Case Challenge

Foot & Ankle

Stephen J Pomeranz

Gain confidence interpreting Foot & Ankle MRI Cases with MRI Online. Quiz yourself using real-world, interactive scrollable cases & earn CME. Try it free!

Case Review

Musculoskeletal (MSK)

Post-Course Activities

This Power Pack is comprised of 25 unique Foot / Ankle MRI cases that you can scroll through in our diagnostic web viewer to determine your findings. Quiz yourself and earn CME.

Foot & Ankle MRI Cases

Case 5 - 28-year-old female with left ankle pain

<div>HISTORY:&#160;This 28-year-old female presents with left ankle and foot pain, no history of surgery, and no recent injury.(QUIZ ANSWER) PRIMARY RARE ANOMALY IN THIS CASE:&#160;Talonavicular coalition.Using the&#160;diagnostic web viewer, we have provided images that assist in telling our clinical story. Areas of significance are indicated below.FINDINGS: Bones about the ankle and hindfoot demonstrate no well defined macrofracture or stress fracture. Talar dome intact with no osteochondral defect. No substantive ankle joint arthropathy. Small amount of capsular fluid. No ankle joint loose body.&#160;&#160;&#160;Achilles tendon and plantar fascia are intact. No plantar fasciitis.&#160;&#160;&#160;Study includes the midfoot, demonstrating evidence of mild/early tarsometatarsal joint degenerative arthropathy.Best appreciated on the sagittal and coronal datasets is apparent absence of the tarsal navicular bone. The talar neck appears elongated, and the talar head somewhat large in size. The constellation of findings suggests the rare form of congenital talonavicular coalition, with solid bony coalition present. The enlarged talar head directly articulates with the cuneiform bones, which appear slightly shortened in length. There is moderate severity arthropathy along the talar-cuneiform articulations, with dorsal hypertrophic bony spurring or bony beak along the dorsal aspect of the head of talus. Small ossicle at the dorsal aspect of the talar-cuneiform articulation likely represents a small accessory ossicle.There is prominent and extensive bone marrow edema throughout much of the hindfoot, involving the body of the talus and calcaneus about the posterior subtalar joint. Findings consistent with high grade stress reaction. There is moderate bony spurring about the periphery of the posterior subtalar joint, with evidence of associated capsulosynovitis most apparent within the posterior capsular recess. Evidence of bony sclerosis along the dorsal aspect of the superior calcaneal angle, along with pes planus which is evident on the sagittal datasets. On sagittal datasets image numbers 13 and 14, the middle subtalar joint and calcaneal sustentaculum appear hypoplastic. Hypointense signal seen within this middle subtalar joint is suspicious for fibrocartilaginous talocalcaneal coalition across the middle subtalar joint. CT scan of the hindfoot may be helpful in further evaluation.&#160;&#160;&#160;Prominent bone marrow edema is also seen within the cuboid and lateral cuneiform bones, surrounding the articulation between these two bones. The axial datasets in particular favor moderate to severe cuneocuboid arthropathy over a rare form of fibrocartilaginous cuneocuboid coalition, with prominent hypertrophic bony spurring along the dorsal aspect of its articulation. Mild surrounding soft tissue edema and swelling.Best appreciated on the sagittal datasets also is solid bony fusion or coalition of the base of 2nd metatarsal and a small middle cuneiform bone.No findings suspicious for acute/recent ankle ligament sprain. However, the ATF ligament appears thinned or attenuated, suggesting prior/chronic moderate to high grade ligament sprain. Thickening of the calcaneofibular ligament (CFL), either developmental or reflective of old injury. Deltoid ligament intact. Syndesmotic ligament complex intact with no evidence of recent or high grade high ankle sprain.There is mild to moderate hypertrophic tendinopathy involving the peroneus longus and brevis tendons, most apparent along the juxtamalleolar tendon segments. Small amount of tendon sheath fluid suggests mild peritendinitis, but no discrete tendon tear is noted. Anterior tendon group intact. Medial tendon group including tibialis posterior tendon intact.&#160;&#160;&#160;No soft tissue mass about the ankle or hindfoot. Moderate degree of subcutaneous soft tissue edema and swelling is present along the lateral aspect of the ankle and extends along the dorsolateral foot, of uncertain etiology.&#160;&#160;&#160;CONCLUSION:&#160;&#160;&#160;1. Findings most compatible with congenital, solid osseous talonavicular coalition, with articulation of the enlarged talar head directly with the cuneiform bones and associated moderate severity degenerative arthropathy.&#160;&#160;&#160;2. Hypoplastic middle subtalar joint and sustentaculum tali, with associated signal change suspicious for fibrocartilaginous talocalcaneal coalition across the middle subtalar joint.&#160;&#160;&#160;3. Moderate severity posterior subtalar joint degenerative arthropathy, with associated capsulosynovitis posteriorly. Adjacent high-grade stress reaction, body of talus and calcaneus.&#160;&#160;&#160;4. Moderate to severe arthropathic change along the cuneocuboid articulation, with associated prominent osseous stress reaction, for which degenerative arthropathy is favored over an additional site of fibrocartilaginous coalition.&#160;&#160;&#160;5. Pes planus.&#160;&#160;&#160;6. Congenital osseous coalition, 2nd metatarsal base and small middle cuneiform born.&#160;&#160;&#160;7. Mild to moderate peroneus longus and brevis hypertrophic tendinopathy, with mild peritendinitis but no tendon tear.&#160;&#160;&#160;8. Moderate subcutaneous soft tissue edema and swelling along the lateral ankle and extending distally along the dorsolateral foot, of uncertain etiology.&#160;&#160;&#160;9. Additional findings and pertinent negatives as above.</div>

Case

Which of the following is the PRIMARY rare anomaly in this case?