The Journal of Foot & Ankle Surgery 50 (2011) 413–415

Contents lists available at ScienceDirect

The Journal of Foot & Ankle Surgery

journal homepage: www.jfas.org

Magnetic Resonance Imaging and Incidental Findings of Lateral Ankle

Pathologic Features with Asymptomatic Ankles
Amol Saxena, DPM, FACFAS 1, Amit Luhadiya, DPM 2, Brynn Ewen, DPM 2, Chris Goumas, MD 3
1
Fellowship Director, Palo Alto Division, Palo Alto Foundation Medical Group, Palo Alto, CA
2
Fellow, Palo Alto Division, Palo Alto Foundation Medical Group, Palo Alto, CA
3
Staff Radiologist, Palo Alto Division, Palo Alto Foundation Medical Group, Palo Alto, CA

a r t i c l e i n f o a b s t r a c t

Level of Clinical Evidence: 3 We prospectively evaluated 102 magnetic resonance imaging (MRI) examinations in 100 patients with
Keywords: asymptomatic lateral ankles. The patients were undergoing MRI for other ankle pathologic features, including
fibula medial ankle, posterior ankle, soft tissue masses, or Achilles tendon pain. No patient had had a recent lateral
instability ankle injury or any surgery. Whether the anterior talofibular ligament, calcaneofibular ligament, and peroneal
ligament
tendons were intact, torn, or absent was recorded. The average patient age was 46.4 years. Of the 100 patients,
peroneal tendon
67 (66%) had no history of a lateral ankle sprain, and 35 (34%) had sustained 1 or more sprains in the remote
surgery
talus past. Also, 72 had an intact anterior talofibular ligament (71%), 90 had an intact calcaneofibular ligament (89%),
tibia 67 had intact peroneus brevis tendons (66%), and 68 (67%) had intact peroneus longus tendons. One accessory
peroneal tendon was noted. Approximately 30% of asymptomatic patients undergoing MRI had abnormal
anterior talofibular ligaments and peronei. Because the published data show that functional rehabilitation is
successful for 90% of symptomatic lateral ankle patients, caution is warranted if choosing surgical treatment on
the basis of the MRI findings alone.
Ó 2011 by the American College of Foot and Ankle Surgeons. All rights reserved.

Lateral ankle sprains have a high incidence among athletes and
are the most common musculoskeletal injury in the United States,
with an occurrence of 30,000 daily (1). Nonoperative treatment, such
as bracing and physical therapy, yields good results for most patients
(1–16). In chronic cases, magnetic resonance imaging (MRI) could be
needed. Other types of ankle pain due to osteochondral defects,
Achilles tendinopathy, ankle impingement, ankle synovitis, peroneal
tendon and retinacular pathologic features, posterior tibial tendon
dysfunction, degenerative arthrosis, soft tissue masses, and stress
fractures also can require MRI examination (8–12). These injuries can
be evaluated through direct examination, radiographic studies (MRI),
and functional assessment, and treatment should not determined
from the MRI results alone (1, 2, 8–12, 14, 16). False-positive results
can occur with MRI, and a certain percentage of patients can have
asymptomatically torn peronei or lateral ankle ligaments and
therefore “normal abnormal” findings (1, 3, 8, 15).
The foot position during the MRI study can change the visualiza-
tion of the ankle structures. During the MRI examination, the foot
Financial Disclosure: None reported.
Conflict of Interest: None reported.
Address correspondence to: Amol Saxena, DPM, FACFAS, Department of Sports
Medicine, Palo Alto Foundation Medical Group, Clark Building, 795 El Camino Real,
Palo Alto, CA 94301.
E-mail address: heysax@aol.com (A. Saxena).
must be in the proper position to increase visualization and decrease
the “magic angle” effect (pseudo-appearance of torn structures),
otherwise false-positive results can occur. Wang et al. (15) stated that
imaging the foot in mild plantar flexion (approximately 20
) can help
decrease the magic angle effect because the peroneal tendons
descend down the ankle and the fibers form an angle of 55
with the
main magnetic vector, which, in turn, produces increased signal
intensity. Taking these calibrations into account should provide better
visualization of overlooked lateral ankle diseases concomitant with
other foot and ankle pathologic features (i.e., plantar fasciitis, poste-
rior tibial tendon dysfunction, Achilles tendonitis, tibialis anterior
tendonitis). When evaluating peroneal subluxation, MRI should be
done with the ankle dorsiflexed (12).
Because of the reported incidence of false-positive results when
reviewing MRI studies, we studied the incidence of lateral ankle
pathologic features visualized in asymptomatic individuals. We
specifically wanted to exclude any patients with a recent history of
lateral ankle trauma or any surgery. We recorded the percentage of
patients with no lateral ankle pain whatsoever who had intact lateral
ankle ligaments and tendons on MRI.
Patients and Methods
The patients of 1 practitioner (A.S.) in a sports medicine clinic undergoing MRI
examination of their ankles were prospectively studied for lateral ankle pathologic

1067-2516/$ - see front matter Ó 2011 by the American College of Foot and Ankle Surgeons. All rights reserved.
doi:10.1053/j.jfas.2011.03.011
414 A. Saxena et al. / The Journal of Foot & Ankle Surgery 50 (2011) 413–415
Fig. 1. (A) MRI scan showing intact anterior talofibular ligament. (B) MRI scan showing
intact calcaneofibular ligament and peronei.
findings. The institutional review board approved the present study. The ankles were
scanned using a Philips Achieva 3T (Philips, Amsterdam, The Netherlands) with an
Invivo 8-channel foot and ankle array (Invivo, Amsterdam, The Netherlands). The
reports were evaluated for the presence, absence, or abnormal findings of the lateral
ankle ligaments and peroneal tendons. Specifically, the data were recorded if the
anterior talofibular ligament, calcaneofibular ligament, and peroneal tendons were
intact, torn, or absent. Incidental findings of accessory ossicles and other lesions were
also recorded. The inclusion criteria were patients undergoing an MRI examination
from June 2007 to July 2009 for evaluation of nonlateral ankle pain. These patients
typically complained of medial ankle, posterior ankle, soft tissue masses, or Achilles
tendon pain. The exclusion criteria were any concurrent lateral ankle pain. Any patients
with an injury in the previous 10 years or any previous lateral ankle surgery were also
excluded. We sought to ensure that none of the potential pathologic features found in
the lateral ankle on MRI had resulted from any residual injury. Because of these criteria,
253 patents were excluded, underscoring the frequency of lateral ankle sprains in the
sports medicine population. A total of 100 patients undergoing 102 MRI examinations
(2 bilateral) fulfilled the criteria. Typical examples of normal (Figure 1), asymptomatic
“abnormal” (Figure 2), and symptomatic abnormal (Figure 3) MRI scans were collected.
Results
A total of 102 MRI examinations from 100 patients were evaluated;
52 on the right and 50 on the left ankle (2 patients had bilateral
Fig. 2. (A) MRI scan showing “abnormal” anterior talofibular ligament in asymptomatic patient. (B) MRI scan showing “abnormal” calcaneofibular ligament in asymptomatic patient.
(C) MRI scan showing “abnormal” split peroneus brevis in asymptomatic patient.
examinations). Of the 100 patients, 50 each were male and females,
with an average age of 46.4 years. Twenty-five patients eventually
underwent surgery for nonlateral ankle pathologic features. The most
common abnormality being evaluated by MRI was Achilles tendin-
opathy (N ¼ 40), followed by posterior tibial tendon dysfunction
(N ¼ 26). Of the 100 patients (102 examinations), 67 (66%) had no
history of a lateral ankle sprain and 35 (34%) had sustained 1 or more
sprains in the remote past. Of these patients, 72 had an intact anterior
talofibular ligament (71%), 90 had an intact calcaneofibular ligament
(89%), 67 (66%) had intact peroneus brevis tendons, and 68 (67%) had
intact peroneus longus tendons. One accessory peroneal tendon was
noted. Also, 20 accessory ossicles (with os trigonum the most
common with 7 occurrences) and 15 osteochondral defects (8 medial
and 7 lateral) were noted. One lateral talar lesion necessitated surgery
for subtalar arthrosis. The MRI study changed the original diagnosis in
2 cases.
The practitioner ordering the examinations tallied the number of
ankle stabilizations performed for symptomatic ankle instability
unresponsive to physical therapy and bracing during the same study
period. He performed 42 lateral ankle stabilizations, often with
concomitant tendon or chondral repair. This was compared with the
number of ankle sprains (N ¼ 424) treated during the same period, for
a 10% surgical repair rate.
Discussion
Our study has shown that approximately 30% or more of patients
with asymptomatic lateral ankles have abnormal anterior talofibular
ligament ligaments or peroneal tendons. This can be significant if
clinicians rely on MRI reports on which to base treatment. If clinicians
or patients rely on the MRI results for treatment, they could be misled
and unjustly choose lateral ankle surgery. This needs to be studied
furthered in patients with lateral ankle pain. The study limitations
include that the ankles studied were not truly asymptomatic. Ideally,
truly asymptomatic patients with no history of ankle injuries should
be studied.
Patients with symptoms from lateral ankle instability can be
treated in most cases nonsurgically. In cases in which the patient does
have acute or chronic ankle instability, Schenck and Coughlin (12)
stated that ankle instability is a common problem that is routinely
treated nonoperatively, with a 90% success rate. This should be
 A. Saxena et al. / The Journal of Foot & Ankle Surgery 50 (2011) 413–415
Fig. 3. (A) MRI scan showing ruptured (Grade 3) anterior talofibular ligament in patient
with acute lateral ankle sprain. (B) MRI scan showing ruptured calcaneofibular ligament
and peronei in patient with acute lateral ankle sprain.
studied prospectively with a larger study and surgeon population. The
finding reported in the present study of the senior author’s (A.S.)
surgical rate in symptomatic patients of 10% is consistent with the
published data. We did not study whether the remaining 90% of
patients had undergone surgical treatment elsewhere.
Maffulli and Ferran (9) studied cast immobilization versus func-
tional management (rest, ice, compression, elevation [RICE] followed
by rehabilitation, i.e., proprioceptive retraining and strengthening
exercises) for the acute ankle sprain. Using randomized controlled
trials, they reported that functional management allowed for earlier
resumption of sports training, with fewer symptoms 3 to 6 months
after injury (9). Kerkhoffs et al (5, 6) stated that conservative treat-
ment leads to a full functional recovery for most people. Richie (11)
and others (12, 13, 16) addressed conservative treatment of acute or
chronic ankle instability and also showed the benefits of mechanical
supportive aid to the ankle in the form of taping or bracing.
With respect to lateral ankle ligament pathologic findings in
symptomatic patients and MRI, in a retrospective study of 32 patients,
Lamm et al. (8) showed that a MRI diagnosis of a peroneus brevis
tendon tear had a 83% sensitivity and 75% specificity to the intra-
operative findings. Coexisting conditions identified on MRI included
a low lying muscle belly/peroneus quartus (44%), anterior talofibular
ligament rupture (50%), flattened/hypertrophy peroneus longus
tendon (56%), increased signal intensity within the peroneus longus
415
tendon (53%), and a flat/convex fibular groove (78%) (8). In our study,
we did not assess the fibular groove.
The overall incidence of lateral ankle pathologic findings in
asymptomatic individuals is significant. Approximately 30% of
asymptomatic individuals have abnormal anterior talofibular liga-
ments and peroneal tendons. Because of the success rate of nonop-
erative treatment of lateral ankle sprains and the incidence of
asymptomatic patients, practitioners should use caution when
considering surgery for lateral ankle pain according to the MRI find-
ings, particularly in this patient population.
References
1. DiGiovanni CW, Brodsky A. Current concepts: lateral ankle instability. Foot Ankle
Int 27:854–866, 2006.
2. de Vries JS, Krips R, Sierevelt IN, Blankevoort L, van Dijk CN. Interventions for
treating chronic ankle instability. Cochrane Database System Rev, Issue
4:CD004124, 2006.
3. Heckman D, Reddy S, Pedowitz D, Wapner K, Parekh S. Operative treatment for
peroneal disorders. J Bone Joint Surg Am 90:404–418, 2008.
4. Karlsson J, Lundin O, Lind K, Styf J. Early mobilization versus immobilization after
ankle ligament stabilization. Scand J Med Sci Sports 9:299–303, 1999.
5. Kerkhoffs GMMJ, Handoll HHG, de Bie R, Rowe BH, Strujis PAA. Surgical versus
conservative treatment for acute injuries of the lateral ligament complex of the
ankle in adults. Cochrane Database System Rev, Issue 2:CD000380, 2002.
6. Kerkhoffs GMMJ, Struyss PAA, Marti RK, Assendelft WJJ, Blankevoort L, van
Dijk CN. Different functional treatment strategies for acute lateral ankle ligament
injuries in adults. Cochrane Database System Rev, Issue 3:CD002938, 2002.
7. Klenerman L. The management of sprained ankle. J Bone Joint Surg Br 80:11–12,
1998.
8. Lamm BM, Myers DT, Dombek M, Mendicino RW, Catanzariti AR, Saltrick K.
Magnetic resonance imaging and surgical correlation of peroneus brevis tears.
J Foot Ankle Surg 43:30–36, 2004.
9. Maffulli N, Ferran N. Management of acute and chronic ankle instability. J Am Acad
Orthop Surg 16:608–615, 2008.
10. Pijnenburg AC, Bogaard K, Krips R, Marti RK, Bossuyt PM, Van Dijk CN. Operative
and functional treatment of the lateral ligament of the ankle: a randomized,
prospective trial. J Bone Joint Surg Br 85:525–530, 2003.
11. Richie DH Jr. Functional Instability of the ankle and the role of neuromuscular
control: a comprehensive review. J Foot Ankle Surg 40:240–251, 2001.
12. Schenck R Jr, Coughlin M. Lateral ankle instability and revision surgery alternatives
in the athlete. Foot Ankle Clin North Am 14:205–214, 2009.
13. Specchiulli F, Cofano RE. A comparison of surgical and conservative treatment in
ankle ligament tears. Orthopedics 24:686–688, 2001.
14. Van Dijk CN, Lim LS, Bossuyt PM, Marti RK. Physical examination is sufficient for
the diagnosis of sprained ankles. J Bone Joint Surg Br 78:958–962, 1996.
15. Wang X, Rosenberg Z, Mechlin M, Schweitzer M. Normal variants and diseases of
the peroneal tendons and superior peroneal retinaculum: MR imaging features.
Radiographics 25:587–602, 2005.
16. Zwipp H, Tscherne H, Hoffmann R, Thermann H. Ankle ligament tears: operative or
conservative treatment [Rib der knochelbander: operative oder konservativ
behandlung?]. Deutsches Arzteblatt 31:B2019–B2022, 1988.