Sports Medicine of the Foot & Ankle, the Role of Imaging

  • John Wesley Latting
  • Charles E. SpritzerEmail author


As is true for orthopedics in general, the assessment of a sports related injuries of the foot and ankle begins with a good history and physical. While many maladies are readily diagnosed, often a differential remains. In these instances, imaging assessment is often useful. Additionally, as our understanding of injury to the foot and ankle evolves, a more nuanced approach to treatment has developed. Imaging is often required to optimize treatment. This brief chapter is intended to provide an overview to imaging sports related pedal injuries. This chapter is not a comprehensive review. Whole books intended to provide such information have been written. Rather, this manuscript is intended to provide information to guide the reader in deciding when and with what imaging modality to assess a patient further. By necessity and design, this manuscript is based much upon the author’s opinions and experience. It is understood that different imaging approaches to a clinical problem are possible, depending upon the experience of the imager and which imaging modalities are readily available.


Magnetic resonance imaging Ultrasound Computerized tomography Foot Ankle Achilles tendon Stress Fracture Sesamoid Tendinosis Ankle Ligaments Peroneal tendon Lisfranc Joint 


  1. 1.
    Bearcroft PW, Guy S, Bradley M, Robinson F. MRI of the ankle: effect on diagnostic confidence and patient management. AJR Am J Roentgenol. 2006;187(5):1327–31. doi: 10.2214/ajr.05.1071. Epub 2006/10/24.CrossRefPubMedGoogle Scholar
  2. 2.
    Saha S, Burke C, Desai A, Vijayanathan S, Gnanasegaran G. SPECT-CT: applications in musculoskeletal radiology. Br J Radiol. 2013;86(1031):20120519. Epub 2013/10/08. doi: 10.1259/bjr.20120519. PubMed PMID: 24096590; PubMed Central PMCID: PMCPMC3830427.
  3. 3.
    Wall J, Feller JF. Imaging of stress fractures in runners. Clin Sports Med. 2006;25(4):781–802. doi: 10.1016/j.csm.2006.06.003. Epub 2006/09/12.CrossRefPubMedGoogle Scholar
  4. 4.
    Shindle MK, Endo Y, Warren RF, Lane JM, Helfet DL, Schwartz EN, et al. Stress fractures about the tibia, foot, and ankle. J Am Acad Orthop Surg. 2012;20(3):167–76. doi: 10.5435/jaaos-20-03-167. Epub 2012/03/03.CrossRefPubMedGoogle Scholar
  5. 5.
    Banal F, Gandjbakhch F, Foltz V, Goldcher A, Etchepare F, Rozenberg S, et al. Sensitivity and specificity of ultrasonography in early diagnosis of metatarsal bone stress fractures: a pilot study of 37 patients. J Rheumatol. 2009;36(8):1715–9. doi: 10.3899/jrheum.080657. Epub 2009/07/02.CrossRefPubMedGoogle Scholar
  6. 6.
    Pepper M, Akuthota V, McCarty EC. The pathophysiology of stress fractures. Clin Sports Med. 2006;25(1):1–16. doi: 10.1016/j.csm.2005.08.010. vii. Epub 2005/12/06.CrossRefPubMedGoogle Scholar
  7. 7.
    Gaeta M, Minutoli F, Scribano E, Ascenti G, Vinci S, Bruschetta D, et al. CT and MR imaging findings in athletes with early tibial stress injuries: comparison with bone scintigraphy findings and emphasis on cortical abnormalities. Radiology. 2005;235(2):553–61. doi: 10.1148/radiol.2352040406. Epub 2005/04/29.CrossRefPubMedGoogle Scholar
  8. 8.
    Fredericson M, Bergman AG, Hoffman KL, Dillingham MS. Tibial stress reaction in runners. Correlation of clinical symptoms and scintigraphy with a new magnetic resonance imaging grading system. Am J Sports Med. 1995;23(4):472–81. Epub 1995/07/01.CrossRefPubMedGoogle Scholar
  9. 9.
    Schein AJ, Skalski MR, Patel DB, White EA, Lundquist R, Gottsegen CJ, et al. Turf toe and sesamoiditis: what the radiologist needs to know. Clin Imaging. 2015;39(3):380–9. doi: 10.1016/j.clinimag.2014.11.011. Epub 2014/12/09.CrossRefPubMedGoogle Scholar
  10. 10.
    Nwawka OK, Hayashi D, Diaz LE, Goud AR, Arndt WF, 3rd, Roemer FW, et al. Sesamoids and accessory ossicles of the foot: anatomical variability and related pathology. Insights Imaging. 2013;4(5):581–93. Epub 2013/09/06. doi: 10.1007/s13244-013-0277-1. PubMed PMID: 24006205; PubMed Central PMCID: PMCPMC3781258.
  11. 11.
    Taylor JA, Sartoris DJ, Huang GS, Resnick DL. Painful conditions affecting the first metatarsal sesamoid bones. Radiograph Rev Publ Radiol Soc N Am Inc. 1993;13(4):817–30. doi: 10.1148/radiographics.13.4.8356270. Epub 1993/07/01.Google Scholar
  12. 12.
    Kappis M. Weitere Beiträge zur traumatisch-mechanischen Entstehung der „spontanen” Knorpelablösungen (sogen. Osteochondritis dissecans). Deutsche Zeitschrift für Chirurgie. 1922;171(1):13–29. doi: 10.1007/bf02812921.CrossRefGoogle Scholar
  13. 13.
    Talusan PG, Milewski MD, Toy JO, Wall EJ. Osteochondritis dissecans of the talus: diagnosis and treatment in athletes. Clin Sports Med. 2014;33(2):267–84. doi: 10.1016/j.csm.2014.01.003. Epub 2014/04/05.CrossRefPubMedGoogle Scholar
  14. 14.
    Deol PPS, Cuttica DJ, Smith WB, Berlet GC. Osteochondral lesions of the talus: size, age, and predictors of outcomes. Foot Ankle Clin. 2013;18(1):13–34. Scholar
  15. 15.
    Leumann A, Valderrabano V, Plaass C, Rasch H, Studler U, Hintermann B, et al. A novel imaging method for osteochondral lesions of the talus–comparison of SPECT-CT with MRI. Am J Sports Med. 2011;39(5):1095–101. doi: 10.1177/0363546510392709. Epub 2011/02/09.CrossRefPubMedGoogle Scholar
  16. 16.
    McCollum GA, Calder JD, Longo UG, Loppini M, Romeo G, van Dijk CN, et al. Talus osteochondral bruises and defects: diagnosis and differentiation. Foot Ankle Clin. 2013;18(1):35–47. doi: 10.1016/j.fcl.2012.12.002. Epub 2013/03/08.CrossRefPubMedGoogle Scholar
  17. 17.
    Pache G, Krauss B, Strohm P, Saueressig U, Blanke P, Bulla S, et al. Dual-energy CT virtual noncalcium technique: detecting posttraumatic bone marrow lesions–feasibility study. Radiology. 2010;256(2):617–24. doi: 10.1148/radiol.10091230. Epub 2010/06/17.CrossRefPubMedGoogle Scholar
  18. 18.
    Kijowski R, De Smet AA. MRI findings of osteochondritis dissecans of the capitellum with surgical correlation. AJR Am J Roentgenol. 2005;185(6):1453–9. doi: 10.2214/ajr.04.1570. Epub 2005/11/24.CrossRefPubMedGoogle Scholar
  19. 19.
    Hepple S, Winson IG, Glew D. Osteochondral lesions of the talus: a revised classification. Foot Ankle Int. 1999;20(12):789–93. Epub 1999/12/28.CrossRefPubMedGoogle Scholar
  20. 20.
    Morshed S, Corrales L, Genant H, Miclau T, 3rd. Outcome assessment in clinical trials of fracture-healing. J Bone Joint Surg Am Vol. 2008;90(Suppl 1):62–7. Epub 2008/03/20. doi: 10.2106/jbjs.g.01556.
  21. 21.
    Bamberg F, Dierks A, Nikolaou K, Reiser MF, Becker CR, Johnson TR. Metal artifact reduction by dual energy computed tomography using monoenergetic extrapolation. Eur Radiol. 2011;21(7):1424–9. doi: 10.1007/s00330-011-2062-1. Epub 2011/01/21.CrossRefPubMedGoogle Scholar
  22. 22.
    Guggenberger R, Winklhofer S, Osterhoff G, Wanner GA, Fortunati M, Andreisek G, et al. Metallic artefact reduction with monoenergetic dual-energy CT: systematic ex vivo evaluation of posterior spinal fusion implants from various vendors and different spine levels. Eur Radiol. 2012;22(11):2357–64. doi: 10.1007/s00330-012-2501-7. Epub 2012/05/31.CrossRefPubMedGoogle Scholar
  23. 23.
    Komlosi P, Grady D, Smith JS, Shaffrey CI, Goode AR, Judy PG, et al. Evaluation of monoenergetic imaging to reduce metallic instrumentation artifacts in computed tomography of the cervical spine. J Neurosurg Spine. 2015;22(1):34–8. doi: 10.3171/2014.10.spine14463. Epub 2014/11/08.CrossRefPubMedGoogle Scholar
  24. 24.
    Baron K, Neumayer B, Widek T, Schick F, Scheicher S, Hassler E, et al. Quantitative MR imaging in fracture dating-Initial results. Forensic Sci Int. 2016;261:61–9. doi: 10.1016/j.forsciint.2016.01.020. Epub 2016/02/19.CrossRefPubMedGoogle Scholar
  25. 25.
    Lewis M, Ebreo D, Malcolm PN, Greenwood R, Patel AD, Kasmai B, et al. Pharmacokinetic modeling of multislice dynamic contrast-enhanced MRI in normal-healing radial fractures: a pilot study. J Magnet Reson Imaging JMRI. 2016;43(3):611–9. doi: 10.1002/jmri.25039. Epub 2015/09/04.CrossRefGoogle Scholar
  26. 26.
    Fernandez-Canton, et al. SKEL RAD 03: 32:273–278Google Scholar
  27. 27.
    Starr AM, Wessely MA, Albastaki U, Pierre-Jerome C, Kettner NW. Bone marrow edema: pathophysiology, differential diagnosis, and imaging. Acta Radiologica (Stockholm, Sweden: 1987). 2008;49(7):771–86. Epub 2008/07/09. doi: 10.1080/02841850802161023.
  28. 28.
    Thiryayi WA, Thiryayi SA, Freemont AJ. Histopathological perspective on bone marrow oedema, reactive bone change and haemorrhage. Eur J Radiol. 2008;67(1):62–7. doi: 10.1016/j.ejrad.2008.01.056. Epub 2008/03/14.CrossRefPubMedGoogle Scholar
  29. 29.
    Patel S. Primary bone marrow oedema syndromes. Rheumatology. 2014;53(5):785–92. doi: 10.1093/rheumatology/ket324.CrossRefPubMedGoogle Scholar
  30. 30.
    Orr JD, Sabesan V, Major N, Nunley J. Painful bone marrow edema syndrome of the foot and ankle. Foot Ankle Int. 2010;31(11):949–53. doi: 10.3113/fai.2010.0949. Epub 2010/12/30.CrossRefPubMedGoogle Scholar
  31. 31.
    Bianchi S, Martinoli C, Gaignot C, De Gautard R, Meyer JM. Ultrasound of the ankle: anatomy of the tendons, bursae, and ligaments. Semin Musculoskelet Radiol. 2005;9(3):243–59. doi: 10.1055/s-2005-921943. Epub 2005/10/26.CrossRefPubMedGoogle Scholar
  32. 32.
    Waitches GM, Rockett M, Brage M, Sudakoff G. Ultrasonographic-surgical correlation of ankle tendon tears. J Ultrasound Med Off J Am Instit Ultrasound Med. 1998;17(4):249–56. Epub 1998/04/17.Google Scholar
  33. 33.
    Astrom M, Gentz CF, Nilsson P, Rausing A, Sjoberg S, Westlin N. Imaging in chronic achilles tendinopathy: a comparison of ultrasonography, magnetic resonance imaging and surgical findings in 27 histologically verified cases. Skeletal Radiol. 1996;25(7):615–20. Epub 1996/10/01.CrossRefPubMedGoogle Scholar
  34. 34.
    Paavola M, Paakkala T, Kannus P, Jarvinen M. Ultrasonography in the differential diagnosis of Achilles tendon injuries and related disorders. A comparison between pre-operative ultrasonography and surgical findings. Acta Radiol (Stockholm, Sweden: 1987). 1998;39(6):612–9. Epub 1998/11/17.Google Scholar
  35. 35.
    Grant TH, Kelikian AS, Jereb SE, McCarthy RJ. Ultrasound diagnosis of peroneal tendon tears. A surgical correlation. J Bone Joint Surg Am. 2005;87(8):1788–94. doi: 10.2106/jbjs.d.02450. Epub 2005/08/09.PubMedGoogle Scholar
  36. 36.
    Neustadter J, Raikin SM, Nazarian LN. Dynamic sonographic evaluation of peroneal tendon subluxation. AJR Am J Roentgenol. 2004;183(4):985–8. doi: 10.2214/ajr.183.4.1830985. Epub 2004/09/24.CrossRefPubMedGoogle Scholar
  37. 37.
    Hyer CF, Dawson JM, Philbin TM, Berlet GC, Lee TH. The peroneal tubercle: description, classification, and relevance to peroneus longus tendon pathology. Foot Ankle Int. 2005;26(11):947–50. Epub 2005/11/29.PubMedGoogle Scholar
  38. 38.
    Khoury V, Guillin R, Dhanju J, Cardinal E. Ultrasound of ankle and foot: overuse and sports injuries. Semin Musculoskelet Radiol. 2007;11(2):149–61. doi: 10.1055/s-2007-1001880. Epub 2007/12/21.CrossRefPubMedGoogle Scholar
  39. 39.
    Toye LR, Helms CA, Hoffman BD, Easley M, Nunley JA. MRI of spring ligament tears. AJR Am J Roentgenol. 2005;184(5):1475–80. doi: 10.2214/ajr.184.5.01841475. Epub 2005/04/28.CrossRefPubMedGoogle Scholar
  40. 40.
    Balen PF, Helms CA. Association of posterior tibial tendon injury with spring ligament injury, sinus tarsi abnormality, and plantar fasciitis on MR imaging. AJR Am J Roentgenol. 2001;176(5):1137–43. doi: 10.2214/ajr.176.5.1761137. Epub 2001/04/20.CrossRefPubMedGoogle Scholar
  41. 41.
    Weatherall JM, Mroczek K, Tejwani N. Acute achilles tendon ruptures. Orthopedics. 2010;33(10):758–64. doi: 10.3928/01477447-20100826-21. Epub 2010/10/20.CrossRefPubMedGoogle Scholar
  42. 42.
    Bleakney RR, White LM. Imaging of the Achilles tendon. Foot Ankle Clin. 2005;10(2):239–54. doi: 10.1016/j.fcl.2005.01.006. Epub 2005/06/01.CrossRefPubMedGoogle Scholar
  43. 43.
    Khan KM, Forster BB, Robinson J, Cheong Y, Louis L, Maclean L, et al. Are ultrasound and magnetic resonance imaging of value in assessment of Achilles tendon disorders? A two year prospective study. Br J Sports Med. 2003;37(2):149–53. Epub 2003/03/29. PubMed PMID: 12663358; PubMed Central PMCID: PMCPMC1724608.Google Scholar
  44. 44.
    Tourne Y, Besse JL, Mabit C. Chronic ankle instability. Which tests to assess the lesions? Which therapeutic options? Orthop Traumatol Surg Res OTSR. 2010;96(4):433–46. doi: 10.1016/j.otsr.2010.04.005. Epub 2010/05/25.CrossRefPubMedGoogle Scholar
  45. 45.
    Nazarenko A, Beltran LS, Bencardino JT. Imaging evaluation of traumatic ligamentous injuries of the ankle and foot. Radiol Clin North Am. 2013;51(3):455–78. doi: 10.1016/j.rcl.2012.11.004. Epub 2013/04/30.CrossRefPubMedGoogle Scholar
  46. 46.
    Oae K, Takao M, Naito K, Uchio Y, Kono T, Ishida J, et al. Injury of the tibiofibular syndesmosis: value of MR imaging for diagnosis. Radiology. 2003;227(1):155–61. doi: 10.1148/radiol.2271011865. Epub 2003/03/05.CrossRefPubMedGoogle Scholar
  47. 47.
    Dimmick S, Linklater J. Ankle impingement syndromes. Radiol Clin North Am. 2013;51(3):479–510. doi: 10.1016/j.rcl.2012.11.005. Epub 2013/04/30.CrossRefPubMedGoogle Scholar
  48. 48.
    Nunley JA, Vertullo CJ. Classification, investigation, and management of midfoot sprains: Lisfranc injuries in the athlete. Am J Sports Med. 2002;30(6):871–8. Epub 2002/11/19.PubMedGoogle Scholar
  49. 49.
    DeOrio M, Erickson M, Usuelli FG, Easley M. Lisfranc injuries in sport. Foot Ankle Clin. 2009;14(2):169–86. doi: 10.1016/j.fcl.2009.03.008. Epub 2009/06/09.CrossRefPubMedGoogle Scholar
  50. 50.
    Watson TS, Shurnas PS, Denker J. Treatment of Lisfranc joint injury: current concepts. J Am Acad Orthop Surg. 2010;18(12):718–28. Epub 2010/12/02.CrossRefPubMedGoogle Scholar
  51. 51.
    Myerson MS, Fisher RT, Burgess AR, Kenzora JE. Fracture dislocations of the tarsometatarsal joints: end results correlated with pathology and treatment. Foot Ankle. 1986;6(5):225–42. Epub 1986/04/01.CrossRefPubMedGoogle Scholar
  52. 52.
    Peicha G, Preidler KW, Lajtai G, Seibert FJ, Grechenig W, Unfallchirurg, Springer-Verlag. 2001;104:1134–9.Google Scholar
  53. 53.
    Raikin SM, Elias I, Dheer S, Besser MP, Morrison WB, Zoga AC. Prediction of midfoot instability in the subtle Lisfranc injury. Comparison of magnetic resonance imaging with intraoperative findings. J Bone Joint Surg Am. 2009;91(4):892–9. doi: 10.2106/jbjs.h.01075. Epub 2009/04/03.CrossRefPubMedGoogle Scholar
  54. 54.
    Haaga JR, Lanzieri CF, Gilkeson RC. CT and MR imaging of the whole body. St. Louis: Mosby; 2003.Google Scholar
  55. 55.
    McCormick JJ, Anderson RB. Turf toe: anatomy, diagnosis, and treatment. Sports Health. 2010;2(6):487–94. Epub 2010/11/01. doi: 10.1177/1941738110386681. PubMed PMID: 23015979; PubMed Central PMCID: PMCPMC3438874.
  56. 56.
    Waldrop 3rd NE, Zirker CA, Wijdicks CA, Laprade RF, Clanton TO. Radiographic evaluation of plantar plate injury: an in vitro biomechanical study. Foot Ankle Int. 2013;34(3):403–8. doi: 10.1177/1071100712464953. Epub 2013/03/23.CrossRefPubMedGoogle Scholar
  57. 57.
    Umans HR, Elsinger E. The plantar plate of the lesser metatarsophalangeal joints: potential for injury and role of MR imaging. Magn Reson Imaging Clin N Am. 2001;9(3):659–69. xii. Epub 2001/11/06.PubMedGoogle Scholar
  58. 58.
    Gregg J, Silberstein M, Schneider T, Marks P. Sonographic and MRI evaluation of the plantar plate: a prospective study. Eur Radiol. 2006;16(12):2661–9. doi: 10.1007/s00330-006-0345-8. Epub 2006/07/05.CrossRefPubMedGoogle Scholar
  59. 59.
    Klein EE, Weil Jr L, Weil Sr LS, Knight J. Magnetic resonance imaging versus musculoskeletal ultrasound for identification and localization of plantar plate tears. Foot Ankle Spec. 2012;5(6):359–65. doi: 10.1177/1938640012463061. Epub 2012/10/18.CrossRefPubMedGoogle Scholar
  60. 60.
    Kane D, Greaney T, Shanahan M, Duffy G, Bresnihan B, Gibney R, et al. The role of ultrasonography in the diagnosis and management of idiopathic plantar fasciitis. Rheumatology (Oxford, England). 2001;40(9):1002–8. Epub 2001/09/19.CrossRefGoogle Scholar
  61. 61.
    Sabir N, Demirlenk S, Yagci B, Karabulut N, Cubukcu S. Clinical utility of sonography in diagnosing plantar fasciitis. J Ultrasound Med Off J Am Instit Ultrasound Med. 2005;24(8):1041–8. Epub 2005/07/26.Google Scholar
  62. 62.
    Theodorou DJ, Theodorou SJ, Kakitsubata Y, Lektrakul N, Gold GE, Roger B, et al. Plantar fasciitis and fascial rupture: MR imaging findings in 26 patients supplemented with anatomic data in cadavers. Radiograph Rev Publ Radiol Soc N Am, Inc. 2000;20 Spec No:S181–97. Epub 2000/10/25. doi: 10.1148/radiographics.20.suppl_1.g00oc01s181.

Copyright information

© Springer International Publishing Switzerland 2016

Authors and Affiliations

  1. 1.Department of RadiologyDuke University HospitalDurhamUSA
  2. 2.Department of Radiology, Duke University School of MedicineDuke University Medical CenterDurhamUSA

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