CHAPTER 7
The Normal Foot and Ankle
ROBERT A. CHRISTMAN
ver the years I have observed that the most
O common pitfall when interpreting foot and ankle
radiographs is mistaking normal anatomic shadows
for pathology. To truly appreciate abnormalities of position,
form, density, and architecture, the interpreter must have a
working knowledge and appreciation of normal radio-
graphic anatomy. In the foot and ankle, this requires correla-
tion of normal three-dimensional osteology (the bone
specimen) to two-dimensional radiographic anatomy (the
film), The reader is therefore encouraged to compare the
images to a foot skeleton.
The following collection of illustrations, tracings of
"rectus" foot images, and their respective radiographs should
be used as a general reference guide. Slight variations in the
appearance of each bone occur depending on the position of
the foot relative to the film. For example, a pronated or
supinated foot affects the overall appearance of the entire
foot as well as each individual bone. Therefore it is
130
important to concentrate on the correlation of gross
anatomy to the radiograph, not to memorize the appearance
of each bone per se.
Sarrafian's Anatomy ofthe Foot andAnklel was used as the
reference for the terminology in the labels. Occasionally,
however, I used the best generic term to label a radio-
graphic "shadow" that Sarrafian had not specifically
identified, The label key (Box 7-1) is located at the end of
the chapter.
I have spent years studying foot and ankle bone
specimens (normal three-dimensional osteology) and
correlating them to two-dimensional radiographs.i" The
original manuscript for this chapter was written to serve as
the complete reference guide to radiographic anatomy of the
foot and ankle. However, because of its large size and
numerous images, it has been replaced with this overview.
The original completed manuscript will be submitted to and
(I hope!) made available in the medical literature soon.
CHAPTER 7 The Normal Foot and Ankle 131

~r--------- UT

> r - - - - - - BPB

.-_--J~-_+_----- PR

MTM

G--~:...-+__+~""__I
f1-t-+-+--+--1f---- LTS

PEM ---+-t----+-~

LTM---~"""'-{

PL

~:::;~d---- MCJS

MCJI

5MT BC

~"7""-NT

LNCJ

Figure 7-1 Dorsoplantar (DP) foot view.

 SECTION 2 Radiographic Anatomy
132

LPT
PLT
PMT
ST

BPC --1--

Ca

MTC -----""'"--1--

LTC TC

Figure 7-2 Lateral foot view.

CHAPTER 7 The Normal Foot and Ankle 133

lTAS

\---+---- MTAS

PEL

MTM -/l--~-f--=r1 l-fl.,.,::=::r---+----- FS

LTM --~=::i--H +---1------ TS

PEM

MPA ---~-_+_+_-~I\.:l,
ILR ---+-----+~

MPA ---+---+;,..<::......c~-4.

TC ---\---/-'/--..l1lI'"

LTC

Figure 7-3 Medial oblique foot view.

134 SECTION 2 Radiographic Anatomy

~------BPB

~--TS
PEM -----F-::.......,H---f---+----\
-+"d-;~-- FS

LTM ----+--~

-+------- NT
GAC -----JV==::::::::::;::-
ALET---l

1--------- ST

"'<----MTC

Figure 7-4 Lateral oblique foot view.

CHAPTER 7 The Normal Foot and Ankle 135

Figure 7-5 Sesamoid axialview.

_=~---- TCJM

TCJP

RTE - - - - 4

Ca

---+--------- MTC
LTC

Figure 7-6 Calcaneal axial view.

 136 SECTION 2 Radiographic Anatomy

PBlS -+--+---\--\
ABLS - - 1 - - - \

FF--\---+-

Figure 7-7 Anteroposterior (AP) ankle view.

CHAPTER 7 The Normal Foot and Ankle 137

ABLS --+-----1

PTT --I------l---it:;~::::-;;::?--

FF ---.:~--+-

TCJP ------/--t'~
...... """"'o_

Figure 7-8 Mortise ankle view.

 138 SECTION 2 Radiographic Anatomy

PBLS ----+---\

FF - - - - 1 ' - - - 7 ' ' ' -

v----->o.,,.-- ACTM

LPT ---~,.,.L------..::.... -+-----1-- STC

Figure 7-9 Medial oblique ankle view.

CHAPTER 7 The Normal Foot and Ankle 139

F
Ti

_=--'-.----->,.......,.rE-~- PCTM
_.c.-+-__ ACTM

~--PMT

Figure 7-10 Lateral oblique ankle view.

 SECT ION 2 Radiog raphic Anatom y
140

F Ti

PTF

LPT

PLT

PMT

BPC

8T ---+--------~r--

LTC -----...::.~---.=--'"

MTC ---~""--

ATC

Figure 7-11 Lateral ankle view.

 The r--- or mal Foot and Ankle 141
C Ii A I' T E R 7

BOX 7-1 Label Key

e First cuneiform (medial cuneiform) MCjI Inferior aspect of first metatarsocuneiform joint
Second cuneiform (intermediate cuneiform) MCjS Superior aspect of first metatarsocuneiform joint
'c
IC Third cuneiform (lateral cuneiform) MNCj Medial naviculocuneiform joint
,MT Tuberosity of fifth-metatarsal base Mp Middle phalanx
~BLS Anterior border of distal tibial lateral surface MpA Medial and lateral marqins of plantar apex of bone
'ICTM Anterior collkulu: (of tibial malleolus) rvHAS Medial trochlear articular surface (hallux proximal
'ILET Anterolateral extension of trochlear surface (talus) phalanx)
il,MET Anteromedial extension of trochlear surface (talus) MTC Medial tuberosity (medial tubercle)
il,SMA Articular surface lor medial malleolus, anterior MTM Medial tubercle (for metatarsophalanqcal ligaments)
margin MTS Medal trochlear surface (first met)
ASMP Articular surface lor medial malleolus, posterior 1\1 Navicular
rnarqin I\IT Tuberosity of navicular
ATC Anterior tuberosi .y (anterior tubercle) PBLS Posterior border of distal tibial lateral surface
ArT Anterior tibial tubercle peTM Posterior colliculus (of tibial malleolus)
BC Seiik of cuboid PEL Proximal extension of metatarsal head articular
SPS Bony projection, dista] phalanx base (varies in size) surface, laterally
BPC Bursal projection, posterior calcaneus pEM Proximal extension of metatarsal head articular
e Crista (crest of metatarsal head) surface. medially
Ca Calcaneus PL Tubercle for insertion of peroneus longus tendon
Cli Cuboid ELT Posterolateral tubercle (talus) (trigonal process)
DP Distal phalanx EMT Posteromedial tuberc:le (talus)
F Fibula PI' Proximal phalanx
FF Fibular (digital) fossa PR Phalangeal ridge
FM Fibular malleolu-. PTF Posterior tubercle (fibula)
FS Fibular sesarnoic pn Posterior tibial tubercle
C Groove separating tubercle and articular surface RP Remnant of physis
CAe Great apophysis (anterior process of calcaneus) RTE Retrotrochlear eminence
INC) Intermediate naviculocuneiforrn joint ST Sustentaculum tali
ILR Interosseous lig< ment rugosity STC Sinus tarsi/tarsal canal
LNC] Lateral naviculocuneiform joint Ta Talus
LPT Lateral process (talus) TC Tuberosity of cuboid
l.TAS Lateral trochlear articular surface (hallux proximal TCjA Talocalcaneal joint, anterior
phalanx) TCjM Talocalcaneal joint, middle
LTC Lateral tuberosity (lateral tubercle) TCjp Takcalcaneal joint, posterior
LTM Lateral tubercle (for metatarsophalangeal ligaments) n Tibia
lTS Lateral trochlear surface (first metatarsal) rs Tibial sesamoid
MCjI First metatarsocuneiform joint UT Unqual tuberosity (tuft of distal phalanx)
MCI2 Second metatarsocuneiform joint

1, Sarrafian SK: /lnatc mv or the foot and ankle: delCriptivc,
topographic, functional, cd 2, Philadelphia, 1993,
Lippincott.
2. Christman RA: Rad ographic anatomy of the calcaneus. I.
Inferior surface, J rl-n Podiatr Mcd rlssoc 77(10):549-553,
1987.
3. Christman RA: Radiographic anatomy of the calcaneus.
Il. Posterior surface. JAm Podiatr Med rlssoc 77(11):581-
585,1987.
4. Christman RA: Radiographic anatomy of the calcaneus.
Ill. Superior surface,.J /im Podiarr Mc.! rlssoc 77(12):633-
637,l Q87.
5. Christman RA: Radiographic anatomy of the calcaneus.
IV Lateral and medial surfaces. JAm Poduur Mc.! rlss»:
78(1):11-14,1988.
6. Christ nan RJ\, Ly P: Radiographic anatomy of the
first metatarsal, J Am Podiatr !'vIed rlssoc 80(4):177-203,
1990.