Hong Kong J Radiol. 2017;20:17-27 | DOI: 10.

12809/hkjr1716848

REVIEW ARTICLE

Magnetic Resonance Imaging of Ligamentous Injuries in

Ankle Sprain
PY Chu, WSW Chan, HC Lee, YW Hon, JCS Chan, KKL Lo
Department of Radiology and Organ Imaging, United Christian Hospital, Kwun Tong, Hong Kong

ABSTRACT
Ankle sprains are common. Injury to the ankle ligaments is increasingly diagnosed by magnetic resonance
imaging (MRI). In this review, 3-dimensional MRI sequence is discussed, the normal and injured MRI
appearance of various components of the ankle ligaments is illustrated, and associated complications of ankle
sprain are briefly presented.

Key Words: Ankle injuries; Ligament; Magnetic resonance imaging

MRI
MRIMRI

INTRODUCTION injuries in ankle sprain. 3 MRI helps differentiate

Ligamentous injury caused by excessive range of ligament injuries from other causes of ankle pain such
motion at the joint in the absence of fracture or as fracture, osteochondral injury, and tendon injury.
dislocation is called a sprain. Ankle sprain is common
and accounts for >90% of ankle injuries sustained in We review the MRI technique for the ankle, describe the
football, hockey, basketball, martial arts, and indoor normal and injured MRI features of various components
volleyball.1 Subsequent re-injury can result in chronic of the ankle ligaments, the associated complication of
instability and disability.2 Treatment of acute ligament sinus tarsi syndrome, and discuss the management of
injuries is based on clinical history and physical ligament injuries.
examination. With its multiplanar capability and superb
soft tissue contrast, magnetic resonance imaging (MRI) IMAGING TECHNIQUE
is the tool of choice to evaluate the extent of ligament In our institution, routine MRI of the ankle is performed

Correspondence: Dr PY Chu, Department of Radiology and Organ Imaging, United Christian Hospital, 130 Hip Wo Street, Kwun
Tong, Hong Kong.
Email: [email protected]

Submitted: 17 Jan 2017; Accepted: 6 Feb 2017.

Disclosure of Conflicts of Interest: All authors have disclosed no conflicts of interest.

2017 Hong Kong College of Radiologists 17

Magnetic Resonance Imaging of Ligamentous Injuries in Ankle Sprain

by experienced radiologists using a 1.5-T magnetic sequences use parallel imaging, long-echo trains,
resonance scanner (MAGNETOM Aera; Siemens and large turbo factors to reduce imaging time.8 The
Medical Solutions, Erlangen, Germany). Axial, coronal, contrast characteristics in FSE 3D pulse sequence
and sagittal planes are obtained. The ankle is imaged images are similar to those of FSE sequences and
in the oblique axial plane parallel to the talar dome, are a more attractive option than gradient-echo 3D
the oblique coronal plane perpendicular to the long pulse sequences. 7 Such 3D FSE pulse sequences
axis of the calcaneus, and the oblique sagittal plane include sampling perfection with application-
parallel to bilateral malleoli and perpendicular to optimised contrasts with different flip-angle evolutions
the talar dome. The patient is positioned supine with (SPACE) by Siemens Healthcare9 and extended echo-
the foot in slight plantar flexion. Plantar flexion can train acquisition and FSE-Cube acquisition by GE
decrease the magic angle effect, accentuate the fat plane Healthcare.10,11
between the peroneal tendons, and better visualise the
calcaneofibular ligament (CFL).4 A dedicated extremity At our institution, 3D MRI pulse sequences are
surface coil (Foot/Ankle 16-Channel Coil; Siemens incorporated into ankle MRI protocols. We use FSE
Medical Solution) is used to enhance spatial resolution. proton density (PD)-weighted 3D pulse sequence
The standard MRI protocol for evaluation of ankle SPACE. It is particularly important in the evaluation of
ligamentous injury is summarised in the Table. ankle ligaments as they are often obliquely oriented to
the standard anatomic orthogonal imaging planes. 3D
Three-dimensional Magnetic Resonance isotropic pulse sequences enable generation of multiple
Imaging Pulse Sequences high-quality post-processing reformatted images from
Three-dimensional (3D) MRI sequences have the an original isotropic data acquisition along any user-
advantage of acquiring thin continuous slices that defined imaging plane (Figure 1) using picture archiving
reduce the effects of partial volume averaging.5 3D MRI and communication system station (IMPAX; Agfa
sequences with isotropic resolution enable high-quality Healthcare, NV, Belgium).
multiplanar reformat images to be obtained following a
single acquisition.5 Preliminary results for the diagnostic ANATOMY OF ANKLE LIGAMENTS
performance of 3D isotropic resolution sequences are The ankle joint is supported by three groups of
encouraging. 3D MRI sequences have been reported ligaments: lateral collateral ligaments, medial collateral
to have 94% accuracy in detecting anterior talofibular ligaments, and the syndesmotic ligament complex.
ligament (ATFL) and CFL tears, and 92% sensitivity and Ligaments that generally appear homogeneously
100% specificity in diagnosing ATFL and CFL rupture.6 hypointense on all imaging sequences may include
the ATFL, CFL, and superficial deltoid ligament. 12
A variety of 3D MRI pulse sequences have been used Other ankle ligaments may show a mixed or striated
to detect internal derangement of joints. These include signal intensity pattern; these include the posterior
gradient-echo and fast spin-echo (FSE) 3D acquisition talofibular ligament (PTFL), posterior tibiofibular
sequences. 7 Potential disadvantages of gradient- ligament, and deep deltoid ligament.4 Nonetheless, there
echo 3D MRI techniques include the relatively long are exceptions to typical appearances. Awareness of
acquisition time and inherent sensitivity to intravoxel the normal and atypical MRI characteristics of ankle
dephasing and susceptibility artefacts.7 FSE 3D pulse ligaments may improve diagnostic accuracy.

Table. Routine magnetic resonance imaging protocols for the ankle.

Sequence FOV (mm) TR (ms) TE (ms) Matrix Slice thickness (mm)

Axial PDW TSE, FS 150 3500 31 256 x 256 3
Axial T2-weighted TSE, FS 150 4190 77 256 x 256 3
Coronal PDW TSE, FS 160 3500 36 162 x 320 3
Sagittal T1-weighted, no FS 150 400 11 240 x 320 3
Sagittal T2-weighted TSE, FS 150 3000 73 256 x 256 3
Coronal 3D PDW SPACE TSE, no FS 23 1100 23 156 x 256 0.6
Abbreviations: 3D = 3-dimensional; FOV = field of view; FS = fat saturation; PDW = proton density-weighted; SPACE = sampling perfection
with application-optimised contrast with different flip-angle evolutions; TE = echo time; TR = repetition time; TSE = turbo spin-echo.

18 Hong Kong J Radiol. 2017;20:17-27

 PY Chu, WSW Chan, HC Lee, et al

(a) (b)

(c) (d)

Figure 1. (a) to (d) Normal anterior

talofibular ligament (ATFL) on fast
spin-echo proton densityweighted
three-dimensional SPACE image:
the ATFL (arrows) extends from
the anterior aspect of the tip of
lateral malleolus of the fibula (F) and
courses anteromedially downward
to the talar neck (T). It is thin,
straight, and of low signal intensity.
Abbreviation: SPACE = sampling
perfection with application-optimised
contrasts using different flip angle
evolutions.

The lateral collateral ligament complex includes the extending from the fibular fossa of the distal fibula,
ATFL, PTFL, and CFL. The ATFL extends from the running horizontally and attaching to the posterior
anterior aspect of the lateral malleolus and courses talar process (Figure 2). It is the strongest component
anteromedially downward to attach onto the talar neck of the lateral collateral ligament complex. It is best
(Figure 2). It is best demonstrated on axial T1-wighted demonstrated on axial and coronal images, appearing
or high-resolution PD-weighted MRI. It usually appears striated due to the presence of interspersed fat. It often
as a thin, flat, and straight low-signal-intensity band has marked heterogeneity and thickening, with high-
in a single axial image. In most cases, ATFL actually signal elements on fat-suppressed sequences, which
consists of two separate fascicles, and occasionally is normal and should not be interpreted as a tear. 4
of one or more fascicles.13,14 The fascicles may not The PTFL and the posterior intermalleolar ligament
be differentiated in the axial plane, although may be course transversely behind the tibiotalar joint and are
depicted with high-resolution images (Figure 2).14 The typically seen as punctate low-signal-intensity structures
ATFL may also appear striated with mildly increased posteriorly in the sagittal plane, potentially mimicking
intra-ligamentous signal intensity on T2-weighted and intraarticular bodies in the posterior ankle. 16 It is
PD-weighted images.15 important to track each of these ligaments from their
origin to their insertion on orthogonal imaging planes to
The PTFL has a broad, fan-shaped appearance avoid misdiagnosis. In addition, the pseudodefect of the

Hong Kong J Radiol. 2017;20:17-27 19

Magnetic Resonance Imaging of Ligamentous Injuries in Ankle Sprain

(a) (b)

Figure 2. Normal anterior and

posterior talofibular ligament (ATFL
and PTFL): (a) axial proton density
(PD)-weighted image with fat
saturation showing ATFL (arrow) as
a straight, thin, low-signal-intensity
band between the tip of fibula (F)
and talus (T). The talus (T) is oblong-
shaped and the medial indentation
of the fibula (F) represents the
malleolar fossa. The PTFL (thin
arrow) showing a broad, fan-shaped
(c) (d) appearance with striated pattern due
to interspersed fat. It extends from
the posterior talus (T) to the fibular
malleolar fossa (F). (b) In another
patient, the ATFL is shown as two
separate fascicles with interspersed
intermediate signal intensity (arrow).
The PTFL (thin arrow) is also shown.
(c) Reformatted turbo spin-echo PD-
weighted 3D SPACE images better
demonstrate the thin linear fascicles
of the ATFL (arrows). (d) Coronal T2-
weighted image with fat saturation
showing normal striated pattern of
the PTFL (arrow).
Abbreviation: SPACE = sampling
perfection with application-optimised
contrasts using different flip angle
evolutions.

talus represents a normal groove containing the PTFL.17 posteroinferiorly to attach to a small tubercle on the
lateral aspect of the calcaneus. It is best demonstrated
The ATFL and PTFL can be distinguished from the on coronal and axial images. It appears as a thin low-
anterior and posterior inferior tibiofibular ligament signal-intensity band deep to the peroneal tendons
(AiTFL and PiTFL) by the morphological appearance and is often incompletely visualised due to its oblique
of the talus and the distal fibula on axial MRI.18 The orientation (Figure 3).12 The complete course of the CFL
ATFL and PTFL are located inferior to the AiTFL and can usually be depicted using multiplanar reconstruction
PiTFL, respectively, where the talus is oblong and the from thin-section 3D MRI sequences (Figure 3).
fibula demonstrates a medial indentation representing
the malleolar fossa (Figures 1 and 2). AiTFL and PiTFL The medial collateral ligament complex, also known
are detected in the talar dome that is somewhat square. as the deltoid ligament, consists of deep and superficial
In addition, these ligaments insert onto the fibula above layers (Figure 4). The deep ligaments have talar
the malleolar fossa, where the fibula is round with a flat attachment and cross one joint, and consist of anterior
medial border. and posterior tibiotalar ligaments. The superficial
ligaments have variable attachments and cross two
The CFL extends from the tip of the lateral malleolus joints. The three components of the superficial layer are

20 Hong Kong J Radiol. 2017;20:17-27

 PY Chu, WSW Chan, HC Lee, et al

(a) (b)

Figure 3. Normal calcaneofibular

ligament: (a) axial proton
density (PD)-weighted image
with fat saturation showing the
calcaneofibular ligament (arrow)
as a thin low-signal-intensity band
deep to the peroneal tendons (thin
arrow) and is incompletely visualised
due to its oblique orientation.
(b) Coronal T2-weighted image
(c) (d) with fat saturation showing the
calcaneofibular ligament (arrow) as a
thin low-signal-intensity band deep
to the peroneal tendons (thin arrow)
and is also incompletely visualised.
Multiple images are often needed
to visualise the entire course of the
calcaneofibular ligament. (c) Sagittal
turbo spin-echo PD-weighted 3D
SPACE image showing the course
of the calcaneofibular ligament
(arrow) from the tip of the lateral
malleolus to the small tubercle on
the lateral aspect of the calcaneus.
(d) Reformatted SPACE images
showing the entire course of the
calcaneaofibular ligament (arrows).
Abbreviation: SPACE = sampling
perfection with application-optimised
contrasts using different flip angle
evolutions.

the tibiocalcaneal ligament, tibionavicular ligament, and to the presence of intervening fat between its fibres. It
tibiospring ligament. These components are variably should not be confused with injury.19
present.19 On standard MRI, the tibionavicular ligament
and anterior tibiotalar ligament may not always be The syndesmotic ligaments consist of the AiTFL,
visible.20 The mostly present components include the PiTFL, inferior transverse tibiofibular ligament, and
tibiocalcaneal ligament and tibiospring ligament in the inferior interosseous ligament or membrane. These
superficial layer, and the posterior tibiotalar ligament in ligaments are best demonstrated on axial and coronal
the deep layer.20 The various components of the deltoid MRI with low-to-intermediate signal intensity.4 The
ligament are usually best demonstrated on axial and AiTFL and PiTFL are usually seen on two or more
coronal images. The posterior tibiotalar component is sequential axial and coronal MR images at the level of
the strongest and the most readily visualised component. the tibial plafond and talar dome (Figure 5). The AiTFL
It extends between the tip of the medial malleolus to the is the weakest and the most commonly torn syndesmotic
medial talar surface. It is a thick structure comprising ligament. 21 The AiTFL often appears striated and
multiple fascicles and has a striated appearance due discontinuous due to interposition of fat between

Hong Kong J Radiol. 2017;20:17-27 21

Magnetic Resonance Imaging of Ligamentous Injuries in Ankle Sprain

(a) (b)

(c) (d)
Figure 4. Normal deltoid ligament:
(a) coronal turbo spin-echo proton
density-weighted 3D SPACE image
showing a normal anterior tibiotalar
ligament (arrow), tibiospring
ligament (thin arrow), and tibialis
posterior tendon (curved arrow).
Coronal SPACE images showing (b)
a normal posterior tibiotalar ligament
(arrow), with a striated appearance,
and the flexor retinaculum (curved
arrow), (c) a normal tibiocalcaneal
ligament (arrow), and (d) a normal
tibionavicular ligament (arrow).
Abbreviation: SPACE = sampling
perfection with application-optimised
contrasts using different flip angle
evolutions.

Figure 5. Normal syndesmotic

(a) (b) ligaments: (a) axial proton density
(PD)-weighted image with fat
saturation showing the anterior
inferior tibiofibular ligament (AiTFL)
(arrow) and posterior inferior
tibiofibular ligament (PiTFL) (thin
arrow). (b) Axial turbo spin-echo PD-
weighted 3D SPACE image showing
the normal AiTFL (arrow) and PiTFL
(thin arrow) as low-signal-intensity
bands. They are detected in the talar
dome, which is somewhat square.
They insert onto the fibula above the
malleolar fossa, where the fibula is
oval with a flat medial border.
Abbreviation: SPACE = sampling
perfection with application-optimised
contrasts using different flip angle
evolutions.

22 Hong Kong J Radiol. 2017;20:17-27

 PY Chu, WSW Chan, HC Lee, et al

(a) (b)

Figure 6. Acute left ankle sprain with

inversion type injury in a 28-year-old
man: (a) axial T2-weighted image
with fat saturation showing complete
absence of the anterior talofibular
ligament (arrow). Partial tear of the
posterior talofibular ligament at
the talar attachment is also noted
(curved arrow). Note the fluid at
the anterolateral recess, ankle joint
effusion, and fluid around the flexor
hallucis longus tendon. (b) Sagittal
(c) (d) turbo spin-echo proton density
(PD)-weighted 3D SPACE showing
thickened calcaneofibular ligament
with intermediate signal intensity
(arrow). (c) Axial T2-weighted image
with fat saturation showing partial
tearing of the calcaneofibular
ligament (arrow). (d) Coronal PD-
weighted image with fat saturation
showing partial tear of the deep
and superficial components of the
deltoid ligament (arrow), associated
bone marrow oedema (curved
arrow) at the medial malleolus, and
osteochondral defect at the talar
dome (asterisk).
Abbreviation: SPACE = sampling
perfection with application-optimised
contrasts using different flip angle
evolutions.

fascicles and the downward oblique course of the intensity on fluid-sensitive MRI sequences, which
ligaments from the anterior tubercle of the distal tibia to indicate intra-ligamentous oedema or haemorrhage.
the anterior tubercle of the distal fibula. It can result in Other associated features include obliteration of the fat
depiction of a partly interrupted ligament, leading to a planes around the ligament, extravasation of joint fluid
false-positive diagnosis of a rupture.16 into the adjacent spaces, and bone marrow oedema or
contusion. Acute ligamentous injuries are rarely treated
ANKLE LIGAMENTOUS INJURIES surgically. Concomitant injuries such as fracture,
The MRI characteristics of acute injuries to the ankle osteochondral injury, or tendon injury are common
ligaments include morphological and signal intensity (Figures 6 to 8). These concomitant injuries are often
alterations within and around the ligaments. 4,22 more crucial in determining treatment and prognosis
Morphological alterations may include abnormal than the ligamentous injuries themselves.4,18,19 The MRI
thinning, thickening, irregularity, discontinuity, manifestations of chronic ligamentous tear of ankle
or detachment. Signal intensity alterations can be ligaments may be similar to acute injuries, which could
heterogeneous with increased intra-ligamentous signal be thickening, thinning, or irregular appearance of the

Hong Kong J Radiol. 2017;20:17-27 23

Magnetic Resonance Imaging of Ligamentous Injuries in Ankle Sprain

Figure 7. Subacute right ankle sprain

(a) (b) in a middle-aged man: (a) coronal T2-
weighted image with fat saturation
showing full-thickness tear of the
tibiospring ligament of the superficial
component of the deltoid ligament
(arrow). Bone marrow oedema is seen
in the medial malleolus (arrowhead)
with adjacent mild soft tissue swelling.
There is also bone marrow oedema
in the lateral malleolus (asterisk) with
adjacent mild soft tissue swelling.
Concomitant osteochondral injury
(curved arrow) in the talar dome is
seen. (b) Slightly posteriorly image
showing partial tear of the deep
layer of the deltoid ligament (arrow).
Bone marrow oedema in the medial
malleolus (arrowhead) and lateral
malleolus (asterisk) with adjacent mild
soft tissue swelling. Concomitant
osteochondral injury (curved arrow) in
the talar dome is again seen.

(a) (b)

Figure 8. Left ankle sprain 3 months

previously in a 44-year-old female: (a)
plain radiography showing oblique
fracture of the low shaft of the fibula
suggestive of Weber type B trans-
syndesmotic fracture (arrow), with
no diastasis of the distal tibiofibular
(c) (d) joint. (b) Axial proton density (PD)-
weighted image with fat saturation
showing complete tear of the
anterior inferior tibiofibular ligament
(arrow). The posterior inferior
tibiofibular ligament (curved arrow)
appears striated, which could be
normal or due to strain / partial tear.
(c) Axial PD-weighted image with
fat saturation showing thickening
of the anterior talofibular ligament
(arrow), also evident on magnetic
resonance images 2 years previously
and suggestive of a chronic partial
tear. (d) Coronal T2-weighted image
with fat saturation showing avulsion
fracture of the tip of the medial
malleolus (curved arrow) and partial
tear of the deep layer of the deltoid
ligament (arrow).

24 Hong Kong J Radiol. 2017;20:17-27

 PY Chu, WSW Chan, HC Lee, et al

ligaments.4 Nonetheless, there is usually no residual soft not infrequent and can be seen in up to 26% of severe
tissue oedema or haemorrhage. Scarring or synovial inversion injuries.24 A three-point MRI grading system
proliferation may be encountered surrounding the is used to describe acute ankle ligament injuries.25 Grade
ligaments with decreased signal intensity in all pulse I injury is defined as mild sprain with superficial soft
sequences. tissue oedema around the ligament. Grade II injury is a
partial thickness tear and is seen as thickening / oedema
Lateral ankle sprains represent 16% to 21% of all sports- and internal signal alteration within the substance of the
related traumatic lesions,4 and typically occur during ligament on MRI. Grade III injury is a complete tear,
forced plantar flexion and inversion.18 The ATFL is and MRI shows complete disruption or avulsion of the
the weakest ligament and therefore the most frequently ligament. In chronic injuries of the ATFL, granulation
torn (Figure 6). The lateral collateral ligamentous and scar tissue may form within the anterolateral gutter,
complex usually demonstrates a predictable pattern of leading to impingement from entrapment of the synovial
injury depending on the severity of ankle inversion. membrane between the anterior talus and the adjacent
The ATFL is injured first, followed by the CFL and tibia or fibula.4 This has been described as a meniscoid
then the PTFL (Figure 6).22 The ATFL is injured in lesion due to its similar morphology to a meniscus in
83% of cases, the CFL in 67%, and the PTFL in 34%.23 the knee. This anterolateral impingement is the most
Avulsion fractures of the lateral ankle ligaments are common form of ankle impingement, and patients often

(a) (b)

Figure 9. Right ankle pain after

sprain several years ago in a
63-year-old male: (a) sagittal T1-
(c) (d)
weighted image showing loss of
normal hyperintense fat signal in the
sinus tarsi (arrow). (b) Sagittal T2-
weighted image with fat saturation
showing bright signal intensity
with indistinct ligaments (arrow).
A small subchondral cyst (curved
arrow) is seen in the distal tibia
likely due to degenerative changes.
(c) Axial proton density-weighted
image with fat saturation showing
thin anterior talofibular ligament
(arrow), likely due to prior sprain or
partial tear. (d) Coronal T2-weighted
image with fat saturation showing
disruption of the deltoid ligament
(arrow). Degenerative changes with
subchondral oedema and cysts are
seen (asterisks).

Hong Kong J Radiol. 2017;20:17-27 25

Magnetic Resonance Imaging of Ligamentous Injuries in Ankle Sprain

present with persistent lateral ankle pain and instability. It is a common complication of ankle sprains;
70% of cases have a trauma history, and 30% have
Deltoid ligament complex injuries account for about miscellaneous causes such as ganglion cysts, gout
5% of ankle sprains.26 Pronation-eversion and extreme or pigmented villonodular synovitis. 33 Sinus tarsi
rotation are known to be the mechanism that leads to syndrome is a clinical diagnosis and should not be
deltoid ligament injuries.19 Recent studies show deltoid established solely on MRI findings alone. The sinus
ligament injuries may be more frequent than previously tarsi is best evaluated on T1- and T2-weighted sagittal
thought. 27 Isolated deltoid ligament injuries are images. In MRI, the normal sinus tarsi is T1-weighted
infrequent and often associated with lateral ligamentous hyperintense due to abundant fat, and the ligamentous
injuries, syndesmotic injuries, or malleolar fractures structures are clearly outlined by the bright fat signal.
particularly in Weber type B fracture (Figures 6 to 8).19 In sinus tarsi syndrome, the T1-weighted hyperintense
The deep layer is more commonly injured than the fat signal is replaced with a low signal on T1-weighted
superficial layer, and partial tears are more common images due to fluid or scar tissue, and a bright signal
than full-thickness tears.18,19 Sprains of the deep layer on T2-weighed images, with disruption of or indistinct
of the deltoid ligament are frequently noted on MRI in cervical and interosseous ligaments. 4,18 Associated
patients after inversion injuries (Figure 6).18 MRI findings include osteoarthritis of the subtalar
joint with subchondral oedema or cysts of the talus or
Syndesmotic ligament injury or high ankle sprain calcaneus, or contrast enhancement of the hypertrophied
accounts for approximately 7% of ankle sprains.26 The synovium.4,18
mechanism of injury is thought to be forced external
rotation with ankle dorsiflexion and pronation.28 The TREATMENT
AiTFL is the most commonly torn ligament, and Non-operative management remains the gold standard
is almost always torn before the other syndesmotic for ankle sprains. 34 In acute injuries, conservative
ligaments (Figure 8). 29 The injuries can be either treatment in the form of RICE (rest, ice, compression,
ligamentous tear, avulsion fracture, or both. They can elevation) is recommended.34,35 Functional rehabilitation
be isolated or may occur in conjunction with other (e.g. motion restoration and strengthening exercises)
ankle ligamentous groups, or associated with Weber remains the cornerstone of conservative treatment and is
B or C ankle fractures.30 It is associated with a greater preferred over immobilisation in low-grade sprains.35 In
risk of chronic ankle dysfunction and persistent pain severe ankle sprain, treatment is controversial. Several
and usually requires a longer time to recover previous prospective level I studies have compared non-operative
level of function, compared with other ankle sprains of treatment and operative treatment for grade III sprains
similar severity that do not involve the syndesmosis.31 and shown no significant difference in outcome.36,37
Surgical repair may be considered in patients with
POST-TRAUMATIC SINUS TARSI persistent symptoms and instability who are recalcitrant
SYNDROME to conservative measures.18,34
The sinus tarsi is a cone-shaped cavity in the lateral
aspect of the midfoot between the anterosuperior aspect CONCLUSION
of the calcaneus and the inferior aspect of the talar neck. It is important for the radiologist to recognise the
It opens laterally anterior to the lateral malleolus and complex ligamentous structures in the ankle, including
terminates posteromedially behind the sustentaculum the normal anatomic variants and imaging pitfalls.
tali. The contents of the sinus tarsi include abundant Better understanding of the MRI appearance of various
fat surrounding vessels, nerves, and a ligamentous ligamentous injuries and the associated pathological
complex that comprises the medial, intermediate, and conditions may help guide clinical decision making for
lateral roots of the inferior extensor retinaculum, lateral early and appropriate intervention, and thus prevent
cervical ligament, and medial talocalcaneal interosseous long-term morbidity.
ligament. The sinus tarsi ligaments, nerves, and
vessels play an important role in the stabilisation and REFERENCES
proprioception of the subtalar joint.32 1. Fong DT, Hong Y, Chan LK, Yung PS, Chan KM. A systematic
review on ankle injury and ankle sprain in sports. Sports Med.
2007;37:73-94. cross ref
Sinus tarsi syndrome is a clinical syndrome characterised 2. Marchi AG, Di Bello D, Messi G, Gazzola G. Permanent sequelae
by persistent lateral ankle pain and hindfoot instability.18 in sports injuries: a population based study. Arch Dis Child.

26 Hong Kong J Radiol. 2017;20:17-27

 PY Chu, WSW Chan, HC Lee, et al

1999;81:324-8. cross ref ligament pathologic findings and associated impingement

3. Aerts P, Disler DG. Abnormalities of the foot and ankle: MR syndromes. Radiographics. 2010;30:751-61. cross ref
imaging findings. AJR Am J Roentgenol. 1995;165:119-24. cross ref 20. Mengiardi B, Pfirrmann CW, Vienne P, Hodler J, Zanetti M.
4. Rosenberg ZS, Beltran J, Bencardino JT. From the RSNA Medial collateral ligament complex of the ankle: MR appearance in
Refresher Courses. Radiological Society of North America. MR asymptomatic subjects. Radiology. 2007;242:817-24. cross ref
Imaging of the ankle and foot. Radiographics. 2000;20:S153- 21. Oae K, Takao M, Naito K, Uchio Y, Kono T, Ishida J, et al. Injury
79. cross ref of the tibiofibular syndesmosis: value of MR imaging for diagnosis.
5. Kijowski R, Gold GE. Routine 3D magnetic resonance imaging of Radiology. 2003;227:155-61. cross ref
joints. J Magn Reson Imaging. 2011;33:758-71. cross ref 22. Bencardino J, Rosenberg ZS, Delfaut E. MR imaging of sports
6. Verhaven EF, Shahabpour M, Handelberg FW, Vaes PH, Opdecam injuries of the foot and ankle. Magn Reson Imaging Clin N Am.
PJ. The accuracy of three-dimensional magnetic resonance imaging 1999;7:131-49.
in the diagnosis of ruptures of the lateral ligaments of the ankle. Am 23. Fallat L, Grimm DJ, Saracco JA. Sprained ankle syndrome:
J Sports Med. 1991;19:583-7. cross ref prevalence and analysis of 639 acute injuries. J Foot Ankle Surg.
7. Naraghi A, White LM. Three-dimensional MRI of the 1998;37:280-5. cross ref
musculoskeletal system. AJR Am J Roentgenol. 2012;199:W283- 24. Haraguchi N, Toga H, Shiba N, Kato F. Avulsion fracture of the
93. cross ref lateral ankle ligament complex in severe inversion injury: incidence
8. Park J, Mugler JP 3rd, Horger W, Kiefer B. Optimized T1- and clinical outcome. Am J Sports Med. 2007;35:1144-52. cross ref
weighted contrast for single-slab 3D turbo spin-echo imaging with 25. Gonzalez FM, Morrison WB. Magnetic resonance imaging of
long echo trains: application to whole-brain imaging. Magn Reson sports injuries involving the ankle. Top Magn Reson Imaging.
Med. 2007;58:982-92. cross ref 2015;24:205-13. cross ref
9. Lichy MP, Wietek BM, Mugler JP 3rd, Horger W, Menzel MI, 26. Waterman BR, Belmont PJ Jr, Cameron KL, Svoboda SJ, Alitz CJ,
Anastasiadis A, et al. Magnetic resonance imaging of the body Owens BD. Risk factors for syndesmotic and medial ankle sprain:
trunk using a single-slab, 3-dimensional, T2-weighted turbo-spin- role of sex, sport, and level of competition. Am J Sports Med.
echo sequence with high sampling efficiency (SPACE) for high 2011;39:992-8. cross ref
spatial resolution imaging: initial clinical experiences. Invest Radiol 27. Hintermann B, Knupp M, Pagenstert GI. Deltoid ligament injuries:
2005;40:754-60. cross ref diagnosis and management. Foot Ankle Clin. 2006;11:625-
10. Gold GE, Busse RF, Beehler C, Han E, Brau AC, Beatty PJ, et al. 37. cross ref
Isotropic MRI of the knee with 3D fast spin-echo extended echo- 28. Williams GN, Jones MH, Amendola A. Syndesmotic ankle sprains
train acquisition (XETA): initial experience. AJR Am J Roentgenol. in athletes. Am J Sports Med. 2007;35:1197-207. cross ref
2007;188:1287-93. cross ref 29. Rasmussen O. Stability of the ankle joint. Analysis of the function
11. Ristow O, Steinbach L, Sabo G, Krug R, Huber M, Rauscher I, et and traumatology of the ankle ligaments. Acta Orthop Scand Suppl.
al. Isotropic 3D fast spin-echo imaging versus standard 2D imaging 1985;211:1-75. cross ref
at 3.0 T of the knee: image quality and diagnostic performance. Eur 30. Perrich KD, Goodwin DW, Hecht PJ, Cheung Y. Ankle ligaments
Radiol. 2009;19:1263-72. cross ref on MRI: appearance of normal and injured ligaments. AJR Am J
12. Muhle C, Frank LR, Rand T, Yeh L, Wong EC, Skaf A, et al. Roentgenol. 2009;193:687-95. cross ref
Collateral ligaments of the ankle: high-resolution MR imaging 31. Amendola A, Williams G, Foster D. Evidence-based approach
with a local gradient coil and anatomic correlation in cadavers. to treatment of acute traumatic syndesmosis (high ankle) sprains.
Radiographics. 1999;19:673-83. cross ref Sports Med Arthrosc. 2006;14:232-6. cross ref
13. Milner CE, Soames RW. Anatomical variations of the anterior 32. Lektrakul N, Chung CB, Lai Ym, Theodorou DJ, Yu J, Haghighi P,
talofibular ligament of the human ankle joint. J Anat. 1997;191:457- et al. Tarsal sinus: arthrographic, MR imaging, MR arthrographic,
8. cross ref and pathologic findings in cadavers and retrospective study data
14. Choo HJ, Lee SJ, Kim DW, Jeong HW, Gwak H. Multibanded in patients with sinus tarsi syndrome. Radiology. 2001;219:802-
anterior talofibular ligaments in normal ankles and sprained ankles 10. cross ref
using 3D isotropic proton density-weighted fast spin-echo MRI 33. Breitenseher MJ, Haller J, Kukla C, Gaebler C, Kaider A,
sequence. AJR Am J Roentgenol. 2014;202:W87-94. cross ref Fleischmann D, et al. MRI of the sinus tarsi in acute ankle sprain
15. Delfaut EM, Demondion X, Boutry N, Cotten H, Mestdagh injuries. J Comput Assist Tomogr. 1997;21:274-9. cross ref
H, Cotten A. Multi-fasciculated anterior talo-fibular ligament: 34. Fong DT, Chan YY, Mok KM, Yung PSh, Chan KM.
reassessment of normal findings. Eur Radiol. 2003;13:1836- Understanding acute ankle ligamentous sprain injury in sports.
42. cross ref Sports Med Arthrosc Rehabil Ther Technol. 2009;1:14. cross ref
16. Gyftopoulos S, Bencardino JT. Normal variants and pitfalls in MR 35. Ivins D. Acute ankle sprain: an update. Am Fam Physician.
imaging of the ankle and foot. Magn Reson Imaging Clin N Am. 2006;74:1714-20.
2010;18:691-705. cross ref 36. Kerkhoffs GM, Handoll HH, de Bie R, Rowe BH, Struijs PA.
17. Arnold G, Vohra S, Marcantonio D, Doshi S. Normal magnetic Surgical versus conservative treatment for acute injuries of the
resonance imaging anatomy of the ankle & foot. Magn Reson lateral ligament complex of the ankle in adults. Cochrane Database
Imaging Clin N Am. 2011;19:655-79. cross ref Syst Rev. 2007;2:CD000380. cross ref
18. Nazarenko A, Beltran LS, Bencardino JT. Imaging evaluation of 37. Povacz P, Unger SF, Miller WK, Tockner R, Resch H. A
traumatic ligamentous injuries of the ankle and foot. Radiol Clin randomized, prospective study of operative and non-operative
North Am. 2013;51:455-78. cross ref treatment of injuries of the fibular collateral ligaments of the ankle.
19. Chhabra A, Subhawong TK, Carrino JA. MR imaging of deltoid J Bone Joint Surg Am. 1998;80:345-51. cross ref

Hong Kong J Radiol. 2017;20:17-27 27