AJR Integrative Imaging

LIFELONG LEARNING
FOR RADIOLOGY

Imaging Evaluation of Foot and Ankle Pathology:

Self-Assessment Module
Catherine C. Roberts1, William B. Morrison2, and Patrick T. Liu1
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ABSTRACT REQUIRED ACTIVITIES

The educational objectives of this self-assessment module
are for the participant to exercise, self-assess, and improve
his or her understanding of the imaging evaluation of foot
and ankle pathology.
INTRODUCTION
This self-assessment module on the imaging evaluation of
foot and ankle pathology has an educational component and
a self-assessment component. The educational component
consists of three 30-minute webcasts for the participant to
view. The self-assessment component consists of nine multi-
ple-choice questions with solutions. All of these materials
are available on the ARRS Web site (www.arrs.org). To claim
CME and SAM credit, each participant must enter his or her
responses to the questions online.
EDUCATIONAL OBJECTIVES
By completing this educational activity, the participant will:
A. Exercise, self-assess, and improve his or her understand-
ing of the imaging evaluation of foot and ankle masses.
B. Exercise, self-assess, and improve his or her understand-
ing of the imaging of foot and ankle infections.
C. Exercise, self-assess, and improve his or her understand-
ing of optimizing CT of the foot and ankle.
(available at www.arrs.org)
1. Roberts CC. MRI of foot and ankle masses. ARRS web-
cast. http://ndgo.net/arrs/2007/roberts/. Published Feb-
ruary 20, 2007. Accessed February 20, 2007
2. Morrison WB. Imaging of foot and ankle infection. ARRS
webcast. http://ndgo.net/arrs/2007/morrison/. Published
February 20, 2007. Accessed February 20, 2007
3. Liu PT. MDCT of the foot and ankle: technique and ap-
plications. ARRS webcast. http://ndgo.net/arrs/2007/
liu/. Published February 20, 2007. Accessed February 20,
2007
INSTRUCTIONS
1. View the required webcast materials.
2. Visit www.arrs.org and select Publications/Journals/
SAM Articles from the left-hand menu bar.
3. Using your member login, order the online SAM as directed.
4. Follow the online instructions for entering your responses
to the self-assessment questions and then complete the
test by answering the questions online.

Keywords: ankle, CT, foot, infection, mass, MRI

DOI:10.2214/AJR.07.7023
Received June 19, 2007; accepted after revision September 17, 2007.
Department of Radiology, Mayo Clinic College of Medicine, 5777 E Mayo Blvd., Phoenix, AZ 85054. Address correspondence to C. C. Roberts (roberts.catherine@mayo.edu).
1

Department of Radiology, Thomas Jefferson University Hospital, Philadelphia, PA.

2

AJR 2008;190:S18S22 0361803X/08/1903S18 American Roentgen Ray Society

S18 AJR:190, March 2008

 Foot and Ankle Pathology

QUESTION 1
Which soft-tissue mass is MOST common in foot
and ankle?
A. Mortons neuroma.
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B. Pigmented villonodular synovitis.

C. Ganglion cyst.
D. Plantar fibromatosis.
E. Hemangioma.

QUESTION 2
An MRI appearance of homogeneous low
T1- and T2-weighted signal with enhancement Fig. 1Short-axis T1-weighted fat-suppressed contrast-enhanced image
is MOST typical of which foot and ankle mass? of the foot of 56-year-old diabetic man with plantar ulceration.

A. Mortons neuroma.
B. Lipoma.
QUESTION 5
C. Ganglion cyst.
D. Plantar fibromatosis. Regarding the MRI protocol for evaluation of
E. Hemangioma. diabetic pedal disease, which of the following
statements is TRUE?
QUESTION 3 A. The head coil is recommended for imaging both
Which is the most specific examination for feet at once.
characterization of a soft-tissue neoplasm in B. Field of view should always be large to include
the foot? the lower calf.
C. No fat suppression is needed for T2-weighted
A. MRI. imaging.
B. PET. D. A STIR sequence can be useful to provide more
C. CT. homogeneous fat suppression.
D. Sonography. E. IV gadolinium contrast material provides no
E. Radiography. benefit.

QUESTION 4
With respect to the foot of a diabetic patient
in Figure 1, which of the following
statements is TRUE?
A. Enhancement of the soft tissue around the ulcer
represents devitalization.
B. A rim-enhancing sinus tract extends from the ulcer to
the bone, but there is clearly no osteomyelitis.
C. Cystic change seen at the midfoot is compatible
with osteoarthritis or neuropathic
osteoarthropathy.
D. There is evidence of osteomyelitis involving the
fifth metatarsal bone.
E. Findings are compatible with neuropathic disease
with no osteomyelitis.
QUESTION 6
Which of the following statements is TRUE?
A. After amputation, marrow edema and
enhancement of the marrow is considered a nor-
mal finding on MRI.
B. In the setting of diabetes, soft-tissue edema on
T2-weighted MR images is consistent with cel-
lulitis.
C. Diabetic pedal infection typically is due to the
hematogenous spread of bacteria.
D. Neuropathic disease of the feet in diabetes makes
a patient more susceptible to infection.
E. The most common site for neuropathic
osteoarthropathy of the diabetic foot is the
metatarsophalangeal region.

AJR:190, March 2008 S19


QUESTION 7
When performing a CT examination on a
patient who has a metal fixation screw placed
for posterior subtalar arthrodesis, which of the
following is TRUE?
A. The scanning plane should be oriented
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perpendicular to the long axis of the screw to
limit metal artifact to the fewest number of slices.
B. Multiplanar reformations are made from raw CT
data sets.
C. The hindfoot should be scanned in both the axial
and the coronal planes.
D. Detector collimation should be increased to > 1 mm
to maximize the signal-to-noise ratio of the images.
E. If the subtalar joint has bone fusion across 50% of
the length of the joint on a sagittal series, then the
fusion is probably stable.
QUESTION 8
Which of the following statements about
fractures around the ankle is TRUE?
A. Pilon fractures are usually due to external rotation
injuries.
B. Extension of a talar neck fracture through the
talar dome articular surface is associated with a
high rate of posttraumatic arthritis.
C. The risk of talar dome avascular necrosis after a
talar neck fracture is high if the fracture extends
through the anterior process.
D. Fractures of the sustentaculum tali are usually due
to avulsion by the deltoid ligament.
E. The blood supply to the talar dome enters at the
anterior process.
QUESTION 9
Concerning fracture healing, which of the
following is TRUE?
A. A 10-month-old fracture that has not yet healed, but
shows slight progression of endosteal bridging and
callus formation, can be considered a nonunion.
B. A 6-month-old fracture that has radiolucency of
the fracture line and mild callus formation cannot
be considered a delayed union.
C. A hypertrophic fracture nonunion will have a
better chance of healing if a bone graft is used to
increase mechanical stability.
D. An atrophic fracture nonunion will have an
increased chance of healing if an external fixator
is used to improve stability.
S20 AJR:190, March 2008
Solution to Question 1
Ganglion cyst is the most common soft-tissue mass of the
foot and ankle [1]. Ganglion cysts are focal collections of
mucoid material found near a joint or tendon sheath [2].
Option C is the best response. Mortons neuroma is less com-
mon than ganglion cyst. Mortons neuromas are a fibrosing
degenerative process surrounding a plantar digital nerve,
not a true neuroma. Option A is not the best response. Pig-
mented villonodular synovitis (PVNS) is less common than
ganglion cysts. PVNS is a proliferative synovial disorder re-
sulting in a single or multiple intraarticular masses. Giant
cell tumor of tendon sheath is the focal form of PVNS af-
fecting a tendon sheath or bursa. These lesions can show
intense heterogeneous enhancement. The multiple synovial
masses in PVNS contain regions of low T1- and T2-weighted
signal, which bloom on gradient-echo sequences because of
hemosiderin. Option B is not the best response. Plantar fi-
bromatosis consists of aggregates of fibroblasts in the plan-
tar fascia. The classic location involves the superficial me-
dial aspect of the plantar fascia. Option D is not the best
response. Hemangiomas are not the most common mass in
the foot, although they are the most common tumor of vas-
cular origin [3]. Option E is not the best response.
Solution to Question 2
Masses predominantly composed of fibrous tissue can
have homogeneously low T1- and T2-weighted signal with
enhancement. This is most commonly seen in fibrous masses
containing mature collagen. Fibrosing masses containing
immature fibrous tissue or fibroblasts can have intermedi-
ate signal intensity. Fibrosing masses include plantar fibro-
matosis and fibroma of tendon sheath. Option D is the best
response. Mortons neuromas typically have intermediate
signal that is isointense to muscle on T1-weighted and low
signal on T2-weighted sequences with variable enhance-
ment [4]. Option A is not the best response. Lipomas follow
fat signal intensity. They typically have high T1- and T2-
weighted signal and low signal on fat-suppressed sequences
[5]. Option B is not the best response. The typical appear-
ance of a ganglion cyst on MRI is a well-defined mass with
low T1- and high T2-weighted signal. Uncomplicated gan-
glion cysts do not have central enhancement, although a
thin rim of enhancement may surround the ganglion. If a
suspected ganglion cyst has central enhancement, then ma-
lignancy must be excluded. Option C is not the best re-
sponse. Hemangiomas have mixed signal on T1- and T2-
weighted sequences because of the presence of vessels, fat,
and fibrous tissue [3]. The vascular portions of heman-
giomas homogeneously enhance. Option E is not the best
response. Densely calcified masses can have low T1- and T2-
weighted signal, but would not be expected to enhance.
Solution to Question 3
MRI is the study of choice for the evaluation of soft-tissue
neoplastic masses in the foot [6]. MRI signal characteristics
combined with the location of the mass can reveal a character-
 Foot and Ankle Pathology
istic appearance for several entities. Enhancement characteris-
tics can be important when assessing soft-tissue masses in the
foot and are most helpful in differentiating benign cysts from
solid masses [6]. Malignant masses in the foot can be well de-
fined and have T1- and T2-weighted signal similar to cysts,
thus making the presence or absence of enhancement critical
for differentiation [7]. Unenhanced MRI is also widely used
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and, for some foot masses, performs as well as enhanced MRI.
Option A is the best response. PET, especially when combined
with CT, has great promise for staging musculoskeletal neo-
plasms but has not been proven to characterize masses more
specifically than MRI. Option B is not the best response. CT is
not the diagnostic imaging study of choice. CT can be useful
for assessing the underlying bone, but does not best character-
ize soft-tissue masses. However, CT can confirm the presence
of fat in a mass. Option C is not the best response. Sonography
of soft-tissue masses is relatively nonspecific when compared
with enhanced MRI. Option D is not the best response. Radi-
ography poorly characterizes soft-tissue masses, but can assess
the underlying bone. Option E is not the best response.
Solution to Question 4
Subchondral cysts are a hallmark of degenerative arthritis;
osteoarthritis is common at Lisfrancs (tarsometatarsal) joint.
In the setting of diabetes, chronic neuropathic osteoarthropa-
thy should also be considered. Acute inflammatory conditions
such as septic arthritis do not result in cyst formation. There-
fore, the presence of subchondral cysts argues against septic
arthritis in patients with marrow abnormality. Osteoarthritis
with superimposed infection remains a possibility, but infection
rapidly destroys the cartilage and subchondral plate, resulting
in the initial disappearance or obscuration of cysts [8]. After
infection clears, secondary osteoarthritis results in the reap-
pearance of cysts. Option C is the best response. Although en-
hancement is present in the medial plantar tissues around the
ulcer, no enhancement would be seen with devitalization of the
soft tissues [9, 10]. This finding represents cellulitis. Option A is
not the best response. In general, in the setting of diabetic foot
ulceration when there is communication of the skin surface and
bone (via deep ulceration or sinus tract), osteomyelitis is often
present [9, 11, 12]. Enhancement of the first cuneiform adja-
cent to the sinus tract disproportionate to the rest of the Lis-
franc joint suggests early osteomyelitis. Option B is not the best
response. The fifth metatarsal bone shows normal signal, which
is low on this fat-suppressed T1-weighted image [12]. Option D
is not the best response. As with option C, cysts are compatible
with a neuropathic joint. However, a sinus tract extending from
an ulcer to the medial cuneiform with adjacent marrow en-
hancement should suggest the presence of superimposed osteo-
myelitis [9, 11, 12]. Option E is not the best response.
Solution to Question 5
Heterogeneous fat suppression can result from a variety
of factors, including nearby metal or a large field of view. If
AJR:190, March 2008 S21
presaturation of fat resonance frequency results in a hetero
geneous signal, an inversion recovery sequence, which pro-
vides more homogeneous fat suppression, should be per-
formed [9, 12]. Option D is the best response. The smallest
coil available to image the desired field of view should al-
ways be used [9]. Imaging both feet with a head coil ap-
pears more efficient but results in suboptimal imaging of
both sides. Each foot should be imaged separately. Option
A is not the best response. The calf should be included if
there is clinical concern for proximal spread of infection.
However, this is relatively rare [11], and the large field of
view renders interpretation of the small bones of the foot
limited because they are subject to volume averaging ef-
fects. Option B is not the best response. Infection results in
edema: marrow edema in osteomyelitis and soft-tissue ede-
ma in cellulitis [12]. On T2-weighted spin-echo and espe-
cially fast spin-echo imaging, fat in marrow and subcutane-
ous tissues is hyperintense, which can obscure subtle areas
of edema [9]. Fat suppression should be used when avail-
able unless there is significant artifact [9, 10, 12]. Option C
is not the best response. IV gadolinium contrast material
facilitates identification of abscesses, sinus tracts, and devi-
talized regions; differentiation of cellulitis from diabetic
soft-tissue edema; and differentiation of bland fluid from
septic arthritis and septic tenosynovitis [912]. Option E is
not the best response.
Solution to Question 6
Neuropathic disease can lead to skin breaks due to minor
trauma such as toenail cutting. Also, decreased perception
of injury and inflammation can cause propagation of ulcers
as well as superinfection [9, 11, 12]. Neuropathic disease
with joint deformity and muscle imbalance can also lead to
abnormal prominences that result in callus formation. Isch-
emic calluses subsequently break down, forming ulcers [8].
Option D is the best response. After amputation, marrow
signal is generally normal, even shortly after surgery. There-
fore, a diabetic patient presenting with wound breakdown
after amputation who has marrow edema and enhancement
at the amputation site on MRI should be considered highly
suspicious for underlying osteomyelitis [9]. Option A is not
the best response. Diffuse soft-tissue edema is quite com-
mon in the feet of diabetic patients on MR images [9, 10,
12]. This may be related to vascular insufficiency or neu-
ropathy, but it does not necessarily imply the presence of
inflammation. IV contrast material can distinguish dia-
betic edema from inflammation if there is adequate blood
flow [10, 12]. Option B is not the best response. In most
areas of the body, the hematogenous route is the most com-
mon mode for the spread of infection. However, in the dia-
betic foot, the overwhelming mode ( 90%) is contiguous
spread from adjacent soft-tissue ulceration [9, 11, 12]. Op-
tion C is not the best response. The most common site for
neuropathic osteoarthropathy in feet of diabetic patients is
 Roberts et al.
Lisfrancs joint. The metatarsal bases subluxate superiorly
relative to the midfoot, leading to a rocker-bottom foot de-
formity. The intertarsal joints, Choparts joint, ankle, and
subtalar joint also are common sites of involvement. Neu-
ropathic osteoarthropathy occurs at the metatarsophalan-
geal joints but is relatively less common in this location [8].
Option E is not the best response.
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Solution to Question 7
Bone fusion across more than 50% of the joint space in-
dicates that the arthrodesis is likely stable. Option E is the
best response. To limit metal artifact from the screw to the
fewest number of slices, the scanning plane should be
aligned parallel to metal screws, not perpendicular. This
will concentrate all of the artifact on a few slices, leaving
the rest of the slices essentially undegraded. This can be
useful when assessing an arthrodesis of a small joint, such
as the subtalar joint. Orienting the gantry perpendicular to
metal screws is another good positioning option. This will
spread the artifact over all of the slices, instead of concen-
trating it in a few. Option A is not the best response. Raw
CT data are the digital form of scan data, not viewable in
an image format until they are reconstructed with operator-
specified field of view, kernel, slice thickness, and spacing.
Multiplanar reformations (MPRs) are made from minimal-
thickness axial source images, not raw data [13]. Option B
is not the best response. The ankle should be scanned in
only one plane. Two reconstructions should be made: one
set of axial 2- to 3-mm thick axial slices for routine review
and a set of thin overlapping source images that will be
used to make MPRs in the other desired planes. Option C is
not the best response. Because the minimum slice recon-
struction width is limited by the detector collimation, in-
creasing the collimation width will result in thicker source
images to be used for MPRs. The resulting MPRs will have
blurring of small structures such as bone trabeculae. Op-
tion D is not the best response.
Solution to Question 8
Extension of a fracture into the talar dome is likely to
lead to posttraumatic degenerative joint disease, usually af-
fecting both the ankle and the subtalar joints [14]. Option B
is the best response. Pilon fractures usually are due to axial
loading injuries, such as a fall from a height. Option A is not
the best response. The risk of avascular necrosis of the talus
is increased with subluxation or dislocation of the subtalar
or ankle joint but is unrelated to involvement of the ante-
rior process. Option C is not the best response. Fractures of
the sustentaculum tali usually are due to vertical shear
forces from axial loading injuries. Option D is not the best
response. The blood supply to the talar dome consists of
branches of the anterior tibial artery that enter the bone at
the talar neck. Option E is not the best response.
S22 AJR:190, March 2008
Solution to Question 9
A hypertrophic nonunion is thought to have hypervascu-
larity and a capacity for biologic activity; however, healing
is hindered by a lack of mechanical stability. Option C is the
best response. Fracture nonunion is defined as a lack of
healing 9 months after the fracture occurred and 3 months
without progression of healing [15]. Option A is not the
best response. Delayed union of a fracture is defined as fail-
ure to unite completely as expected, but with continued
biologic activity. Option B is not the best response. An atro-
phic nonunion is thought to be avascular and lacks the bio-
logic capacity to heal, even with proper stabilization. Deb-
ridement or a vascularized bone graft would be needed to
stimulate healing. Option D is not the best response.
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