Imaging Evaluation of Chronic Ankle and Hindfoot Pain in Athletes

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Acute ankle and hindfoot injuries are common in athletes and typically are treated conservatively. Persistent pain that has not responded to appropriate conservative treatment and prevents the patient from returning to play is more problematic for the athlete and the treating sports clinician. Making a specific clinical and imaging diagnosis in these patients can be quite challenging. This article discusses the imaging evaluation of chronic ankle and hindfoot pain related to osseous and soft-tissue injuries in athletes. MR imaging is the preferred imaging modality in most of the presented cases.

Section snippets

Occult Fractures

The sports clinician's differential diagnosis for osseous pathology in these patients includes occult traumatic fractures of the tibial plafond, the lateral and posterior processes of the talus, the anterior process of the calcaneus, and the base of the fifth metatarsal. These fractures may be very difficult to detect on the initial radiographs and may be overlooked during the initial evaluation. If the clinical and imaging differential is limited to occult fracture, high-resolution,

Osteochondral injuries

Posttraumatic chondral or osteochondral injuries of the talar dome, otherwise known as an “osteochondral lesion of the talus” (OLT), may be radiographically occult and may present with persistent vague ankle pain in athletes. An OLT also may coexist with other osseous and soft tissue pathology. Brown and colleagues28 demonstrated the presence of osteochondral lesions in 28% of 59 patients who had distal tibiofibular syndesmotic injuries documented by MR imaging. Traumatic torsional forces

Ligament Injuries

The clinical differential diagnosis for soft tissue injuries in sports participants who have chronic ankle and hindfoot pain despite negative radiographs and appropriate conservative management includes complex ligamentous injuries, such as syndesmotic sprains, deltoid ligament injury, and multiple ligament instability; impingement syndromes; and sinus tarsi syndrome.

Routine lateral ankle sprains do not require advanced imaging, except in professional athletes, who may require immediate imaging

Summary

Persistent ankle and hindfoot pain in athletes who do not respond to conservative management may be attributed to many different clinical diagnoses including soft tissue, chondral, or osseous pathology that is not immediately apparent at the time of initial clinical evaluation and imaging. Subsequent imaging evaluation should begin with repeat conventional radiographs looking for occult traumatic fractures, osteochondral injuries, loose bodies, osteophytes, accessory ossicles, and periarticular

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