hello everybody and welcome back to another Anatomy tutorial today we're going to be looking at an ankle MRI and this is a talk that's following on from our previous talk where we looked at an ankle and foot radiograph so if you haven't watched that video I'd highly suggest watching that first and make sure you've got the Bony Anatomy waxed now there's a lot to cover on an ankle MRI and we're going to take this systematically identifying the various different bones and Joint spaces in the ankle then looking at the various ligaments tendons and some miscellaneous structures that we're going to need to look at for our part 1 Anatomy exams so let's start by having a look at the sagittal PD image of the ankle we can see superiorly our tibia and our tibia is articulating with our Talus here with our tailored Dome we have our tailored Dome our tailored body neck here and tailor head the tailor head then articulates without navicular bone anteriorly below the talus is our subtalar joint that's the articulation between the talus and our calcaneus so we can see how cocaine is here here is our posterior articulation we can scroll right the way through that posterior articulation then we have a middle articulation here which is our sustentaculum Tali of the calcaneus articulating with the talus so we can go through that joint space here and then anteriorly on the anterior process of our calcaneus there's a small joint here our anterior subtalar joint so there's three joint spaces that we need to look at in the subtalar join space and then we can scroll across the dorm of the tailors as well to make sure we've got continuous cartilage there's no disruption of the cartilage along that Taylor dome in the tibialplified we can see that our cartilage here is hypo intense compared to the subchondral Bone plate here so our TBO we can scroll all the way out to our medial malleolus come back in here we can then scroll all the way laterally to our fibula you can see the fibula bone there oh calcaneus has an anterior process that articulates with our cuboid bone here so we can scroll all the way through the cuboid look at that calcanea cuboid joint as well our cuboid bone articulates with our fourth and our fifth metatarsals at the metatarsal bases here then if we go back to our Talus tailor head articulating with our navicular bone our navicular bone articulates without lateral Canaveral our intermediate Canaveral and our medial cane form here which then articulates with our first second and third metatarsals respectively but that's getting onto our foot MRI these are the major bones that we're looking at on our ankle MRI now when you're trying to identify various different structures within the ankle our axial image is going to give us the most bang for our back when trying to look at these different structures so I'm going to start by scrolling proximally and we're going to see how tibia lies medially and our fibula lies laterally now the first ligament that I want to look at is our tibiofibular syndesmosis now if we have a look at a CT reconstruction of the ankle we can see the various different bones that we're dealing with here if I rotate this slightly round we can see our tibia with our medial malleolus and our fibula with our lateral malleolus now the tibial fibulus in desmosis occurs here it's actually technically not an ankle joint but it is included as part of our ankle series we have an anterior inferior tibiofibular ligament that runs from the superior lateral portion of altibia and runs inferior laterally down towards our fibula in this direction here and the same happens on the other side of the ankle we've got a posterior inferior tibiofibular ligament that runs at this angle here from the posterior lateral surface of the tibia down infrar laterally towards alphability here so let's have a look at that on our MRI we're going to start by having a look at the axial MRI again I'm going to scroll up above the ankle joint and here we can see our interosseous membrane that is attaching our tibia to our fibula this is our syndesmosis here and we can see these bundles running from Superior down inferior laterally to the medial surface of that fibula here so we can see those bundles there at the level of this type of fibulation desmosis here is our posterior inferior tibiofibular ligament we can scroll down and we can see that the inferior portion of our tibia here what we looked at is called our posterior malleolus of the ankle there is our ligament heading across towards the fibula anteriorly if we scroll superiorly a little bit we can see that ligament coming from the tibia to the fibula here and it's often quite difficult to see on this axial plane if we look in our coronal planes here we can see some of those fibers heading across so let me head posteriorly in this image so we should just see just our calcaneus and scroll anteriorly until we can see our tibia and our fibula coming into view here is that posterior inferior tibiofibulate ligaments as we scroll more and more anteriorly we then should see those anterior fibers heading from the tibia to the fibula there now the reason I'm stressing that we must look at where the fibers are going is we don't want to get these confused with our talofibular ligaments our lateral ligaments of the ankle our talofibular ligaments run from the talus to the fibula they are actually Crossing that ankle joint so if we have a look here at our 3D reconstructions our talofibular ligament our anterior one is running from the anterior surface of the tailors here towards the fibula and the same thing happens on the posterior side it runs from this lateral tuberosity of our posterior process across two alphabila we also have a ligament that runs from our fibula down towards our calcaneus our calcaneofibular ligament you'll notice that when we're naming these we're talking about the bone that's coming from heading towards the fibula a calcaneofibula our anterior talofibula posterior Taylor fibula the opposite happens on the medial side where we talk about tibio Taylor tibial cocaine is so let's identify those three ligaments our three lateral ligaments of the ankle and we'll start by looking at the axial view again so we know the lateral on the fibula here we've seen our posterior inferior tibiofibular ligaments now let's scroll down inferiorly more until that tibia comes out of you and we should see this large broad-based ligament coming from the posterior aspect of our Talus here we can see a hypo intense structure Fanning out towards this ligamentous surface of our fibula here we can see we get some signal heterogeneity in this posterior Taylor fibular ligament which is normal anteriorly we've got this dark band this is our anterior talofibular ligament this is perhaps the most important ligament to look at when looking at the ankle because it's the most commonly torn when you stand on the edge of a step or the edge of a pool and you hyperplant to flex your ankle here this is the first ligament that normally ruptures we normally Rapture ligaments from anterior to posterior so this is our anterior Taylor fibular ligament and this is our posterior Taylor fibula ligament we can see those on our coronal views as well here we can see our posterior talofibular ligament and as we had our anterior dvcr anterior table fibular ligament now we can look at our calcaneofibular ligament so we go down to the inferior process of our lateral malleolus and we keep heading down inferiorly and we should see medial to these two tendons a ligament coming down inferiorly and posteriorly there see that ligament coming up it's going to hit and attach to the inferior surface of our fibula it's normally easier to see on our coronal Planes find our calcaneus required posterior here we can't see tibial fibula and it's often easy to find the ligament coming off the calcaneus first we see it here here is that ligament it runs medial to these tendons our peroneus brevis and our perineous longest tendons that we're going to look at runs medial to those tendons and then wraps around them and inserts into this lateral malleaters so we can follow it down posteriorly attaching to the cocaine is a cocaine fibular ligament so we've identified the three lateral ligaments of the ankle our anterior Taylor fibula are called canoe fibula and our posterior telofibula let's head on to our medial structures our deltoid ligaments of the medial aspect of the ankle now we can separate our deltoid ligament into a deep layer and a superficial layer now our deep layer is a long band hitting from anterior to posterior and it's actually a continuous band we can separate them arbitrarily into an anterior band and a posterior band but in fact it's a continuous band heading from our medial malleolus to our talusia this is what's known as altibio Taylor ligament or tibial Taylor deltoid ligament which makes up the Deep layer of the deltoid ligament so posteriorly we can see this thick band coming from the inferior surface of our medial malleolus heading towards the talus and as we head out anteriorly we can see that band continuing and here's the anterior section of that sibio tailor ligament a superficial deltoid ligament has a tibio calcaneal band we can see it here and a tibial navicular band which is quite difficult to see on these images as we head out towards our navicular here but perhaps our most important is our tibial calcaneal ligament here otherwise known as artibial spring ligament you can see the Assassin technium Taylor of the calcaneus here has a ligament attaching to this lateral surface of our medial meliodas it runs immediately to this posterior tibial tendon and this flexor digitorum longus tending here this is called our tibial spring ligament because it becomes contiguous with our spring ligaments of the ankle we're going to have a look at our spring ligaments next let's go back to our 3D reconstruction I want to describe to you how this tibial spring ligament works so we go to the medial surface of our foot here we can see our system tackling Taylor here coming underneath that Talus here now our spring ligaments are also known as our calcaneonovicular ligaments there ligaments that head out from the calcaneus to the navicular and what they do is they provide a hammock for this Talus joint they provide structural support for the talus they prevent the tailors from dislocating inferiorly they provide that tailor height preventing a flat foot now there's three main bands of our spring ligaments the first and most important band is our Superior medial band that runs from this sustentaculum Taylor medally to the tailor head and attaches to the superior medial surface of the navicular bone now you'll notice that we name these spring ligaments according to where they attach on the navicular bone so this first ligament is called a superior medial ligament because it attaches to these Superior and medial aspect of the naviculus then we've got two inferior ligaments one running to the medial plantar surface of this navicular and one running to this inferior plantar surface of the navicular this is what's known as our medial plants are oblique ligament because as we'll see it runs obliquely in the foot and our infero plants are lateral ligament because it runs laterally to the foot so we've got our super and medial ligament here our medial plants are oblique ligament and our inferior plants are lateral ligament let me show you what they look like on an MRI so we can start upping the ankle at the level of the tibia and we can follow our tibial calcaneal ligament down in towards the ankle here's that tibial calcaneal ligament we can see laterally is our posterior tibial tendon separated from this ligament by the slip of fluid here known as our gliding section allows that posterior tibial tendon to Glide along this ligament without getting any friction now as we head down one further in fear we see that this band thickens and Heads anteriorly This is the first ligament that we're going to look at in our spring ligament complex our Superior medial band of the spring ligament it runs from the sustentacular anteriorly attaching to this navicular the sound of vicular tuberosity you can see that navicular tuberosity is the attachment point for this Superior medial spring ligament now as we head down inferiorly we said there are two bands that run underneath the tailor head from the calcaneus to the navicular now the two structures I want to point out here is this coronoid fossa of the calcaneus bone our calcaneus has a certain technium Taylor a coronoid fossa and then our anterior process here with our posterior tuberosity out posteriorly so here this coronoid phosphate is the insertion site for this medial plantar oblique tendon we can see there are two bands of the medial plants are oblique heading to the medial surface and the plantar surface of this navicular bone so here are two glands of like medial plantar oblique ligament and in between that we have a little bit of fat separating those bands our inferior plants are longitudinal ligament runs alongitudinally along the axis of the foot also coming from this coronoid fossa of the calcaneus and it heads out to this navicular beak we can see the navicular has this Spike hitting backwards that's our navicular beak and if I scroll one down inferiorly we can see that inferior plantar longitudinal ligament attaching to that under surface of our navicular bone here so those are our spring ligaments now this medial plantar oblique and this infra planter longitudinal ligaments are often quite difficult to see and the most important ligament to look at is the superior medial ligament heading out towards our navicular tuberosity so those are the main ligaments that I want to cover in the ankle let's move on to the tendons of the ankle I like to separate the tendons into four different tendon groups we've got a posterior group an anterior group medial and lateral groups if this was a clock face we would separate them into the 12 6 3 and 9 o'clock on the clock face so let's start with our posterior tendons because that's the one we all know and this is our Achilles tendon posteriorly it should have this concave shape this smiling Achilles we can see the small little tendon here which is known as alplant Taurus tendon which lies medially to the Achilles tendon as we head down in Fairly we can see our Soleus joining the tendon of that gastrocnemius forming our Achilles tendon here the fats ahead of this Achilles tendon is what's known as archaicus fat pad and we know that Achilles tendon inserts onto the posterior tuberosity of the calcaneus on that middle facet that we had looked at previously if we look at this on a lateral view or A sagittal view we can see our Achilles tendon here inserting onto that middle facet of our posterior tuberosity of the calcaneus here we have a smooth facet of the posterior calcaneus here and that's where there's a little Bursa preventing friction happening on this Achilles tendon if we head across to LPD fatsat we should be able to see that retrococaneal Bursa here anterior to our Achilles tendon here is our weight bearing section here is the insertion of our Achilles 10 and here is cagus fat pad that I mentioned before we can get a bony deformity here called haglin's deformity which is caused by multiple things including wearing high heels so those are our posterior tendons let's look at our medial tendons I'm going to go back to our axial view we can head up in the ankle immediately on our tibia here we have three tendons and most people remember this by saying Tom Dick and Harry passing immediately our posterior tibial tendon our flexor digitorum longus and our flexor hallucis longus now posterior tibial tendon should be about twice the size of our flexor digitorum tendon here if it's not we should suspect a tear or disruption of that posterior typical tendon so let's follow the posterior tibial tendon round it runs laterally to our medial malleolus runs down into the foot and we've seen this before it's running laterally to this tibial spring ligament as we head down we can see that gliding section here and here is our Superior medial spring ligament and that posterior tibial tendon runs and attaches to the navicular bone you can see it running and attaching there to the navicular bone it also sends off a couple of other tendons heading out towards our cuneiforms but the most important attachment is here to that navicular tuberosity or the inferior surface of that navicular tuberosity let's head back up and follow the path of our flexor digitorum longus it runs slightly posterior to that posterior tibial tendon it heads down laterally again runs underneath the medial malleolus and we can follow it around here running into the foot and then sending out branches to the phalanges within the foot our flexor hallucis longus has a different course it runs much more immediately runs underneath the sustentaculum taillight before then heading out immediately towards the greater toe so let's follow that down you can see it running here we see it runs underneath that sustentacular here running much more laterally than these two tendons that we just looked at before heading out immediately to the greater toe we can follow it up there now some people remember this tarsal tunnel the ligaments running through this tarsal tunnel as Tom Dick and very very nervous Harry because they include this neurovascular bundle here now we can see here that there are two veins an artery and a nerve here so when we say Tom Dick and very very nervous Harry I mean artery vein vein nerve we can head down we should be able to see our posterior tibial nerve here separating into a medial and a lateral Branch here let's now head across to our lateral tendons there are two lateral tendons that I want to draw your attention to and we've seen them when we were looking at our calcaneofibular ligament they run laterally to that calcaneofibular ligament we've got our perennials brevis tendon and our peroneus longus tendon a good way to remember this is perineous brevis runs closer to the bones apparently its longest runs laterally so apparently as brevis has a shorter cause brevis runs posterior to this fibula or this lateral malleolus if they mustn't be running out laterally they must be posterior to the lateral malleolus of the fibula we can see it run and beneath that lateral malleolus to see how it curves under that lateral malleolus heads out towards the base of our fifth metatarsal here see it inserting onto the base of the fifth metatarsal our Pioneer's longest tendon has a longer course it starts laterally before diving underneath our calcaneus and our cuboid and then heading out to that medial cane form so let's follow it down underneath that lateral malleolus hitting out laterally to the calcaneus we can see this perineal tubercle here it then heads underneath the calcaneus underneath the cuboid and as we then scroll up we can see it heading towards that medial canae form there so it runs underneath the foot it wraps itself underneath the foot and then when we Flex both the Pyrenees brevis and the perennials longus it causes the foot to Evert like that lastly we can look at our anterior tendons which are much much less commonly injured than our medial or our lateral tendons or alchilles tendon for that matter we've got three major tendons in this anterior space and some people remember this as Tom hates dick we've got a anterior tibial tendon and extends a hallucis tendon and an extensor digitorum tendon and it becomes quite difficult when we come in this axial plane to follow those down into the foot and we can look at them if we want to on our coronals and outside your tools so those are the major tendons that we need to know when looking at the ankle now I'm going to head on to a couple of miscellaneous structures the first I want to look at is our plantar fascia so if we head out posteriorly in this image we can see our posterior calcaneal tuberosity has this lateral and medial processes here we know that this is lateral because we can see how fibula out here laterally so our plantar fascia comes from this lateral and medial processes of this posterior tuberosity there are three main plantar fasciae planes that come out our lateral Central and medial plantar flesha bands our lateral plantar fascia band comes from that lateral process our Central and medial plantar fascial bands come from this medial process so we can see as we head out anteriorly we've got our lateral plantar fascial band our Central plantar fascial band and our medial plantar fascia band these are divided from our medial process here so we've got those three bands we can also look at them on our Satchel View we can see here our Central plantar fascia band and as we head out laterally we can see that lateral plantar fascia band there we want to assess the thickness of these bands and make sure there's no hyper intense signal Within These bands the next structure I want to look at is what's known as sinus tarsity and often people find this quite difficult to conceptualize but as we scroll through the subtalar joint here we can see that there's this gap between the talus and the calcaneus here this Gap is filled with fat this is what's known as our sinus tarsi this is a region that can have fluid accumulations or mass accumulations we can get impingement of the various different ligaments within that space and it's important to assess the Integrity of that space here we can see that also on our axial views as we head down into the tailors here we can see the tailor neck below the tailor neck here is our sinus tarsity running from medial to lateral there that's about all that I want to cover in the ankle joint there is a lot to go through but I find the ankle joint very logical if you start superiorly and head your way down follow all the bones then look at the various different ligaments we can see our tibiofibulus and desmosis then look at our lateral ligaments our anterior Taylor fibula our posterior Taylor fibula and alcohol ligaments then it'll cross to the medial section we can look at our deltoid ligaments both the deep and superficial ligaments then head out to the spring ligaments of the mid foot now they're called the Spring ligaments because people once thought that they provided some sort of spring within that foot but actually their function is to cradle that tailor head preventing inferior dislocation of their tailor head and medial dislocation of their tailor head then look at the various tendons that pass the ankle our anterior posterior medial and lateral tendons of the ankle and then look at the plantar fascia and some of these soft tissue structures that surround the ankle now what I haven't covered here are the muscles of the foot and they're four different layers of the of the foot and that's going to be a separate video on its own otherwise this is just going to become too long and too difficult to remember everything so I hope you found this helpful there is a lot to cover I encourage you to go over as many ankle MRIs as you can and until next video I'll see you all then goodbye everybody