104

Ankle and Foot Injuries in the Young Athlete

Nancy A. Chauvin, MD1,3 Camilo Jaimes, MD2 Asef Khwaja, MD1,3

1 Department of Radiology, The Children’s Hospital of Philadelphia,
Philadelphia, Pennsylvania
2 Division of Pediatric Radiology, Massachusetts General Hospital,
Harvard Medical School, Boston, Massachusetts
3 Department of Radiology, Perelman School of Medicine at the
University of Pennsylvania, Philadelphia, Pennsylvania
Address for correspondence Nancy A. Chauvin, MD, Department of
Radiology, The Children’s Hospital of Philadelphia, 34th Street and
Civic Center Boulevard, Philadelphia, PA 19104-4399
(e-mail: chauvinn@email.chop.edu).

Semin Musculoskelet Radiol 2018;22:104–117.

Abstract Injuries to the ankle and foot are common in the young athlete, especially with
increasing participation and high levels of competitiveness in youth sports programs.
Knowledge of the normal development of the foot and ankle is crucial to understand
age-specific injury patterns because acute or chronic/repetitive stress to the develop-

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Keywords ing skeleton results in injuries that differ from those seen in adults. Congenital
► ankle injuries abnormalities may also predispose children to increased risk of injury and pain.
► foot trauma Radiologists must be aware of these distinctions to diagnose and classify injuries
► children correctly for optimum treatment. We describe common and unique foot and ankle
► pediatric athlete injuries in the young athlete. Throughout the article we focus not only on imaging
► sports injuries findings but also on the mechanism of injury.

Children are becoming more involved in sports at earlier ages
with higher levels of competitiveness. This has given rise to an
increasing number and complexity of sports-related injuries.1
Foot and ankle injuries are common in the young athlete and
account for  30% of visits to sports medicine clinics.2 During
periods of active growth, alterations in flexibility and strength
contribute to the risk of injury. Acute trauma and overuse
injuries are two common mechanisms of foot and ankle dis-
orders in active children. In addition, injury can arise from
congenital problems that are aggravated by physical activity.
Ankle and foot injuries include a wide range of ligament,
tendon, muscle, cartilaginous, and osseous conditions. When
interpreting images, it is important to consider the anatomical
differences that exist between the growing and the mature
athlete. In children, the weakest portion of the musculoskeletal
system is the physis. Physeal cartilage is prone to injury and
most vulnerable during periods of active growth, such as
during early adolescence. Because the physis is weaker than
both bone and ligaments, physeal-epiphyseal disruptions and
metaphyseal fractures are far more common than ligament
and tendon injuries.3 In addition, immature bone consists of
porous Haversian canals that makes it vulnerable to compres-
sive and increased tensile forces, predisposing them to buck-
ling and stress fractures.4
Overuse sports injuries are related to constant repetitive
stress applied to normal tissue without allowing for adequate
recovery/repair time. In the young athlete, overuse injuries
present at tendinous insertions, the articular cartilage, and the
growing bone.5
Overuse athletic injuries tend to occur in athletes who
increase their physical activity level quickly without adequate
training, in children who lack adequate mechanical sport-
specific skills, and in elite athletes who do not provide their
bodies with appropriate rest from activity. In many cases, ankle
injuries are not as trivial as they might seem and can ultimately
lead to disabling conditions that reduce the patient’s activity
and lower quality of life. A thorough understanding of the
development of the foot and ankle, along with the knowledge of
common sports-specific mechanisms of injury, is crucial in the
radiologic evaluation of the pediatric athlete.
Normal Development of the Foot and Ankle
Knowledge of normal developmental anatomy of the foot and
ankle is important in the radiologic evaluation of pain. Ossi-
fication of the metatarsals begins in the second through fourth
fetal month, ossification of the talus and calcaneus begins in
the third fetal month, and the cuboid occurs in the sixth fetal

Issue Theme Pediatric Musculoskeletal Copyright © 2018 by Thieme Medical DOI https://doi.org/
Imaging; Guest Editors, Ramesh S. Iyer, Publishers, Inc., 333 Seventh Avenue, 10.1055/s-0037-1609012.
MD and Matthew Cody O’Dell, MD, MPH New York, NY 10001, USA. ISSN 1089-7860.
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 Ankle and Foot Injuries in the Young Athlete
month. The cuneiforms begin to ossify in the first postnatal
year, and the navicular ossifies at 2 to 4 years of age and may
have multiple ossification centers. Ossification of the hind- and
midfoot bones begins and proceeds eccentrically in a predict-
able pattern. Secondary ossification centers of the metatarsals
and phalanges ossify at 6 to 24 months of age and the calcaneal
apophysis at 5 to 12 years of age.6
Primary tibial and fibular ossification is present at birth.6
The distal tibial epiphyseal ossification centers appear be-
tween 3 and 10 months of age and the distal fibular center by
9 to 22 months of age.7 The medial and lateral ossification
centers appear later within the cartilaginous anlage. By
2 years of age, the distal tibial physis is normally undulating
with a focal anteromedial upward deviation referred to as
Kump’s bump. Distal tibial physeal closure is completed in
girls between the ages of 12 and 15 years and boys between
15 and 18 years.7 The distal tibial physis provides 40% of the
growth of the tibia and 17% of the lower extremity growth,
with  3 to 4 mm of growth per year during childhood. An
injury to the distal tibial physis at a young age may result in a
significant leg length discrepancy.8
On magnetic resonance imaging (MRI), fatty marrow con-
version begins  6 months after the radiologic appearance of
the ossification center.9 Discrete foci of high signal intensity
(SI) on fluid-sensitive sequences may be seen in the endosteal
aspect of bones in the ankles and feet of healthy children
(►Fig. 1). These residual foci of hematopoietic marrow are
symmetrical and do not involve the soft tissues, thus allowing
them to be differentiated from a true stress injury.10
Congenital Abnormalities
Congenital abnormalities may not pose a problem in children
who are inactive but may become painful once participating
Fig. 1 Normal marrow in an 11-year-old girl. Sagittal fluid-sensitive
image of the hindfoot demonstrates ill-defined foci of increased signal
scattered within the hind- and midfoot bones that are thought to
represent islands of hematopoietic marrow. There is no confluent
abnormal marrow signal.
Chauvin et al. 105
in strenuous sports.11 Such anomalies include tarsal coali-
tions, accessory ossicles, and accessory muscles.
Tarsal Coalitions
Tarsal coalitions are abnormal cartilaginous, bony, or fibrous
bridges between tarsal bones. The prevalence of tarsal coali-
tions has been estimated at  1% of the population.12 One
series reported a prevalence approaching 13% and attributed
the substantial underdiagnosis to the absence of symptoms
in most individuals.13 Symptomatic tarsal coalitions more
commonly present during the first and second decades as
individuals become more active and involved in sports
activities. Common presentations include foot pain, valgus
deformity, stiffness, repeated ankle sprains, and sprains with
persistent symptoms.14
The most common types of coalitions are talocalcaneal
and calcaneonavicular. Tarsal coalitions are bilateral in 50%
of cases.13,15 In patients with unilateral tarsal coalitions, a
larger sustentaculum tali and hypoplastic middle facet are
often identified in the contralateral foot.16 Symptoms arise
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from the loss of flexibility of the tarsus as the coalition
ossifies. Talocalcaneal coalitions ossify between 12 and
16 years of age and calcaneonavicular coalitions between 8
and 12 years.14,17
Conventional radiographs including frontal, lateral, and
45-degree oblique weightbearing projections are usually the
first diagnostic images obtained.14 The aberrant bony union
of a coalition may not be apparent due to bony overlap with
other tarsal bones or to the cartilaginous or fibrous nature of
the coalition. However, indirect signs are usually present and
aid in the diagnosis. So-called talar beaking, for instance,
results from an increase in the mobility of the talonavicular
joint in an attempt to compensate for a decrease in the range
of motion.18 Talar beaking can occur in talocalcaneal or
calcaneonavicular coalitions. Indirect signs suggestive of
calcaneonavicular coalitions include the anteater sign (elon-
gated anterior calcaneal process), reverse anteater sign
(elongated lateral navicular approaching the calcaneus),
decreased calcaneonavicular gap, irregular and sclerotic
cortices, and hypoplasia of the lateral talar head (►Fig. 2).19
For the evaluation of talocalcaneal coalitions, additional
axial or “ski-jump” views are helpful additions.19 Oblitera-
tion of the joint or the presence of irregular cortices in the
sustentaculum tali indicates the presence of a coalition. The
presence of smooth density joining the inferomedial border
of the talus and the sustentaculum tali on conventional
radiographs is known as the continuous C-sign that is highly
sensitive and specific for the diagnosis of talocalcaneal
coalitions.20 Indirect signs of talocalcaneal coalitions include
a short talar neck, narrow posterior facet of the subtalar joint,
and absence of the middle facet.21,22
Computed tomography (CT) and MRI are the most reliable
methods for the evaluation of tarsal coalitions.21 Besides
identification of the coalition, these advanced methods
provide information such as the exact location and size of
the coalition, which are useful to guide surgical proce-
dures.23 CT depicts osseous coalitions in exquisite detail
and also may demonstrate some indirect findings such as
Seminars in Musculoskeletal Radiology Vol. 22 No. 1/2018
106 Ankle and Foot Injuries in the Young Athlete
Fig. 2 Calcaneonavicular coalition in a 13-year-old boy with foot pain. (a) Sagittal and (b) axial fluid-sensitive images of the ankle demonstrate an
elongated and broad appearance of the anterior process of the calcaneus (arrow) with irregular articulation with the navicular (arrowheads) with
adjacent marrow and soft tissue edema.
sclerosis, joint space narrowing, and abnormal configuration
of the affected bones.23 In addition, MRI demonstrates
edema in the affected bones and may be superior to CT in
cases of cartilaginous or fibrous coalitions. Other signs of
altered biomechanics such as peroneal and flexor tendino-
pathy can also be identified.15
Accessory Ossicles
Accessory ossicles are separate ossification centers that are
located extrachondrally, exist at the ends of certain bones,
and tend to fuse  1 year after ossification. When they do not
fuse, the ossicles may become symptomatic. The most com-
mon sites are at the posterior talus “os trigonum” (discussed
later in this article), the navicular known as an “accessory
navicular” or “os navicularis,” and the medial malleolus.5,24
Os Navicularis
An os navicularis is an accessory ossicle at the posterior
tibialis tendon insertion, along the medial aspect of the tarsal
navicular. The overall prevalence is 2 to 12% of children, and
approximately half of these eventually fuse to the navicular.8
The os navicularis can be associated with a flat foot deformity
because the accessory ossicle can displace the tendon and
allow the foot to deviate into a valgus position.9 Athletes
present with chronic medial foot pain due to chronic stress
within the os navicularis. Radiographs demonstrate a well-
ossified ossicle along the proximal medial border of the
navicular. On fluid-sensitive MRI, there will be edema in
the accessory ossicle extending across the fibrocartilaginous
layer into the adjacent tarsal bone (►Fig. 3).25 Careful
inspection should be made to assess for injury of the poster-
Seminars in Musculoskeletal Radiology Vol. 22 No. 1/2018
Chauvin et al.
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ior tibial tendon because fibers typically insert on both the
ossicle and the navicular bone.8
Medial Malleolar Ossicle
The medial malleolus ossification center typically appears at
1 to 2 years of age and is present in all children. The center
typically fuses by 12 years of age but occasionally can persist
into adulthood. A nonunited medial malleolar ossification
center can become painful in very active adolescents due to
repeated medial ankle stress, causing a traction apophysi-
tis.26 Radiographs demonstrate an irregular medial malleo-
lar ossification center with an associated ossicle. On fluid-
sensitive MRI, there will be edema in and around the ossicle
(►Fig. 4). Treatment generally includes rest with at least 3 to
6 weeks of short leg cast immobilization. If there is no
improvement, surgical removal of the ossicle should be
considered.5,9
Accessory Muscles
Several anomalous muscles around the ankle have been
described and are relatively common in the general popula-
tion. Most of these anomalous muscles are asymptomatic;
however, they can cause recalcitrant pain after an ankle
sprain in athletes due to their high level of activity. The
symptoms arise from direct soft tissue impingement from
the anomalous muscle bellies.27
Accessory Soleus Muscle
The accessory soleus muscle is the most common accessory
muscle in the ankle and the most common soft tissue mass
seen within Kager’s fat pad (►Fig. 5).28 It is thought to arise
 Ankle and Foot Injuries in the Young Athlete Chauvin et al. 107

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Fig. 3 Symptomatic os navicularis in a 10-year-old girl participating in karate with chronic medial foot pain. (a) Frontal radiograph of the foot
demonstrates a well-defined ossicle along the proximal medial border of the navicular (arrow) compatible with an os navicularis. (b) Sagittal
T1-weighted image of the medial aspect of the midfoot demonstrates mild decreased signal intensity within the distal aspect of the os
navicularis and the adjacent tarsal bone (arrows). (c) Footprint T2-weighted fat-suppressed image of the mid- and hindfoot demonstrates
abnormal increased signal at the os navicular and adjacent navicular (arrow) compatible with stress-related changes.

during early embryology when the single anlage of the soleus

muscle undergoes early splitting, resulting in an accessory
muscle.29 Patients may present with pain or a mass within
the posteromedial ankle. The accessory soleus muscle may
cause compression neuropathy of the posterior tibial nerve
and its branches against the tibia or calcaneus.28 On MRI, the
accessory soleus muscle courses anteriorly relative to the
Achilles tendon and is isointense relative to the surrounding
muscles (►Fig. 5).
Osseous Abnormalities
Osteochondral injuries and osteochondroses of the foot and
ankle are discussed elsewhere in this issue.
Fractures
Stress Fractures
Repetitive activities that outpace the capacity of the bone to
repair itself lead to stress fractures.30 In skeletally immature
athletes, the rapid increase in muscle strength, presence of
narrower bones with thinner cortices, low mineral density, and
hormonal factors increase the susceptibility to stress frac-
tures.31,32 The most common site for stress fractures in young
athletes is the tibia, followed by the metatarsal and tarsal bones.
These overuse injuries tend to occur in association with endur-
ance sports or with activities requiring sudden stops or changes
in direction.33 Stress fractures that involve the metatarsal bones
are common in runners, ballet dancers, and gymnasts.34

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108 Ankle and Foot Injuries in the Young Athlete Chauvin et al.

Fig. 4 Symptomatic medial malleolar ossicle in an 8-year-old female soccer player with medial ankle pain and no known injury. (a) Frontal
radiograph of the ankle shows a well-corticated ossicle at the medial malleolus (arrow) without significant soft tissue edema. (b) Coronal and
(c) axial fluid-sensitive MR images demonstrate edema within the ossicle as well as within the adjacent tibial plateau (arrows).

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Fig. 5 Accessory soleus muscle in an 11-year-old boy with pain and mass within the posterior aspect of the ankle after basketball camp.
(a) Lateral radiograph demonstrates partial obliteration of Kager’s fat pad by a well-defined area of soft tissue opacity (arrows). (b) Axial and
(c) coronal T1-weighted MR images show an accessory muscle (arrows) within Kager’s fat pad that demonstrated a fleshy insertion into the
medial aspect of the calcaneus.

Conventional radiographs are relatively insensitive in the Metatarsal Fractures

acute setting and demonstrate findings suggestive of a stress
fracture in only 15% of patients.30 In the subacute setting,
however, conventional radiographs may be positive and de-
monstrate signs of healing such as periosteal reaction, cortical
thickening, and sclerosis. Imaging findings may be very subtle.
For instance, mild cortical thickening in a metatarsal or a subtle
band of sclerosis in a tarsal bone may be the only radiographic
evidence of injury.35 Scintigraphy is more sensitive for the
diagnosis of stress fractures but has very low specificity.36 On
MRI, stress fractures have a discrete fracture band of low SI
contiguous with the cortex on both T1-weighted and fluid-
sensitive imaging surrounded by low SI on T1-weighted
images and high SI on fluid-sensitive sequences with generally
a small amount of adjacent soft tissue edema37,38 (►Fig. 6). If
amorphous edema is present without a discrete fracture,
findings suggest a stress response in the appropriate clinical
setting.39
The fifth metatarsal is the most commonly fractured meta-
tarsal in children, representing 45% of all pediatric metatarsal
fractures. Approximately 90% of fifth metatarsal fractures
occur in children < 10 years of age.25 Fractures occur due to
an inversion-type injury and are thought to be due to either
stress from the peroneus brevis tendon avulsing the base of the
fifth metatarsal or stress of the tendinous portion of the
abductor digiti minimi and the lateral cord of the aponeuro-
sis.5,40 Radiographs demonstrate a fracture that is transverse
along the bone and usually intra-articular, as opposed to the
apophysis that lies parallel to the base (►Fig. 7). Treatment is
usually conservative unless there is > 2 to 3 mm of displace-
ment, in which case open reduction and internal fixation is
typically performed.5 Fractures of the fifth metatarsal occur-
ring at the proximal diaphysis are known as a “Jones fracture”
and typically occur in older athletes with the average between
15 and 21 years (►Fig. 8). These fractures have a higher rate of

Seminars in Musculoskeletal Radiology Vol. 22 No. 1/2018

 Ankle and Foot Injuries in the Young Athlete
Fig. 6 Metatarsal stress fracture in a 15-year-old boy who participates
in marching band presented with pain while walking. Radiographs
were normal (not shown). Footprint T2-weighted MR image of the
foot shows abnormal hyperintense marrow signal throughout
the second metatarsal (arrow) with linear hypointense line at the base
(dashed arrow) consistent with a stress fracture.
nonunion because of the poor blood supply to the region. A
non-weightbearing cast is used for 6 to 8 weeks, and patients
with nonhealing fractures undergo screw fixation.5,9,25
Lateral Process of the Talus Fracture
Fractures of the lateral process of the talus are uncommon
fractures but are important to describe because they are often
misdiagnosed as lateral ankle sprains. The superolateral sur-
face of the lateral process of the talus articulates with the lateral
malleolus, and the inferolateral surface is part of the posterior
facet of the talocalcaneal joint. The lateral talocalcaneal liga-
ment and the anterior talofibular ligament attach to the lateral
process of the talus.41 The fracture is classically described as
occurring in dorsiflexion and inversion of the ankle combined
with axial loading and is unique to snowboarders, dubbed the
“snowboarder’s talus fracture.”42 Shear forces transmitted
from the calcaneus to the lateral process of the talus can result
in fracture fragments of variable sizes. Small fractures require
only symptomatic treatment; larger fractures require casting
(►Fig. 9). Significant displaced fractures undergo open reduc-
tion and internal fixation. CT imaging is often needed to
determine the degree of fracture displacement.43
Transitional Fractures
Distal tibial physeal fractures are the second most common
growth plate injuries in children.44 They are twice as common
Chauvin et al. 109
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Fig. 7 Base of the fifth metatarsal avulsion fracture in a 13-year-old
boy with lateral foot pain who twisted his ankle playing dodgeball.
Oblique radiograph of the foot shows a transverse intra-articular
fracture at the base of the fifth metatarsal (arrow). Of note, the
adjacent apophysis lies parallel to the base of the metatarsal.
in boys, and the peak incidence is at 8 to 15 years of age.45
Distal tibial fractures occur during sports requiring pivoting
movements and rapid changes in direction. The Salter-Harris
(SH) classification is the most common method to describe the
fracture. The Dias-Tachdjian classification denotes the me-
chanism of injury, especially the position of the foot during the
trauma and the direction of the force.46 Intra-articular frac-
tures involve SH type III and IV fractures as well as transitional
fractures. Transitional fractures, the triplane, and the Tillaux
fractures are only seen in adolescents in a period of 
18 months (generally between the ages of 10 and 16 years)
when the physis closes in an asymmetric pattern.45,47 Distal
tibial physeal closure begins centrally and then proceeds in an
anteromedial direction, then posteromedial, and finally later-
ally. This pattern of closure predicts the specific tibial physeal
patterns seen in adolescent ankle injuries.8
Triplane Fractures
Triplane fractures behave like a SH IV fracture and have
sagittal, transverse, and coronal components traversing the
physis. The average age at injury is 13 years in girls and 15 years
in boys. Most fractures are due to supination and external
rotation. Eight triplane fracture configurations have been
described including variants.48 The number of fracture com-
ponents depends on the degree of distal tibial physeal closure.
On radiographs, the anteroposterior (AP) radiograph shows a
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110 Ankle and Foot Injuries in the Young Athlete Chauvin et al.

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Fig. 8 Jones fracture in a 17-year-old skeletally mature female cheerleader who presented with lateral foot pain after a twisting injury. (a) Frontal
radiograph demonstrates a transverse fracture at the proximal metatarsal shaft (arrow). She was closely followed and after 2 months had no
significant healing and underwent open reduction and screw fixation for her nonunion fracture. (b) Oblique radiograph of the foot obtained
2 months after surgery shows a healed fracture with intact hardware.

SH III fracture of the distal tibia, and the lateral radiograph
demonstrates a SH II fracture (►Fig. 10). Brown et al48 re-
viewed the CTs of 51 patients with triplane fractures and found
that the classic two-fragment type with medial epiphyseal
extension occurred most frequently. Often CT is performed to
identify the number of fracture fragments as well as the degree
of displacement.47 On CT, if there is > 2 mm of displacement
after attempted closed reduction, operative treatment is in-
dicated to avoid posttraumatic osteoarthritis or growth dis-
turbance.49,50 Of note, extra-articular triplane fractures do not
require anatomical reduction because they do not violate the
ankle joint.49
Tillaux Fractures
Juvenile Tillaux fractures are isolated fractures of the ante-
rolateral portion of the distal tibial epiphysis (SH III). This

Fig. 9 Lateral process of the talus fracture in a 16-year-old female dancer with inversion ankle injury after a jump. (a) Frontal radiograph of the
ankle shows significant ankle swelling with a small mildly displaced fracture of the lateral process of the talus (arrow). (b) Coronal T2-weighted
fat-suppressed MR image of the ankle demonstrates the fracture fragment (arrow) and significant soft tissue edema. (c) Axial T2-weighted
fat-suppressed MR image of the ankle shows abnormal signal and thickening of the anterior talofibular ligament (arrow) compatible with sprain.
The patient was casted for 6 weeks. (d) Coronal reformatted computed tomography image of the ankle obtained 4 months after in the injury
demonstrates interval healing of the fracture (arrow).

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 Ankle and Foot Injuries in the Young Athlete Chauvin et al. 111

Fig. 10 Triplane fracture in a 13-year-old girl who tripped during a basketball game. (a) Frontal and (b) posterior oblique three-dimensional computed
tomography reformatted images of the ankle demonstrate a triplane fracture with a sagittal component of the distal tibial epiphysis (solid black arrow),

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transverse component through the open distal tibial physis (dashed black arrow), and coronal component through the distal tibial metaphysis (solid white
arrow). After reduction, the maximum displacement was < 2 mm, and the child was treated conservatively with a cast.

fracture occurs in teenagers nearing skeletal maturity and Lisfranc Injuries

affects the only remaining open portion of the distal tibial
physis. Tillaux fractures are caused by an external rotation
force about the ankle.25 AP radiographs demonstrate a
vertical line within the distal tibial epiphysis with and
then extending laterally. The lateral radiograph shows the
avulsed fragment displaced anteriorly. For minimally dis-
placed fractures, the only abnormality may be a slight
widening of the lateral aspect of the distal tibial physis.25
As with triplane fractures, CT may be useful for further
characterization, and fractures displaced > 2 mm should be
treated operatively5,49 (►Fig. 11).
Injuries to the Lisfranc joint are rare in children. The
mechanism of injury in children is similar to adult injuries.
Fracture-dislocations involve high-impact trauma such as
motor vehicle crashes or falls from a significant height; low-
impact injuries result in ligamentous or minimally dis-
placed fractures.51 Incomplete ossification of the bones in
young athletes makes it difficult to assess for injuries on
radiographs. A retrospective study by Knijnenberg et al51
evaluated normal pediatric foot radiographs and deter-
mined that the distance between the base of the first
and second metatarsal was constant and < 3 mm. The

Fig. 11 Tillaux fracture in a 13-year-old female softball player who twisted her ankle sliding into third base. (a) Axial computed tomography (CT) image of
the distal tibia at the level of the distal tibial epiphysis shows a fracture of the anterolateral aspect of the distal tibial epiphysis (arrow) with  4 mm of
anterolateral displacement. (b) Three-dimensional CTreformatted image of the ankle demonstrates the fracture (solid arrow) with physiologic closure of the
central and medial aspect of the distal tibial physis (dashed arrow). A small ossific fragment is seen along the inferior aspect of the distal fibula from prior
trauma. The patient underwent open reduction and screw fixation of the fracture due to the degree of displacement.

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112 Ankle and Foot Injuries in the Young Athlete Chauvin et al.

distance between the medial cuneiform and the base of

the second metatarsal was larger before the age of 6 years,
but both measurements approached adult values by 6 years
of age. If there is clinical suspicion of a Lisfranc injury and
distances within the Lisfranc interval exceed these values
on radiographs, MRI should be performed.51

Apophysitis
Apophyses are bony attachment sites that develop as secondary
ossification centers and mimic the maturation of an epiphysis
while serving as the attachment site for a muscle-tendon unit.8
Recurrent microtrauma or overuse can produce an inflamma-
tory process, a traction apophysitis. A repetitively strained
muscle-tendon unit incites stress to the area of tendon attach-
ment, resulting in microfractures about Sharpey’s fibers (the
matrix of strong collagen fibers connecting periosteum to
bone). Severe overloading can result in a separation or slip at
the physis. Microfractures eventually produce low-grade in-
flammation that is part of the healing process, leading to focal
hyperemia, tenderness, and overgrowth.4

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Sever Disease
The calcaneal apophysis begins to ossify at  9 years of age
(range: 5–12 years) and fuses at 16 years of age.6,52 It serves
as the attachment site for the Achilles tendon superiorly and
the plantar fascia inferiorly. Calcaneal apophysitis, or Sever
disease, is the most common cause of heel pain in physically
active children, occurring most frequently between 9 and
11 years of age.53,54 Overuse is thought to be the most
common causative factor; however, poorly fitting shoes
and contractures of the Achilles tendon may also play a
role. The diagnosis of calcaneal apophysitis is usually made
with a typical history and clinical examination. The child
usually presents with heel pain when running and walking
and especially when participating in sports that require
jumping. Children often walk on their tiptoes to alleviate
the pain.54 On physical examination, the heel is very tender
to palpation, elicited clinically by the “heel squeeze test.” It is
commonly seen in association with a tight Achilles-plantar
fascia complex.1
Radiographs are typically not useful in the diagnosis
because the calcaneal apophysis is frequently fragmented
and sclerotic in normal children; however, conventional
imaging is usually performed to exclude other etiologies
that may cause heel pain such as a Brodie’s abscess, stress
fracture, osteoid osteoma, or tarsal coalition.4 When patients
do not respond to the usual treatment of nonsteroidal anti-
inflammatory drugs, physical therapy, and orthoses, MRI
may be useful to exclude more complex injuries. The MRI
appearance of Sever disease has not been well described. It
should be noted that increased fluid-sensitive signal can be
seen in the calcaneal apophysis in asymptomatic children.55
Calcaneal apophysitis typically demonstrates hypointense
T1 signal with corresponding hyperintense signal on fluid-
sensitive sequences within the calcaneal apophysis and the
adjacent posterior calcaneus along with edema in the ad-
jacent soft tissues and fluid at the Achilles tendon insertion
(►Fig. 12).55
Fig. 12 Sever disease in an 8-year-old boy who plays soccer presented
with chronic heel pain. On examination, he had tight heel cords.
Sagittal T2-weighted fat-suppressed image of the hindfoot demon-
strates a small amount of increased signal within the calcaneal
apophysis with a small amount of edema in the posterior calcaneal
body (arrow). There is a small amount of adjacent soft tissue edema
and a small amount of fluid at the Achilles insertion (dashed arrow).
Iselin Disease
Iselin disease is a traction apophysitis at the base of the fifth
metatarsal, the attachment site for the peroneus brevis
tendon. The apophysis usually begins to ossify between 10
and 13 years of age.4,8 Iselin disease occurs during periods of
rapid growth and is more common in children who partici-
pate in sports that require repetitive traction, although it
may also arise from a simple inversion injury. Patients
present with lateral foot pain with weightbearing and soft
tissue swelling at the base of the fifth metatarsal. Conven-
tional radiographs are often obtained in the setting of pain at
the base of the fifth metatarsal to exclude a fracture. MRI may
be obtained in clinically unclear cases and demonstrates
edema at the base of the fifth metatarsal and the apophysis
(►Fig. 13). Patients presenting with pain at the proximal fifth
metatarsal without radiographic evidence of fracture are
generally treated with a short period of immobilization with
follow-up radiographs in 2 weeks and additional immobili-
zation as needed.8
Ligament Injuries
In the skeletally immature athlete, serious ankle sprains are
uncommon because the ligaments are stronger than the
physeal cartilage and bone, predisposing children to osseous
injuries. Once the physes close, the incidence of ankle sprains
dramatically increases, accounting for 10 to 28% of all athletic
injuries in the skeletally mature population. Sprained ankles
occur most often in soccer, basketball, and handball.56 On MRI,

Seminars in Musculoskeletal Radiology Vol. 22 No. 1/2018

 Ankle and Foot Injuries in the Young Athlete
Fig. 13 Iselin disease in an 11-year-old girl who practices Irish step dancing with lateral foot pain for several weeks. (a) Oblique radiograph of the
foot demonstrates a normal appearance of the base of the fifth metatarsal apophysis (arrow). (b) Short axis T2-weighted fat-suppressed image
through the proximal forefoot demonstrates edema within the base of the fifth metatarsal (arrow) adjacent to the apophysis. Findings are
compatible with apophysitis.
the normal ankle ligaments are hypointense in signal but may
have longitudinal streaks of intermediate SI, particularly the
tibiotalar ligament (which forms the deep fibers of the deltoid
ligament) and the posterior talofibular ligament. Coronal
imaging provides the best depiction of the deltoid and calca-
neofibular ligaments. Axial images are best for demonstrating
the anterior and posterior talofibular ligaments.57 A 2015
prospective study demonstrated that in children with acute
inversion ankle injuries, MRI did not result in any additional
therapeutic value over the combination of clinical evaluation,
plain film radiography, and ultrasound.47
Lateral Ankle Sprain
Children with lateral ankle injuries and no radiographic ab-
normality are presumed to have a SH type I fracture of the
distal fibula and are managed with immobilization and ortho-
paedic follow-up. A prospective study by Boutis et al58 of 135
children demonstrated that only 3% of patients with normal
ankle radiographs after lateral ankle injury had a distal fibular
SH type I fracture, and most patients had ligamentous injuries
followed by bone contusions. Almost 30% of patients with
ligamentous injuries also had radiographically occult fibular
avulsion fractures. Thus lateral ankle injuries in the setting of
normal radiographs can be managed with bracing.
The lateral ankle stabilizers include the anterior talofib-
ular ligament (ATFL) and the calcaneofibular ligament (CFL)
and serve to prevent excessive lateral or varus translation of
the ankle. Once the distal fibular physis fuses, insults to the
ATFL and CFL complex are the most common lateral ankle
injuries in young athletes.5 Overall, 85% of all ankle sprains
occur laterally. The ATFL is the weakest of the lateral collat-
eral ligaments, and tears are frequently associated with
capsular rupture and extravasation of joint fluid into the
anterolateral soft tissues. The ATFL is usually injured when
the athlete inverts the foot in a plantar-flexed position.
Chauvin et al. 113
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Occasionally, an avulsed ATFL can be associated with a small
avulsion fracture of the fibular tip.59 When there is a con-
comitant CFL injury, there is widening of the lateral joint
space with medial tilting of the talus. On MRI, the ATFL is a
hypointense 2- to 3-mm linear band that is oriented ante-
romedially. The CFL is an extracapsular cord-like structure
that is  2 cm in length and 4 to 6 mm in diameter. The CFL is
the second most frequently injured ankle ligament with tears
frequently occurring within the midsubstance.60
Medial Ankle Sprain
The medial aspect of the ankle is stabilized by the deltoid and
syndesmotic ligaments that can be injured with eversion and
external rotation. Medial injuries are less common than
lateral sprains and have a higher incidence of associated
syndesmosis sprains. Medial ankle sprains are treated with
non-weightbearing casting for 2 to 3 weeks followed by
rehabilitation.9
Turf Toe
Turf toe is a plantar capsule ligament sprain or tear at the first
metatarsophalangeal (MTP) joint. Although the cause of turf
toe is still debated, early reports suggested increased injury
rates in athletes playing on artificial surfaces (turf). More
recent studies have theorized that injuries are thought to occur
due to the construction of lighter, more flexible turf shoes that
places increased traction at the forefoot.61 This type of injury is
most commonly seen in athletes who participate in cutting or
pivoting sports such as football and soccer and in basketball
players. The mechanism of injury is hyperextension that
occurs when an axial load is placed along a foot that is firmly
planted, leading to excessive dorsiflexion of the forefoot, with
or without additional varus or valgus stress.62 Turf toe is
associated with high morbidity, with  50% of athletes experi-
encing persistent symptoms 5 years after injury.63
Seminars in Musculoskeletal Radiology Vol. 22 No. 1/2018
114 Ankle and Foot Injuries in the Young Athlete Chauvin et al.
MRI is useful in the evaluation because the extent of injury
helps dictate return to play. The first MTP joint consists of three
articulations: the metatarsophalangeal and the two metatarso-
sesamoid articulations. Footprint imaging is useful in demon-
strating injuries to the flexor hallucis longus and brevis tendons,
and sagittal views aid the detection of capsular ligament injuries
(►Fig. 14). The severity of turf toe can be graded by the signal
and morphology of the ligament involved. Tears of the MTP joint
capsule usually occur at the metatarsal neck, which is weaker
than the proximal phalangeal attachment.
Impingement Syndromes
Soft tissue and osseous impingement syndromes of the ankle
are uncommon in the general population but can be a cause
of chronic pain in the young athlete. Impingement syn-
dromes arise from initial ankle injuries, which, in the sub-
acute or chronic situation, lead to development of abnormal
osseous and soft tissue changes within the ankle joint. This
gives rise to a physical impingement with painful, limited
movement of the ankle.64 The main impingement syndromes
are anterolateral, anterior, anteromedial, and posterior. Plain
radiography is the first step in the evaluation because it may
identify certain anatomical variants that may be associated
with impingement; however, MRI is the preferred method of
evaluation due to its high soft tissue contrast resolution.
Anterolateral Impingement
The anterolateral gutter of the ankle is the space bounded by
the anterior inferior tibiofibular ligament, the ATFL, and the
calcaneofibular ligament anteriorly. The lateral border is the
fibula; the medial border is the talus. This space extends from
the tibial plafond to the calcaneofibular ligament.65 Antero-
lateral ankle impingement arises from an inversion injury with
tearing of the ATFL or anterior inferior tibiofibular ligament,
the synovial tissue, or both. Without proper immobilization or
rehabilitation, scar tissue develops that can be entrapped
between the talus and the lateral malleolus, leading to in-
Fig. 14 Turf toe in a 17-year-old female soccer player who sustained
injury during kicking with diffuse medially foot pain. (a) Sagittal fluid-
sensitive fat-suppressed MR image of the forefoot through the medial
sesamoid demonstrates edema within the plantar plate in the region
of the medial sesamoid phalangeal ligament (arrow). The sesamoid is
mildly retracted, and there is edema and partial tearing within the
medial head of the flexor hallucis brevis muscle (arrowhead) with
adjacent flexor tendinopathy and soft tissue edema. There is also an
impaction fracture of the first metatarsal head (dashed arrow).
Seminars in Musculoskeletal Radiology Vol. 22 No. 1/2018
flammation in the ligament or synovium.66 Symptoms are
often aggravated by supinating or pronating the foot.
Anterolateral impingement remains a clinical diagnosis of
exclusion, confirmed at arthroscopy.64 The role of MRI is
controversial. Several authors have described the MRI features
of anterolateral impingement. On MRI, low T1-weighted SI and
low or intermediate SI on T2-weighted images can be seen
within the soft tissues of the lateral gutter. Evaluation is best
performed on axial images. Other abnormalities detected
include chondral defects, osseous spurs, and laxity or rupture
of the ATFL and/or calcaneofibular ligaments.64,65
Anterior Impingement
Anterior ankle impingement can be bony or soft tissue related.
Young athletes present with anterior ankle pain exacerbated by
extreme dorsiflexion.1 Dorsiflexion injuries are common in
many athletes, particularly in ballet dancers and soccer players.
The condition is characterized by anterior tibiotalar spurs that
form at focal areas of premature degeneration within the joint
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capsule. These spurs most commonly form at the margin of the
articular cartilage rim and become symptomatic in association
with anterior synovial thickening and scarring.64
Conventional radiographs demonstrating osseous spurs are
often diagnostic in the clinical setting of anterior ankle pain.
MRI aids in depiction of the positioning of the spurs within the
capsular margin with associated synovial thickening. Synovial
thickening usually has low SI on T1-weighted images and low
to intermediate signal intensity on T2-weighted images. An
anterior joint effusion may be present; however, bone marrow
edema within the spurs is uncommon.64
Anteromedial Impingement
Anteromedial ankle impingement is a relative rare condition
characterized by chronic anteromedial pain exacerbated with
dorsiflexion. The exact mechanism of injury is not well under-
stood but thought to arise from a supination injury with
perhaps a rotational component, leading to a tear in the
anteromedial aspect of the capsule.64 Continued repeated
microtrauma results in a synovitis with thickening of the
capsule. Over time, this can lead to osseous and cartilage
injury with development of anteromedial bone spurs.
Posterior Impingement
Posterior ankle impingement or “talar compression syndrome”
results from compression of the talus and the surrounding soft
tissues between the tibia and the calcaneus on plantar flexion of
the ankle. It may follow an acute injury such as 4 to 6 weeks after
a posterior talofibular ligament avulsion, fracture of the lateral
talar process, or acute disruption of the os trigonum synchon-
drosis.67 This results in regional inflammation and pain that is
aggravated by repetitive or forced plantar flexion of the foot.
Structures implicated in posterior ankle impingement include
an os trigonum, an enlarged lateral process of the talus (Stieda
process), enlarged posterior process of the calcaneus (Haglund
deformity), low-lying or accessory muscles, and loose bodies.
On clinical examination, a positive posterior impingement test
consists of reproduction of the symptoms with forced plantar
flexion of the ankle.27
 Ankle and Foot Injuries in the Young Athlete
Fig. 15 Os trigonum syndrome in an 11-year-old female softball catcher
with posterior ankle pain. Sagittal T2-weighted fat-suppressed image of the
hindfoot demonstrates marrow edema within the os trigonum (arrow) with
increased signal within the adjacent synchondrosis. There is adjacent fluid
within the posterior ankle joint with mild thickening of the capsule.
Os Trigonum Syndrome
A separate ossification center is often seen along the posterior
aspect of the talus that appears at 8 to 10 years in girls and 11 to
13 years in boys. Fusion usually occurs 1 year after its ossifica-
tion. If this forms a large lateral talar process, it is called a Stieda
process. Fusion does not occur in  10% of the general popula-
tion, and an os trigonum is formed.64 The ossicle can also result
from a fracture of the posterior talus that does not unite, a
Shepherd fracture.68 The os trigonum can become symptomatic
in young athletes who actively plantar flex their ankle, com-
pressing the posterior talus between the posterior tibia and
Fig. 16 Low-lying flexor hallucis longus muscle in a 17-year-old female dancer with posteromedial ankle pain and no known injury. (a) Sagittal
T1-weighted MR image at the level of the sustentaculum tali and (b) axial intermediate-weighted MR image at the level of the talar dome show a
low-lying belly of the flexor hallucis longus muscle (arrows) that extends below the level of the tibial plafond. The muscle belly can become
impinged within the posterior ankle during maximum plantar flexion.
Chauvin et al. 115
calcaneus, the so-called nutcracker phenomenon. Repetitive
impingement of the soft tissues in this interval can also result in
hypertrophic capsulitis.1 This condition presents as poster-
olateral ankle pain and can be seen in ballet dancers (en pointe),
gymnasts, ice skaters, and, less commonly, soccer players.1
A lateral radiograph of the ankle is useful to demonstrate
the anatomy of the posterior ankle joint and to evaluate for an
os trigonum, Stieda process, or a joint effusion. An MRI is useful
to determine whether this may be the source of the patient’s
symptoms. On MRI, there will be abnormal bone edema within
the os trigonum, as demonstrated by increased signal on fluid-
sensitive sequences. There may be linear fluid signal within the
synchondrosis that would indicate an os trigonum fracture
(►Fig. 15). In addition, the posterior capsule may be thickened
with intermediate to low SI on T2-weighted images.64 MRI is
also useful in depicting possible associated abnormalities
within the flexor hallucis longus tendon. In cases in which
the os trigonum synchondrosis is difficult to define, fluoro-
scopy-guided arthrography can be useful as well as guiding
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therapeutic intervention. Other therapies include rest, anti-
inflammatories, avoidance of plantar flexion, physical therapy,
and casting. In recalcitrant cases in the competitive young
athlete, resection of the os trigonum may be necessary.1
Similar posterior ankle impingement symptoms can be seen
with extreme plantar flexion in dancers with a low-lying
insertion of the flexor hallucis longus muscles fibers
(►Fig. 16) that can be a cause of tarsal tunnel syndrome.68
Haglund Syndrome
Haglund deformity refers to an enlarged posterosuperior
calcaneal tuberosity. This disorder, also known as “pump
bump,” is frequently associated with particular athletic foot-
wear such as ice skates and presents as posterior ankle pain.
Although it is usually associated with insertional Achilles
tendonitis and retrocalcaneal bursitis from repeated contrac-
tion of the gastrocnemius-soleus complex, termed Haglund
Seminars in Musculoskeletal Radiology Vol. 22 No. 1/2018
116 Ankle and Foot Injuries in the Young Athlete Chauvin et al.
Fig. 17 Haglund syndrome in a 19-year-old female ice skater with posterior ankle pain. (a) Sagittal fluid-sensitive MR image of the ankle
demonstrates mild marrow edema within the posterior superior calcaneal tuberosity (straight arrow) with associated mild retrocalcaneal
bursitis (curved arrow). (b) Sagittal T1-weighted image of the posterior calcaneus demonstrates osseous irregularity within the superior aspect
(black arrows) and thickening of the distal Achilles tendon (white arrow).
syndrome, it can be associated with posterior ankle impinge-
ment syndrome. The calcaneal tuberosity enlarges in response
to chronic irritation, often resulting in a cycle of reinjury.69 This
may lead to impingement of the Achilles tendon, retrocalca-
neal bursa, and posterior Kager’s fat pad against the poster-
osuperior tubercle of the calcaneus.67 Conventional lateral
radiographs of the heel will demonstrate a prominent poster-
ior superior tubercle. Advanced imaging, with either ultra-
sound or MRI, is often performed to define the soft tissue
abnormalities and direct treatment. MRI will demonstrate an
expanded Achilles tendon at its insertion with varying degrees
of intratendinous mucinous degeneration, partial tears, and
neovascularity (►Fig. 17). Haglund syndrome is typically
managed with resection of the retrocalcaneal bursa and
calcaneal deformity.67
Conclusion
Increasing participation and competitiveness in youth
sports has led to an increase in sports-related injuries.
Given the dramatic changes in patterns of injury as a
function of age, foot and ankle development is important
to understand in order to diagnose sports injuries accu-
rately in the young athlete. Although radiographs remain
the primary modality in the evaluation, CT or MRI is often
supplemented to further characterize injuries. Accurate and
timely diagnosis of sports-related ankle injuries is crucial to
initiate appropriate treatment and decrease the incidence
of long-term sequelae.
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