dorsal surface of
the cuboid (Fig. 1). However, in a cadaveric
study by Dorn-Lange and colleagues [21], al-
most half of the cases showed morphologic
variation including a V-shaped ligament, a
meniscoid band, or two or more separate lig-
aments (dorsal and lateral calcaneocuboid
ligaments). The normal dorsal calcaneocu-
boid ligament is often difficult to identify on
sagittal images because of its small size and
volume-averaging effects with the overlying
extensor digitorum brevis muscle. Melão and
colleagues [19] found dorsal calcaneocuboid
ligaments in all specimens and that the dorsal
calcaneocuboid ligament was better shown
on coronal ankle MR images or short-axis
midfoot MR images. The dorsal calcaneocu-
boid ligament is also well depicted on axial
MR images of the ankle [4, 20] (Fig. 2A).
The plantar calcaneocuboid ligaments—
The long and short plantar ligaments form
the superficial and deep components of the
inferior calcaneocuboid ligament, respec-
tively. The long plantar ligament originates
from the inferior surface of the calcaneus
between the posterior and anterior tubercles
and divides distally into at least two bands
that attach to the cuboid (lateral band) and
variably to the metatarsal bases (medial
band). When present, the medial band forms
the roof of the peroneus longus tunnel [22].
On MRI, the long plantar ligament has ho-
mogeneous to striated low signal intensity
and is well depicted on all ankle and midfoot
planes [19] (Fig. 2C). The short plantar liga-
ment originates at the plantar surface of the
calcaneus, anterior to the long plantar liga-
ment. It extends anteromedially to the plan-
tar surface of the cuboid, proximal to the

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 Walter et al.

TABLE 1: Mechanisms of Midtarsal Sprains

Characteristic
Primary injurious force
Primary injury
Ligaments involved
Secondary injuries
aWith superimposed plantar flexion during injury (e.g., wearing high-heeled shoes).
Mechanism
Ankle Inversion Ankle Eversion
Varus distraction at the lateral calcaneocuboid joint, impaction Valgus compression at the lateral calcaneocuboid joint,
at talonavicular joint, talonavicular plantar flexion distraction at talonavicular joint
Lateral calcaneocuboid ligamentous or bony avulsion, dorsal Lateral calcaneocuboid contusion or impaction fracture (i.e.,
talonavicular ligamentous or bony avulsiona, impaction of nutcracker injuries)
plantar talar head and navicular body
Dorsal calcaneocuboid and calcaneocuboid components of Short and long plantar ligaments
bifurcate ligament, dorsal talonavicular ligament
Medial calcaneocuboid joint impaction, plantar ligament Plantar ligament avulsion, navicular tuberosity avulsion, talar
contusion or avulsion, plantar spring ligament avulsion head impaction

peroneus longus tunnel. The short plantar
ligament appears striated and of intermedi-
ate signal intensity in all ankle and midfoot
planes on MRI [19, 20] (Fig. 2E).
Midtarsal Injuries: Pathomechanisms
Midtarsal sprains reflect a spectrum of in-
juries resulting from low-energy trauma of
the Chopart joint complex and encompass
both soft-tissue capsuloligamentous injuries
American Journal of Roentgenology
torum brevis origin avulsion. Impaction in-
juries medially may produce contusions
or fractures of the talar head and navicu-
lar body. Occasionally, because of its com-
plex saddle shape, the calcaneocuboid joint
may suffer distraction forces laterally and
impaction forces medially. Furthermore, dis-
traction forces across the Chopart joint com-
plex may cause avulsions of the plantar com-
ponents of the spring ligament. When ankle
Although a less common injury mecha-
nism, ankle eversion can also result in mid-
tarsal sprains (Fig. 3B). The distinguish-
ing feature of this injury is the compressive
impaction (instead of distraction) force at the
lateral aspect of the calcaneocuboid joint,
producing impaction fractures of the anteri-
or process of the calcaneus and posterolater-
al cuboid, referred to as “nutcracker” injuries
[23] (Fig. 3B). These impaction fractures are

and bony injuries, including ligament tears
or sprains as well as avulsion or impaction
fractures, depending on the severity of the
trauma and the mechanism-dependent forc-
es involved. Although midtarsal sprains most
commonly result from ankle inversion, ever-
sion injuries are also a possible mechanism.
Each mechanism results in a distinct inju-
ry pattern at the Chopart joint complex, and
recognition of these patterns is critical for ra-
diologists to propose a unified, accurate di-
agnosis of a midtarsal sprain (Table 1).
inversion is accompanied by plantar flex-
ion (as can occur while wearing high-heeled
shoes), distraction forces propagate dorsally
through the talonavicular joint, often caus-
ing dorsal talonavicular ligament avulsion.
Distraction forces at the medial calcaneocu-
boid joint may also produce joint capsule and
short plantar ligament avulsion injuries.
Eversion Midtarsal Sprains
often comminuted and depressed. Distrac-
tion forces medially can cause navicular tu-
berosity avulsion fractures due to pull by the
posterior tibial tendon.
High-Energy Midtarsal Injuries
Other uncommon mechanisms of injury
known to cause Chopart joint complex inju-
ries include direct longitudinal forces propa-
gating along the metatarsal axes from a di-

Inversion Midtarsal Sprains

Most midtarsal sprains are thought to oc-
cur as a result of an inversion injury (Fig.
3A), resulting in distraction forces across the
lateral and dorsolateral aspects of the cal-
caneocuboid joint [1, 2, 6] and, if the mag-
nitude of forces involved are sufficiently se-
vere, impaction along the medial column of
the foot. Distraction injuries often result in
avulsion fractures in combination with a tear
or sprain of the ligament stabilizing the joint.
Impaction injuries frequently cause contusion,
osteochondral injury, or impaction fractures
at the involved bony interfaces; occasionally, A B
ligamentous contusion can also accompany Fig. 3—Schematic drawings show typical inversion and eversion injury mechanisms of Chopart joint complex.
impaction injuries. (Drawings by Tafur M, used with permission)
Common injuries in this setting include A, Inversion, most common mechanism, will cause distraction forces and avulsions of calcaneocuboid
avulsion of the dorsal calcaneocuboid liga- ligaments and concomitant impaction forces at talonavicular joint. Commonly associated plantar flexion can
cause dorsal talonavicular ligament sprain. Arrow shows direction of forces.
ment and calcaneocuboid component of the B, Eversion of foot may lead to impaction injury of calcaneocuboid joint, which is also known as “nutcracker
bifurcate ligament as well as extensor digi- effect.” Arrow shows direction of forces.

4 AJR:211, August 2018


Fig. 4—Chopart fracture-dislocation in 27-year-old
woman after twisting ankle injury. Anteroposterior
radiograph of foot reveals talonavicular and, less
pronounced, calcaneocuboid malalignment with
small fracture fragment (arrow).
rect blow to the forefoot; when this occurs
with ankle plantar flexion, compressive forc-
es at the navicular-cuneiform joints can re-
sult in a crush injury of the midtarsal joint
American Journal of Roentgenology
(usually in high-energy scenarios) or shear-
ing forces, causing sagittally oriented navic-
ular fractures [1, 10].
Midtarsal Fracture-Dislocations
Midtarsal fracture-dislocations occur in
high-energy lower extremity trauma with
an axial loading force and are present in up
to 10% of patients with motor vehicle crash
polytrauma [24, 25]. This injury, although
obvious on imaging, may be initially over-
looked because of life-threatening trauma,
resulting in a delayed diagnosis [26]. Frac-
ture-dislocations among low-energy traumas
are rare but have been reported in misstep in-
juries [27].
Although Chopart joint dislocations are
commonly associated with fractures, isolat-
ed dislocations were found in 25% of cas-
es in one series [28]. Concomitant Lisfranc
joint injuries occur in 20% of patients with
Chopart fracture-dislocations; this combi-
nation portends poorer outcomes compared
with the outcomes of other Chopart fracture-
dislocations [25, 28].
Medial and dorsal direction of dislocation
of the midfoot relative to the hindfoot is most
common (Fig. 4). Talonavicular dislocations
may be associated with subtalar or tibiotalar
dislocations. Fractures along the talonavic-
ular joint shorten the medial column of the
midfoot, causing adduction malalignment
that requires surgical reduction [29]. Accom-
AJR:211, August 2018 5
Chopart Joint Complex
panying talus and navicular fractures are of-
ten comminuted and impacted and are also
frequently underestimated on conventional
radiographs. Avascular necrosis and fracture
nonunion are well-documented complica-
tions, especially after delayed treatment. At
least 60% of the talonavicular articular sur-
face must be intact and congruent to prevent
a high risk of postsurgical instability [30].
Calcaneocuboid fracture-dislocations are
usually accompanied by comminuted calca-
neus and cuboid impaction fractures. They
are commonly associated with medial col-
umn midfoot injuries, usually requiring sur-
gical treatment to restore Chopart joint con-
gruence and correct the lengths of the medial
and lateral midfoot columns. Cuboid frac-
tures rarely occur in isolation and are usual-
ly associated with low-energy trauma, rarely
requiring surgical intervention [29, 31].
MRI is unnecessary and is rarely per-
formed after high-energy trauma. Osseous
injury is more easily diagnosed using radi-
ography or CT, and soft-tissue injuries are
unlikely to be addressed in the acute setting;
therefore, MRI is rightly deferred until the
patient is clinically stabilized.
Subtalar Dislocations
Chopart joint injuries may also occur in
the setting of subtalar dislocations. The lat-
ter are rare injuries, occurring almost exclu-
sively in high-energy trauma related to mo-
tor vehicle crashes or axial loading caused
by falling from a height. Subtalar disloca-
tions universally involve the talocalcaneal
joint, but most cases also result in talona-
vicular dislocation, given that the stabilizing
ligaments of the talonavicular joint are not
as strong as those of the talocalcaneal joint.
These injuries are usually clinically obvi-
ous and are often accompanied by open frac-
tures. Concomitant fractures of the anterior
calcaneus and talus are common in these in-
juries, and talar head avascular necrosis is a
common posttraumatic sequela [32, 33].
Midtarsal Injuries
Clinical Considerations
Because midtarsal sprains most common-
ly occur with inversion-type injuries, the pre-
sumptive clinical diagnosis often mistakenly
favors the more common ankle sprain, in-
volving the lateral collateral ligaments—in
particular, the talofibular and calcaneofibular
ligaments. Therefore, definitive diagnosis of
midtarsal sprain is often delayed or is over-
looked entirely [34, 35]. Diagnostic accuracy
is further confounded by the fact that most
midtarsal sprains are accompanied by lateral
collateral ligament sprains. Conversely, mid-
tarsal sprains also occur in isolation; there-
fore, the diagnosis should not be discounted
in the presence of intact lateral collateral lig-
aments. One study found a negative correla-
tion between findings associated with midtar-
sal sprain and syndesmotic ligament injury,
suggesting distinct injury mechanisms [3].
Nevertheless, the close proximity of the lat-
eral collateral and midtarsal ligaments and
the epidemiologic overlap between midtarsal
and lateral collateral ligament sprains, as well
as the high incidence of the latter, present a
challenge to clinicians evaluating acute inver-
sion-type ankle injuries.
Definitive clinical diagnosis of midtarsal
sprains often requires a high index of suspi-
cion [2, 34]. Pain, swelling, and point tender-
ness over the calcaneocuboid or talonavicu-
lar joints are suggestive of a Chopart joint
injury. Varus stress applied at the lateral cal-
caneocuboid joint may show joint laxity, for
which objective radiographic criteria have
been developed. Varus stress radiographs of
the foot resulting in a calcaneocuboid angle
of greater than 10° are considered diagnos-
tic of a midtarsal sprain with instability [2].
Prolonged lateral foot pain after an acute
ankle injury, reflecting failure of conserva-
tive management, may be the first sign of a
midtarsal sprain. The exact cause is contro-
versial, but Chopart joint instability specif-
ically involving the calcaneocuboid joint is
thought to be the most likely cause. Cuboid
instability, or so-called “cuboid syndrome,”
is an important cause of chronic lateral foot
pain and is at least in part related to posttrau-
matic calcaneocuboid instability [11].
Most lateral ankle sprains are managed
conservatively with a controlled–ankle mo-
tion walking boot or aircast splint, whereas
treatment of midtarsal sprains varies widely
and remains controversial. Often, midtarsal
sprains are treated identically to lateral an-
kle sprains; however, a recent report recom-
mends more aggressive immobilization us-
ing a below-the-knee rigid cast for 6–8 weeks
followed by return to weight-bearing with a
soft brace for 6 weeks [10]. 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 conservative manage-
ment [9, 36] and may require surgical inter-
vention. Traditionally, midtarsal arthrode-
sis is performed for chronic instability, pain,
 Walter et al.

and secondary Chopart osteoarthrosis [1, 10,
26]. New operative techniques have been de-
veloped to address soft-tissue injuries with
or without significant osseous injuries. Spe-
cifically, primary reconstruction of the dorsal
calcaneocuboid ligament has been performed
in patients, usually young athletes, with mid-
tarsal instability and refractory lateral foot
pain. Surgical techniques include perioste-
al flap, extensor digitorum brevis tendon, or
peroneal tendon graft reconstructions of the
dorsolateral ligamentous complex of the cal-
caneocuboid joint [36–38].
Nonreducible dislocations or displaced
fractures are indications for operative man-
agement [1, 9, 10]. A treatment algorithm
American Journal of Roentgenology
based on radiographic evaluation has been
suggested in which the presence of a small
calcaneal or cuboid cortical avulsion fracture
fragment may be treated with casting for 6
weeks but a large fracture fragment with a
widened calcaneocuboid joint angle (>  10°)
requires open plate and screw fixation [2].
Imaging Features With a Focus on MRI
Most acute ankle inversion injuries are
clinically diagnosed through a physical ex-
amination and careful history; occasionally,
radiographic evaluation is required to exclude
fractures or assess syndesmotic integrity.
Cross-sectional imaging, such as MRI or CT,
for initial diagnosis or therapeutic decisions
is not usually indicated and is reserved only
for patients who, with or without known an-
kle sprain, experience persistent severe pain
or chronic ankle instability (symptoms of an-
kle sprain typically resolve within 4 weeks)
[39]. More extensive injuries, such as dis-
ruption of the tibiofibular syndesmosis, frac-
tures, or osteochondral injuries, may be pres-
ent [40]. These patients are also the ones for
whom radiologists should make an extra ef-
fort to search for occult Chopart joint injury.
Radiography should be the initial imag-
ing modality for making the diagnosis of a
Chopart joint injury. Radiographic (or CT)
evaluation is especially useful for detecting
fractures about the Chopart joint that are fre-

A B C
Fig. 5—Inversion-related advanced Chopart joint complex injury with concomitant calcaneocuboid and talonavicular involvement in 55-year-old woman after twisting
right ankle injury.
A–C, Avulsion fractures of anterior calcaneal process at insertion of dorsal calcaneocuboid ligament (arrowheads, A and B) and of dorsum of talar head at insertion of
dorsal talonavicular ligament (arrow, C) can be seen on anteroposterior ankle (A), anteroposterior foot (B), and lateral ankle (C) radiographs. Note typical subfibular soft-
tissue swelling (asterisk, A) as secondary sign of calcaneocuboid joint injury.

A B C
Fig. 6—55-year-old woman who presented for follow-up imaging 3 weeks after falling.
A and B, Sagittal fat-saturated proton density–weighted MR images show dorsal talonavicular ligament avulsion (arrow, A) and nondisplaced fracture of anterior process
of calcaneus due to bifurcate ligament avulsion (arrow, B). Additional marrow edema may be related to capsular avulsion or plantar calcaneal contusion (arrowhead, B).
C, Axial fat-saturated proton density–weighted MR image shows mild edema at calcaneal and cuboid attachments of dorsal calcaneocuboid ligament (arrowheads).
Note edema of extensor digitorum brevis muscle (asterisk), common finding in Chopart joint complex injury.

6 AJR:211, August 2018

 Chopart Joint Complex

quently associated with midtarsal sprains.

In the setting of ankle inversion, distraction
forces produce avulsion fractures along the
calcaneocuboid joint and impaction frac-
tures along the talonavicular joint (Fig. 5).
Concomitant plantar flexion may cause avul-
sion at the dorsal talonavicular joint (Fig.
5C). The reverse pattern will be seen in the
less-common ankle eversion injuries.
Radiographic evaluation for the detection
of subtle avulsion fractures requires scru-
tiny of each view depending on the frac-
ture location. Radiographic examinations of
both the ankle and foot will yield a higher
likelihood of fracture detection than either
examination separately. The lateral ankle or
foot views are optimal for detecting a dor-
sal talonavicular ligament avulsion fracture A
(Fig. 5). Because osteophytes are common
at this location, osseous irregularity may of-
ten be present; overlying soft-tissue swell-
ing is a helpful confirmatory sign of frac-
ture. An oblique view of the foot is optimal B
for visualizing the anterior process of the
calcaneus, although a displaced fracture of
American Journal of Roentgenology

the anterior process of the calcaneus may

also be detected on lateral views. Occasion-
ally, dorsolateral calcaneocuboid avulsion
fractures are seen on only the anteroposte-
rior radiograph of the ankle and are not vis-
ible on foot radiographs.
Avulsion fractures at ligamentous or cap-
sular attachments, in the setting of an inver-
sion injury, include dorsal calcaneocuboid
and bifurcate ligament avulsion fractures
from the anterior process of the calcaneus or
the dorsolateral cuboid [5, 41] and dorsal ta-
lonavicular ligament avulsion from either the
dorsal talar head or navicular (Figs. 5 and 6).
Another common avulsion fracture from the
dorsolateral anterior calcaneus occurs at the C D
origin of the extensor digitorum brevis mus-
Fig. 7—Inversion-related advanced Chopart joint complex injury with involvement of both talonavicular and
cle [42]. Occasionally, calcaneocuboid cap- calcaneocuboid joints in 77-year-old woman.
sular avulsion fractures occur at the lateral A, Fat-saturated proton density–weighted MR image reveals tear of talonavicular ligament (open arrow) and
or lateral-plantar calcaneus or cuboid (Fig. avulsion fracture at navicular attachment of inferoplantar longitudinal component of spring ligament (solid
5B). Avulsions of the plantar ligaments can arrow).
B–D, Fat-saturated proton density–weighted MR images show plantar talar head contusion (arrowhead, B)
occur medially. The least common avulsion and navicular tuberosity fracture (arrow, C). Laterally, there are avulsions at calcaneal attachment of dorsal
fractures are seen at the plantar navicular— calcaneocuboid ligament (arrowhead, C) and at cuboid attachment of calcaneocuboid part of bifurcate ligament
that is, at the attachment of the plantar com- (arrowhead, D).
ponents of the spring ligament (Fig. 7A). Fi-
nally, medial impaction fractures may occur es of the calcaneus and cuboid, and avulsion prompt a thorough search for others. For ex-
along the talonavicular joint, usually involv- fractures of the navicular tuberosity, due to ample, the presence of an avulsion fracture
ing the plantar aspect of the talar head and distraction forces and pull by the posterior of the anterior process of the calcaneus war-
sagittal plane navicular body fractures (Fig. tibial tendon, are associated with eversion in- rants careful inspection for the presence of
7). Osteochondral injuries at the talonavicu- juries (Fig. 8). the often subtle and overlooked dorsal talo-
lar articulation may also occur. Common fractures at the Chopart joint navicular fracture [5, 41, 43].
The typical nutcracker-type impaction often occur simultaneously; therefore, vi- CT is a sensitive, confirmatory examina-
fractures, occurring at the opposing surfac- sualization of any of these fractures should tion and may reveal fractures not otherwise

AJR:211, August 2018 7

 Walter et al.

Because midtarsal sprains are predom-

inantly ligamentous injuries, the superior
soft-tissue contrast of MRI is optimal for es-
tablishing a comprehensive, accurate diagno-
sis of Chopart joint injury. Based on MRI,
most cases of midtarsal sprains involve mul-
tiple ligaments—most commonly, the dor-
sal calcaneocuboid and bifurcate ligaments
(Figs. 6 and 7). Similar to the MRI appear-
ance of ankle ligament sprains, the MRI ap-
pearance of acute or subacute injuries will
be ligamentous edema, discontinuity, irregu-
larity, waviness, and laxity [47]. Focal mar-
row edema at the osseous attachments of the
ligaments typically indicates underlying lig-
A B amentous injury. The evolution of midtarsal
Fig. 8—Eversion-related nutcracker-type fracture pattern in 51-year-old woman. ligamentous sprain is thought to resemble
A, Anteroposterior radiograph of foot reveals impaction fracture of anterior calcaneal process (arrow) and ligaments in other locations with eventual
nondisplaced avulsion fracture of navicular tuberosity (arrowhead).
B, Fat-saturated proton density–weighted MR image shows impaction fracture of proximal cuboid (wavy black scar-remodeling causing low-signal-intensity
arrow) in addition to calcaneal fracture (straight black arrow) and extensive bone marrow edema of distal thickening. Old injury is a common cause of
calcaneus (white arrow). increased ligament conspicuity (Fig. 10).
Careful inspection of the lesser-known
detected on radiography, so the Chopart joint medial calcaneocuboid joint, and dorsolater- ligaments stabilizing the Chopart joint (such
should again be scrutinized (Fig. 9). Over- al calcaneus and cuboid (Figs. 6 and 7). Nut- as the dorsal calcaneocuboid ligament) is
all, radiographic detection of midtarsal inju- cracker injuries associated with ankle ever- particularly important when seeking mid-
American Journal of Roentgenology

ries is thought to be insensitive, missing up sion may be radiographically subtle but are tarsal sprains. Because the normal dorsal
to 33% of cases with fractures [44]. Again, readily seen on MRI with bone marrow ede- calcaneocuboid and calcaneocuboid com-
when a single midtarsal avulsion fracture is ma in the anterior process of the calcaneus ponents of the bifurcate ligament may be
identified, others should be carefully sought and throughout the cuboid (Fig. 8). In contra- difficult to detect on MRI, failure to visual-
and the potential diagnosis of midtarsal distinction to impaction fractures that cause ize them should not automatically be con-
sprain should be invoked. Even in the ab- obvious bone marrow edema, the marrow sidered pathologic; secondary signs of liga-
sence of additional fractures, associated liga- edema caused by ligamentous avulsion with mentous injury should be sought to support
mentous injuries indicating midtarsal sprain or without a fracture fragment is surprisingly the diagnosis of a sprain. For example, mar-
are common and MRI is a useful modality minimal and, therefore, small foci of marrow row edema within the anterior process of the
for their detection [5]. edema on MRI should be carefully assessed calcaneus or dorsolateral cuboid or periliga-
MRI is superior to conventional radiog- in correlation with radiographs or CT images mentous fat edema should heighten suspicion
raphy in the detection of soft-tissue inju- for a potential avulsion injury [45, 46]. of acute injury. Ligament discontinuity or ir-
ries and, sometimes, osseous injuries at the
Chopart joint. In one recent study, calcaneo-
cuboid avulsion fractures were evident in
48% of radiographs and 100% of MR imag-
es [5]. Similarly, talonavicular joint injuries
were evident in 38% of radiographs and 76%
of MR images [5]. Furthermore, simultane-
ous involvement of both the calcaneocuboid
and talonavicular joints, based on the pres-
ence of marrow edema, fractures, or liga-
mentous injury, was noted in 76% of MRI
examinations compared with 14% of radio-
graphs [5] (Figs. 6 and 7).
The Chopart joint complex is readily eval-
uated on ankle MRI; thus, a dedicated mid-
tarsal protocol is not mandatory. MRI is
sensitive for detecting typical contusions or
nondisplaced impaction fractures. Common A B
and consistent patterns of marrow edema in
Fig. 9—CT images depict inversion-related Chopart joint complex injury in 39-year-old woman.
midtarsal sprains include the dorsal or plan- A and B, Sagittal reformatted images show talonavicular avulsion fractures at dorsum of talar head (open
tar talar head, anterior calcaneal process, arrow, A) and navicular (solid arrow, A) and avulsion fracture of anterior calcaneal process (arrow, B).

8 AJR:211, August 2018


Fig. 10—Old Chopart joint injury with osteoarthritis
of calcaneocuboid joint in 67-year-old woman.
Deformity and nonunion of avulsion fracture
of anterior calcaneal process (arrowhead) and
subchondral degenerative changes at opposing
cuboid (arrow) are seen on this sagittal fat-saturated
T2-weighted MR image.
regularity and overlying edema are concrete
signs of ligamentous injury [4].
American Journal of Roentgenology
The dorsal talonavicular ligament, a cap-
sular thickening, traverses the talonavicu-
lar joint dorsally but also extends quite far
medially and laterally [19]. Therefore, par-
tial tears may occur. In our experience, ede-
ma associated with dorsal talonavicular lig-
amentous avulsion is most commonly seen
in the dorsal talar head (Fig. 6A) and is less
commonly seen in the dorsal navicular.
Several pitfalls should be considered when
evaluating the ligaments at the Chopart joint.
The aforementioned anatomic variations
(predominantly involving the dorsal calca-
neocuboid ligament) may produce distinct
MRI appearances. For example, a thick lat-
eral band of the dorsal calcaneocuboid lig-
ament will be conspicuous on axial images.
Alternatively, the meniscoid variant pro-
trudes into the calcaneocuboid joint [21, 48].
The dorsal talonavicular ligament is well
evaluated on sagittal images but may appear
thickened relative to the other midtarsal liga-
ments; care should be taken, particularly in
the absence of associated soft-tissue or mar-
row edema, to avoid overdiagnosing thicken-
ing as evidence of an old midtarsal sprain.
The talonavicular joint is highly mobile and
therefore is susceptible to increased stress
and motion during daily activities, likely ac-
counting for traction-related scarring.
Another potential pitfall occurs in the
presence of a midtarsal joint effusion. Vol-
ume averaging of joint fluid with the sup-
AJR:211, August 2018 9
Chopart Joint Complex
porting ligaments on sagittal fluid-sensitive
images may create the false impression of
ligament signal hyperintensity and be easi-
ly mistaken for a sprain. Additionally, a spu-
rious appearance of “ligament thickening”
may be seen on MR images obtained with fat
saturation because of volume averaging be-
tween the ligament and saturated signal from
adjacent fat. Correlation with T1-weighted
sagittal images clarifies these issues.
Ultrasound evaluation of the midtar-
sal ligaments is of great utility in experi-
enced hands. Sonographic evaluation of the
Chopart joint allows dynamic assessment of
joint stability and is particularly suited for
evaluating the superficial dorsal and later-
al soft tissues about the joint, including the
dorsal calcaneocuboid, dorsal talonavicular,
and calcaneocuboid joint capsules [49]. It
has also been shown to depict some avulsion
fractures associated with midtarsal sprains
[34, 50]. Although MRI evaluation is re-
quired to exclude midtarsal sprain in the set-
ting of normal or equivocal ultrasound find-
ings and is more sensitive for nondisplaced
fractures, ultrasound offers an attractive mo-
dality for point-of-care evaluation.
Conclusion
Chopart joint complex injuries—specifi-
cally, midtarsal sprains—are relatively com-
mon in the setting of inversion-type ankle
injuries and typically present as avulsion in-
juries across the calcaneocuboid joint and
impaction injuries at the talonavicular joint.
Conversely, an eversion mechanism will
cause impaction injuries at the calcaneo-
cuboid joint and medial avulsion fractures,
typically at the navicular tuberosity. Under-
standing midtarsal joint anatomy, the mech-
anisms of injury, and the implications for
management is important for radiologists so
that they are able to provide a timely diagno-
sis and help optimize management of these
frequently overlooked injuries.
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