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Training Collections
Library Memberships
On-demand course library with video lectures, expert case reviews, and more
Fellowship Certificate™ Programs
Practice-focused training programs designed to help you gain experience in a specific subspecialty area.
Ultimate Learning Pass
Unlock access to our full Course Library and all self-paced Fellowships.
Noon Conference (Free)
Get access to free live lectures, every week, from top radiologists.
Case of the Week (Free)
Get a free weekly case delivered right to your inbox.
Dr. Resnick's MSK Conference
Learn directly from the MSK Master himself.
Lower Extremities MRI Conference
Musculoskeletal Imaging
Emergency Imaging
PET Imaging
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For Training Programs
Supplement your training program with case-based learning for residents, registrars, fellows, and more.
For Private Practices
Upskill in high growth, advanced imaging areas.
Emergency Call Prep
Prepare trainees to be on call for the emergency department with this specialized training series.
Practice Cases
Week 1
6 topics, 11 min.
Practice Cases
Week 2
6 topics, 18 min.
Practice Cases
Week 3
6 topics, 27 min.
Practice Cases
Week 4
6 topics, 7 min.
Practice Cases
Week 5
6 topics, 45 min.
0:00
MRI examination on a 64-year-old man who
0:04
is presenting with medial ankle pain.
0:07
On the left, axial fat-
0:09
suppressed T2-weighted images.
0:12
In the center, T2-weighted
0:14
images without fat suppression.
0:17
And on the right, sagittal state images.
0:20
The medial flexor compartment is abnormal.
0:23
We see thickening of the posterior tibial tendon,
0:29
which has a fusiform hypertrophic configuration
0:34
with multiple intrasubstance longitudinal
0:38
split hairs and associated tenosynovitis with
0:42
a small effusion within the tendon sheath.
0:47
Also noted is thickening of the flexor
0:49
retinaculum as it attaches into the medial
0:54
margin of the tibial retromalleolar groove
0:57
with an associated small enthesophyte.
1:01
So this is due to traction-related
1:05
enthesopathy of the flexor retinaculum
1:09
at the insertion into the bone.
1:12
With associated reactive marrow edema,
1:15
ancillary findings of posterior tibial
1:17
tendon dysfunction in a patient who was
1:20
also presenting with flat foot deformity.
1:24
The posterior tibial tendon is the main
1:26
dynamic stabilizer of the medial longitudinal
1:30
arch and is frequently disrupted in patients
1:34
who have acquired this planus deformity.
1:37
So in this patient, to summarize, we have severe
1:41
tendinosis of the posterior tibial tendon
1:45
manifested by fusiform thickening of the
1:50
tendon in the supramalleolar and infra-
1:54
malleolar regions with longitudinal splitter
1:58
of the fibers and associated vir and
2:04
enthesopathy at the insertion of the flexor.
Wk 2, Case 3 - Review
HIDEInteractive Transcript
0:00
MRI examination on a 64-year-old man who
0:04
is presenting with medial ankle pain.
0:07
On the left, axial fat-
0:09
suppressed T2-weighted images.
0:12
In the center, T2-weighted
0:14
images without fat suppression.
0:17
And on the right, sagittal state images.
0:20
The medial flexor compartment is abnormal.
0:23
We see thickening of the posterior tibial tendon,
0:29
which has a fusiform hypertrophic configuration
0:34
with multiple intrasubstance longitudinal
0:38
split hairs and associated tenosynovitis with
0:42
a small effusion within the tendon sheath.
0:47
Also noted is thickening of the flexor
0:49
retinaculum as it attaches into the medial
0:54
margin of the tibial retromalleolar groove
0:57
with an associated small enthesophyte.
1:01
So this is due to traction-related
1:05
enthesopathy of the flexor retinaculum
1:09
at the insertion into the bone.
1:12
With associated reactive marrow edema,
1:15
ancillary findings of posterior tibial
1:17
tendon dysfunction in a patient who was
1:20
also presenting with flat foot deformity.
1:24
The posterior tibial tendon is the main
1:26
dynamic stabilizer of the medial longitudinal
1:30
arch and is frequently disrupted in patients
1:34
who have acquired this planus deformity.
1:37
So in this patient, to summarize, we have severe
1:41
tendinosis of the posterior tibial tendon
1:45
manifested by fusiform thickening of the
1:50
tendon in the supramalleolar and infra-
1:54
malleolar regions with longitudinal splitter
1:58
of the fibers and associated vir and
2:04
enthesopathy at the insertion of the flexor.
Report
Patient History
64-year-old man complaining of medial ankle pain for 6 months.
Findings
SKELETAL/BONES:
Prominent retrotibial DEEP bifid groove with osseous spurring medially (in which the posterior tibial tendon sits). Extensive reactive stress related osteoedema surrounding prominent retrotibial groove.
No other reactive pattern of marrow edema. No micro- or macro-trabecular fracture or stress fracture. No aggressive osseous abnormality.
Hindfoot valgus is noted. No pes planus in the dorsiflexed position.
No os navicularis, os peroneus, or os trigonum.
ARTICULATIONS:
Tibiotalar joint/talar dome: Incidental moderate-sized non-shouldered osteochondral lesion at the medial aspect of the talar dome, measuring 10 mm AP and 4 mm transverse diameter. Associated overlying full-thickness chondral defect. Mild tibiotalar capsulitis associated with a trace effusion.
Ankle mortise/syndesmosis: The ankle mortise is in anatomic alignment. No syndesmotic widening.
Chopart joint: Unremarkable.
Midfoot/hindfoot: No fracture or injury of the anterior calcaneal process. No prominent midfoot or hindfoot arthrosis.
Lisfranc joint: Unremarkable.
LIGAMENTS:
High ankle: Intact.
Low ankle: Intact.
Subtalar/Chopart: Intact. In particular, the spring ligaments and short and long plantar ligaments are intact and unremarkable in appearance.
TENDONS:
Diffuse posterior tibial tendon hypertrophic tendinosis, with associated tenosynovial thickening and edema (tenosynovitis).
Extensive complex hypertrophic supra-, juxta- and inframalleolar tear of the posterior tibial tendon. The tear extends from the supramalleolar portion (at least 5.5 cm above the medial malleolus), to just short of the distal insertion and separation into its individual attachments (measuring a total length of approximately 8 cm). Tear morphology is predominantly longitudinal interstitial, with a short segment split component in the juxtamalleolar region.
Mild reactive synovial thickening of the flexor digitorum longus. Flexor hallucis longus tendon unremarkable.
Extensor digitorum and peroneus tertius tenosynovitis with moderate-sized tenosynovial sheath effusions. Unremarkable tibialis anterior tendon.
Mild juxtamalleolar peroneus longus and brevis tenosynovitis.
Achilles tendon intact and unremarkable in appearance.
Incidental note is made of small amount of dependently positioned fluid at the knot of Henry, with a prominent intertendinous slip.
GENERAL:
Sinus tarsi: Mild diffuse capsulitis. Stem ligament capsulosynovial bursal cyst. Intact cervical and intraosseous ligaments.
Muscles: No traumatic muscle injury. No volumetric muscle atrophy.
Soft tissue: Diffuse soft tissue swelling/edema surrounding the posterior tibial tendon.
Plantar fascia: Diffuse mild thickening of the central cord of the plantar fascia proximally, consistent with chronic plantar fasciitis. No evidence for active fasciitis. No plantar fascial tear.
Neurovascular complex/tarsal tunnel: Unremarkable. No evidence of entrapment neuropathy.
Intra-articular/loose bodies: None.
Impressions
1. Dominant hypertrophic posterior tibial tendinosis/tenosynovitis with 8 cm supra-, juxta- and inframalleolar posterior tibial tendon tear.
2. Prominent bifid retrotibial groove with reactive/stress related osteoedema (likely contributing to the chronic posterior tibial tendinopathy).
3. Incidental extensor digitorum and peroneus tertius tenosynovitis with associated moderate-sized tenosynovial effusions.
4. Incidental moderate-sized non-shouldered talar dome osteochondral lesion.
Case Discussion
Faculty
Stephen J Pomeranz, MD
Chief Medical Officer, ProScan Imaging. Founder, MRI Online
ProScan Imaging
Todd D. Greenberg, MD
Radiologist
ProScan
Tags
Musculoskeletal (MSK)
MRI
Foot & Ankle
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