ORTHOPAEDICS - IV: LOWER LIMB
Imaging of the foot and
ankle
Sinan Al-Qassab
Alun Davies
Abstract
The complexity of foot and ankle anatomy and biomechanics gives im-
aging an essential role in the diagnosis and management of foot and
ankle pathology. This article will focus on the common non-
traumatic and non-neoplastic conditions routinely encountered in or-
thopaedics and musculoskeletal radiology practice.
Keywords Achilles tendon; Morton’s neuroma; plantar fascia; plantar
fibroma; plantar plate; sesamoiditis; sinus tarsi; tarsal coalition
Introduction
Human bipedalism led to numerous evolutionary changes to the
skeleton, including the foot and ankle, to be able to cope with
bearing the weight of the body during different activities. Due to
the complex anatomy and biomechanics, imaging is pivotal in
diagnosing and managing foot and ankle pathologies.
There are a variety of imaging modalities at our disposal;
however the choice is guided by the clinical question. Plain ra-
diographs are readily available, cheap and offer excellent spatial
resolution (ability to detect fine details) making them very useful
in the assessment of the bones but not helpful in the assessment
of soft tissues, due to its poor contrast resolution (ability to
distinguish between different density areas in the image). They
are, however, useful in helping to rule out osseous involvement
associated with soft tissue pathology. They remain the first-line
investigation in trauma.
Ultrasound is very helpful in assessing soft tissues. It is readily
available, efficient, cheap and offers dynamic assessment of the
structures without radiation exposure. Ultrasound can also aid in
the accurate guidance of needles for therapeutic injections. It also
provides excellent resolution, especially of superficial structures.
It is, however, very operator dependent.
CT offers high spatial resolution and multiplanar reformats,
making it extremely helpful in osseous pathology but carries a
radiation dose, albeit low compared to CT imaging of the head,
neck and body. CT has the drawback of having poor soft tissue
contrast differentiation.
MRI is superior in assessing soft tissues; it offers multiplanar
imaging, allows contrast use and does not involve ionizing ra-
diation. However, it can be time consuming, expensive and
certain metal implants such as pacemakers may be incompatible.
Sinan Al-Qassab FRCR is a Radiology Registrar at University Hospital
Plymouth, UK. Conflicts of interest: none declared.
Alun Davies FRCR is a Consultant Musculoskeletal Radiologist at
University Hospital Plymouth, UK. Conflicts of interest: none
declared.
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Some patients are unable to tolerate the scan due to claustro-
phobia, although this is less of an issue with foot and ankle
imaging as only the patient’s lower limbs are inside the scanner.
Nuclear medicine has limited usage in the pathologies dis-
cussed in this article.
Plantar fasciitis
The plantar fascia (aponeurosis) is a strong triangular fibrous
structure with the apex inserted at the calcaneal tuberosity, and
the base divides into five slips inserting into the bases of the
proximal phalanges of the toes. It has three components, each
covering underlying muscles; the central component is the
largest and most frequently injured. It arises from the medial
calcaneal tuberosity and runs anteriorly covering and adherent to
the flexor digitorum brevis (FDB) muscle. The medial component
is the least significant and provides a fascial covering for the
abductor hallucis muscle. The lateral component provides
covering for the abductor digiti minimi. There is a fascial
connection between the Achilles tendon and the posterior part of
the plantar fascia. The function of the plantar fascia is to support
the longitudinal arches of the foot.
Plantar fasciitis is the most common cause of plantar heel
pain. Most commonly it is due to abnormal biomechanics
resulting in microtears that will induce a local inflammatory re-
action. Some authors suggest the use of the term ‘plantar fasci-
opathy’ instead of ‘plantar fasciitis’ due to the similarity in
pathology to degenerative processes in the tendons. It is gener-
ally seen in over-weight middle-aged or elderly patients but can
also present in young people due to sports like running. It can be
associated with enthesopathies due to seronegative arthritis
(ankylosing spondylitis, reactive arthritis, and psoriatic arthritis)
and diabetes mellitus. The typical presentation is sharp heel pain
upon getting out of bed in the morning.
Imaging
Plain radiographs play a minor role in the diagnosis. Calcaneal
spurs may be seen, but their significance is controversial since
they can also be seen in asymptomatic patients.
On ultrasound, normal plantar fascia is seen as echogenic fi-
bres on the background of a low signal matrix. In plantar fasci-
itis, ultrasound can show thickening of the plantar fascia near its
calcaneal attachment (>4 mm on the sagittal plane), disorgani-
zation of its fibres and hypoechogenicity (Figure 1). Other find-
ings may include perifascial fluid, intratendinos calcifications
and partial tears, which are demonstrated as fluid-filled defects
with interruption of the plantar fascia fibres. Hyperaemia is un-
common but may be seen when the symptoms are of less than 6
months’ duration. It is always good practice to compare to the
contralateral side.
On MRI, normal plantar fascia is of low signal on both T1- and
T2-weighted images. In plantar fasciitis, findings include fusi-
form thickening of the proximal portion of the plantar fascia (>4
mm) extending into the calcaneal insertion, an intermediate in-
crease in signal intensity on T1- and proton density (PD)-
weighted images and high signal intensity on T2 and STIR se-
quences. Oedema in the perifascial fat and soft tissue can be seen
on T2/STIR images and may be present in both acute and chronic
fasciitis. Bone marrow oedema at the calcaneal attachment may
1 Ó 2019 Published by Elsevier Ltd.
 ORTHOPAEDICS - IV: LOWER LIMB

Larger lesions may be lobulated and may show a central scar-

like appearance. It is typically hypoechoic or isoechoic relative to
the plantar fascia on ultrasound. There is usually no acoustic
enhancement and it may extend to involve the deeper structure.
Minor internal vascularity may be seen on colour Doppler. On
MRI, plantar fibromas are heterogeneous in signal intensity but
usually low to intermediate on T1- and T2-weighted images. A
high T2 signal may be seen in very cellular lesions. They show
variable enhancement post-contrast administration and can
exhibit linear extensions into the fascia, known as the ‘fascial
tail’ sign.

Achilles tendon
The Achilles tendon forms from the myotendinous junction of the
Figure 1 Sagittal ultrasound image demonstrating a thickened and gastrocnemius and soleus and may have a contribution from
hypoechoic plantar fascia at its calcaneal insertion seen in plantar plantaris. It attaches to the posterior aspect of the calcaneum, distal
fasciitis. to the posterosuperior tubercle (Hagland’s tubercle) (Figure 3). It is
about 6 mm thick. It lacks a true tendon sheath but is surrounded
also be seen, which is more pronounced in enthesiopathies and by paratenon in a U-shaped fashion posteriorly, medially and
may demonstrate post-contrast enhancement. laterally. It has a relatively poor blood supply and is most likely to
Treatment of plantar fasciitis is usually conservative and rupture in the interval 2e6 cm proximal to its insertion.
symptomatic relief is seen in 90e95% of patients with simple Diseases of the Achilles tendon are usually due to degenera-
measures like rest, icepacks, physiotherapy, NSAIDs, and so on, tion rather than inflammation, although paratenonitis can be
but this may take up to 18 months. Extracorporeal shock wave seen in rheumatic disease, especially spondyloarthritidies. They
therapy has been offered, but a randomized controlled multi- can be divided into insertional, which include enthesopathy and
center trial did not show meaningful improvement when Hagland’s disease and non-insertional, which include tendinop-
compared to placebo.1 An ultrasound-guided corticosteroid in- athy and paratenonpathy.
jection can provide temporary pain relief for up to 4 weeks, as
Imaging
was concluded in a randomized controlled trial by McMillan
Plain radiographs are of limited value but can be helpful in
et al.2 Repeated corticosteroid injections carry a 2e10% risk of
assessing for calcifications and also the prominence of the post-
plantar fascia rupture.3 There have been studies comparing
erosuperior calcaneal tubercle (seen in Haglund’s deformity),
platelet-rich plasma to corticosteroid injection suggesting similar
which is a triad of a prominent posterosuperior calcaneal tu-
or more effective outcomes with fewer risks.4
bercle, retrocalcaneal bursitis and changes in the anterior distal
Achilles tendon (see Figure 6).
Plantar fibroma
Ultrasound is usually the first imaging modality. A study
Plantar fibromatosis or Ledderhose’s disease is a benign fibro- conducted by Khan et al. reported ultrasound to have a sensi-
blastic proliferative disorder. It is the most common solid soft tivity of 80% and a specificity of 49% while MRI had a sensitivity
tissue lesion seen in the foot and ankle. The exact etiology is not of 95% and specificity of 50% in diagnosing tendinopathy.7 The
known; however, genetic predisposition and alteration in the tendon and paratenon are assessed in longitudinal and transverse
collagen profile of the plantar fascia have been suggested. The
condition is usually seen in patients between 30 and 50 years of
age and is twice as common in men than women. Lesions may be
single or multiple and can be bilateral in 20e50% of cases.5 They
can be locally aggressive and can recur after surgical treatment,
but do not metastasize. They are associated with palmar fibro-
matosis (Dupuytren’s contracture) in 65% of cases and may be
associated with keloids and Peyronie’s disease.6
Plantar fibromas may be asymptomatic but patients may
present when they feel a nodule or focal thickening on the sole of
the foot and may experience mild pain due to the fibroma being
compressed upon weight-bearing.

Imaging
Due to the higher contrast resolution of ultrasound, it is better
than MRI in detecting small lesions, and it also offers the ability
to scan the contralateral side to assess for multiplicity. The Figure 2 Sagittal ultrasound image demonstrating an oval hypoechoic
typical plantar fibroma is a focal oval disorganization of the lesion (solid arrows) consistent with a plantar fibroma. This is intimately
plantar fascia fibres usually <2 cm (Figure 2). related to the plantar fascia (dotted arrows).

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 ORTHOPAEDICS - IV: LOWER LIMB

Figure 3 (a) Lateral ankle radiograph demonstrating a prominent posterosuperior calcaneal tubercle (Haglund’s tubercle). (b) Sagittal STIR MRI
image demonstrating Haglund’s tubercle (block arrow), Achilles tendinopathy (dotted arrow) and retrocalcaneal bursitis (solid arrow).

sections. Features of tendinopathy include increased thickness Intratendinous fluid collections suggest tears (Figure 5). In par-
(>6 mm) in the anteroposterior diameter with loss of the normal atenonopathy, there will be a rim of increased signal intensity on
flat or slightly concave anterior border, hypoechogenicity, neo- T2 and STIR sequences around the tendon. There may be
vascularity and may show fluid around the tendon in the acute oedema in Kager’s fat pad.
phase (Figure 4). As the disease progresses there will be sepa- There are a number of non-surgical and minimally invasive
ration of the tendon fibres with the appearance of hypoechoic or treatment options available for Achilles tendinopathy including
anechoic spaces which may progress into partial or complete extracorporeal shock wave therapy (ESWT), low-intensity pulse
tears. Intratendinous calcifications and cortical irregularity at the ultrasound, minimally invasive stripping, ultrasound-guided
calcaneal attachment can sometimes be seen. If there is tender- percutaneous tenotomy and injection of corticosteroids, autolo-
ness during the examination, but the Achilles tendon appears gous blood or platelet-rich plasma.8
sonographically normal, paratenonopathy should be considered.
Features of paratenonopathy include a hypoechoic U-shaped Sinus tarsi syndrome
thickening on the dorsal aspect of the tendon with a similar
Sinus tarsi is a cone-like space forming a tunnel between the
configuration in hypervascularity, hyperechogenicity of the pre-
sulcus tali and sulcus calcanei that opens laterally below the
Achilles fat pad (‘Kager fat pad’) and rarely fluid in the para-
tenon. In chronic disease, adhesions may develop limiting the
movement of the tendon. This can be assessed on dynamic ul-
trasound scanning.
MRI is excellent in demonstrating anatomy and is very sen-
sitive to pathological changes. In tendinopathy, MRI will again
demonstrate thickening of the tendon, which may be diffuse,
fusiform or nodular and depict signal changes within the tendon
that are low on T1- and high on T2- and STIR-weighted images.

Figure 4 Sagittal ultrasound image demonstrating insertional Achilles

tendinopathy with thickening (solid arrows), hyperaemia (dotted ar- Figure 5 Sagittal STIR MRI image demonstrating focal thickening of
rows) and fluid in the retrocalcaneal bursa (block arrow). the Achilles tendon and high intratendinous signal intensity.

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 ORTHOPAEDICS - IV: LOWER LIMB
Figure 6 Sagittal T1 and STIR MRI images demonstrating Haglund’s deformity with Achilles tendinopathy (dotted arrow), retrocalcaneal bursitis
(block arrow) and prominent posterosuperior calcaneal tubercle (solid arrow).
lateral malleolus. Medially, it continues as the tarsal canal which
terminates posterior to the sustentaculum tali. It contains adipose
tissue, mechanoreceptors, free nerve endings, vessels and liga-
ments that are responsible for the stability of the hindfoot. These
ligaments from medial to lateral are the interosseous talocalca-
neal ligament, which is the strongest, the cervical ligament and
laterally are slips from the lateral extensor mechanism. The
contents of the sinus tarsi are thought to play a role in proprio-
ception of the ankle.
Sinus tarsi syndrome is thought to occur following trauma
resulting in strain or injury to the interosseous and cervical lig-
aments. In 30% of cases, it is due to other miscellaneous causes
like ganglion cysts, gout and pigmented villonodular synovitis
(PVNS). Patients present following trauma with persistent lateral
foot pain and instability.
On MRI, there will be replacement of the normal sinus tarsi fat
by fluid and inflammatory tissue demonstrating low signal in-
tensity on T1 and high signal intensity on T2/STIR sequences
(Figure 7). Fibrosis will be low on T1/PD and T2/STIR se-
quences. The cervical and interosseous ligaments may not al-
ways be seen on MRI with a sensitivity and specificity of 73%
Figure 7 STIR MRI image showing fluid within the sinus tarsi fat
(arrows).
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and 89% respectively for the cervical ligament, and 44% and
60% for the interosseous ligament.9
Tarsal coalition
Tarsal coalition is an abnormal union between two or more tarsal
bones. It occurs in around 5% of the population. It is more common
in males (M: F 4:1). Coalition can be complete or incomplete and
may be osseous (synostosis), cartilaginous (synchondrosis) or
fibrous (syndesmosis). The majority of tarsal coalition cases are
congenital and present during the second and third decades of life.
Patients may be asymptomatic, especially early in life when
the coalition is fibrous or cartilaginous. Symptoms usually start
to manifest once ossification occurs, when patients may present
with pain, tenderness, reduced mobility of the subtalar joint, pes
planus and peroneal tendon spasm and shortening.
Types of talar coalition
Calcaneonavicular is the most common type. This type can be
diagnosed on the oblique plain foot radiographs (Figure 8) with a
sensitivity of 100% and specificity of 97% if the following
pointers are used:
 Close proximity of the calcaneus to the navicular.
 Flattening and widening of the calcaneus as it approaches
the navicular.
 Eburnation or sclerosis of the cortical surfaces.
 ‘Anteater nose’ sign e elongation of the anterosuperior
portion of the calcaneus.
 Hypoplasia of the talar head.
 ‘Talar beak’ sign e flaring of the superior margin of the
talar head. This can also be seen in talocalcaneal (subtalar)
coalition. However, this is not specific and can be seen in
other conditions such as DISH (Diffuse Idiopathic Skeletal
Hyperostosis), rheumatoid arthritis and in athletes.
CT and MRI may be used for surgical planning.
Talocalcaneal(subtalar) is more common in boys and maybe
bilateral in 20e25% of cases. The articulation between the
calcaneus and talus is through three facets: anterior, middle
and posterior (subtalar joint). This type of coalition most
commonly involves the middle facet between the talus and
sustentaculum tali.
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 ORTHOPAEDICS - IV: LOWER LIMB
Figure 8 Plain DP foot radiograph demonstrating calcaneonavicular
coalition (arrows).
This type of coalition is difficult to diagnose on plain radio-
graphs due to the complex anatomy of the subtalar joint. How-
ever, several signs have been described:
 Talar beak e flaring of the superior margin of the talar
head on lateral radiographs. This can also be seen in cal-
caneonavicular coalition.
 Narrowing of the posterior subtalar joint.
Figure 9 (a) Coronal and (b) sagittal T1 MRI images demonstrating fibrous subtalar coalition (solid arrows). Also note the dorsal talar beak (dotted
arrow).
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 Classic or continuous C sign of Lateur e continuous
cortical contour extending from the medial aspect of the
talus to the sustentaculum tali seen on the lateral
radiograph.
 Absent middle facet sign e bony density crossing the
subtalar middle facet seen on the standing lateral
radiograph.
CT and MRI are the modalities of choice in the diagnosis,
surgical planning and postoperative follow up of patients with
talocalcaneal coalition. CT will show the complex anatomy and
demonstrate bony coalition. Non-osseous coalition is better
assessed on MRI (Figure 9). Ancillary signs to suggest coalition if
the no-osseous bar was not visualised include narrowing of the
subtalar middle facet joint space, which will be oblique rather
than the normal straight orientation and will have an irregular
contour. There may be marrow oedema related to the coalition.
Other uncommon forms of tarsal coalition are seen between
the talus and navicular bones (talonavicular) which can be
congenital or acquired following avascular necrosis of the
naviculum.10 Rarer forms include coalitions between the cuboid
and navicular, navicular and cuneiforms, calcaneus and cuboid
and between multiple bones.
Morton’s neuroma
Morton’s neuroma is a common cause of forefoot pain. It is a non-
neoplastic lesion and not a true neuroma. The exact cause is not
known; however, it is thought that is most likely due to entrap-
ment neuropathy by the distal extent of the transverse inter-
metatarsal ligament resulting in perineural fibrosis and neural
hypertrophy of the interdigital nerve. It is more commonly seen in
females in their fifth and sixth decades. It most frequently affects
the 2/3 interspace, followed by 3/4 interspace. It can be asymp-
tomatic, particularly if less than 5 mm in transverse diameter.
Larger lesions are more likely to be symptomatic, presenting with
focal sharp or dull forefoot pain that may radiate to the toes or the
legs that is aggravated by weight-bearing or footwear.
Imaging
Ultrasound has high sensitivity and specificity in the diagnosis of
Morton’s neuroma. Several sonographic study results have dis-
closed a prospective sensitivity of 95e98% for Morton neuromas
and a retrospective sensitivity of up to 100% whereas MRI has a
sensitivity of 87%.11,12
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 ORTHOPAEDICS - IV: LOWER LIMB

inserts firmly to the bases of the proximal phalanges and serves

Figure 10 Axial ultrasound image demonstrating a rounded hypoe-
choic lesion consistent with a Morton’s neuroma (solid arrows). This is
seen to protrude between the metatarsal heads (dotted arrows).
On ultrasound, the lesion appears as a rounded or oval
hypoechoic lesion. There is no increased vascularity. It is slightly
compressible, which can be helpful in differentiating it from an
intermetatarsal bursa, which is highly compressible (Figure 10).
Sometimes it is difficult to differentiate between the two and
hence the term ‘Morton’s neuroma and intermetatarsal bursa
complex’ is used.
On MRI, the lesion is best assessed on the axial plane and is
isointense to muscle on T1- and hypointense to fat on T2-
weighted images. It may show variable enhancement post-
contrast.
Ultrasound-guided corticosteroid and alcohol injections have
been used. Greenfield et al. reported total symptomatic relief
after repeated injections of corticosteroids and local anaesthetic
in 30% of his sample and partial response in 50%.13 Hughes
et al. reported partial or symptom improvement following
ultrasound-guided alcohol injection in 94% of the patients, with
84% becoming totally pain-free.14
as an important distal attachment of the plantar fascia. It is
anchored to the distal metaphyseal region of the metatarsals by
the collateral ligaments, and each plantar plate apparatus is
coupled together by the deep transverse metatarsal ligament.
There is a fibrous tunnel at the central plantar surface of the
plantar plate, through which the tendons of flexor digitorum
longus and brevis pass. The plantar plate is in direct contact with
the metatarsal heads during gait and functions as the primary
static stabilizer of the MTP joints and prevents hyperextension.
It may be injured due to wearing high heel shoes, hypermo-
bility or trauma resulting in hyperextension. When it occurs at
the 1st metatarsal is then termed ‘turf toe’ or ‘sand toe’, while the
term plantar plate tear is usually reserved for disruption of
second to fifth digits. The second MTP joint is most commonly
involved.
Imaging
Plain radiographs may demonstrate osteoarthritis of the MTP
joint or toe malalignment but are insensitive.
The main imaging modalities used in assessing the plantar
plate are ultrasound and MRI.
Ultrasound demonstrates the normal plantar plate as a ho-
mogenous hyperechoic band overlying the metatarsal head.
Sonographic signs of plantar plate injury include disruption of
the plantar plate, change in its normal echogenicity becoming
discontinuous or heterogeneously hypoechoic when torn. There
may be a small amount of surrounding fluid and associated
tenosynovitis of the flexor tendon.

Plantar plate injury

The plantar plate is a fibrocartilaginous, intracapsular structure
equivalent to the volar plate in the metacarpophalangeal joints. It

Figure 11 Sagittal MRI STIR demonstrating discontinuity of the plantar Figure 12 Plain DP radiograph demonstrating a normal bipartite
plate of the second MTPJ. medial sesamoid.

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 ORTHOPAEDICS - IV: LOWER LIMB

Figure 13 (a) Coronal STIR and (b) T1 MRI images demonstrating medial sesamoiditis with high signal STIR and low signal T1 marrow change in
the medial sesamoid (arrows).

On MRI the plantar plate is best visualized on the sagittal REFERENCES

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The intact plantar plate is low signal on all pulse sequences
and is uniform in morphology. MRI has a sensitivity, specificity,
and accuracy of 74%, 100% and 88 %, respectively, for plantar
plate injury when compared with surgical findings.15,16
The increased intrasubstance signal in the distal plantar plate
without discontinuity may indicate degeneration of the plantar
plate but without disruption. Partial tears are seen as thinning or
partial discontinuity of the plantar plate. Full-thickness tears are
seen as complete discontinuity and retraction of the plate
(Figure 11).
Sesamoiditis
The hallux has two sesamoids, medial and lateral, which are
embedded in the medial and lateral slips of the flexor hallucis
brevis tendon. The medial sesamoid is most commonly bipartite
and is the one usually affected by pathology (Figure 12). The
sesamoid bones are connected to each other by the intersesamoid
ligaments and to the base of the proximal phalanx by the
sesamoid-phalangeal ligament. The flexor hallucis longus tendon
passes between the two sesamoid bones contacting the plantar
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pully to transfer the force of the flexor hallucis brevis to the base
of the proximal phalanx.
The sesamoids can be affected by a variety of pathological
conditions like trauma, degeneration, inflammation, infection,
and ischaemia. These conditions can result in chronic pain which
is termed as ‘sesamoiditis’. Risk factors include repetitive and
excessive axial loading in plantar flexion as in ballet dancing,
running and wearing high-heels.
Imaging
Plain radiographs may show sclerosis and fragmentation sug-
gesting osteonecrosis and are useful in looking at fractures.
Ultrasound may show fragmentation and in some cases
associated tendinopathy of flexor hallucis longus.
MRI will show normal or low signal on T1 and high signal on
T2 weighted images (Figure 13). The differential diagnosis for
these MRI features includes stress injuries, however sesamoiditis
is more likely if the T1 signal is normal, both sesamoids are
affected, and there is associated soft tissue injury. Changes in the
metatarsal heads point towards osteoarthritis.
Ultrasound-guided steroid injection may be offered to reduce
pain.
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A

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SURGERY xxx:xxx 8 Ó 2019 Published by Elsevier Ltd.

Please cite this article as: Al-Qassab S, Davies A, Imaging of the foot and ankle, Surgery, https://doi.org/10.1016/j.mpsur.2019.12.003