Extraarticular later hindfoot impingement with ptt tear mri correlation

Musculoskeletal Imaging • Original Research

Donovan and Rosenberg
MRI of Lateral Hindfoot Impingement

Musculoskeletal Imaging
Original Research

Extraarticular Lateral Hindfoot
FOCUS ON:

Impingement With Posterior Tibial
Tendon Tear: MRI Correlation
Andrea Donovan1 OBJECTIVE. Posterior tibial tendon dysfunction with secondary hindfoot valgus can lead
Zehava Sadka Rosenberg2 to painful extraarticular, lateral talocalcaneal, and subfibular impingements, often necessitating
surgical intervention. The purpose of this study was to correlate findings of lateral hindfoot im-
Donovan A, Rosenberg ZS pingement with grading of posterior tibial tendon tears and severity of hindfoot valgus on MRI.
MATERIALS AND METHODS. MR images from 75 patients (45 women and 30 men)
with MRI evidence of posterior tibial tendon tears were evaluated for grade of posterior tibi-
al tendon tear, hindfoot valgus angle, osseous contact or opposing marrow signal changes at
the talus–calcaneus or fibula–calcaneus, peroneal tendon subluxation–dislocation, and pres-
ence of lateral malleolar bursa. Statistical analyses were performed using Cochran-Armitage,
Fisher’s exact, and Mann-Whitney tests.
RESULTS. Twenty-eight cases (37%) of lateral hindfoot impingement were identified,
including six talocalcaneal, eight subfibular, and 14 talocalcaneal–subfibular impingements.
The prevalence of impingement was significantly increased with greater MRI hindfoot valgus
angle (p < 0.001). The prevalence of talocalcaneal–subfibular impingement significantly in-
creased with grading of posterior tibial tendon tear (p = 0.018). Peroneal tendon subluxation
was present only with advanced hindfoot valgus (p = 0.010) and impingement (p = 0.004).
There was no significant association between the presence of lateral malleolar bursa and
hindfoot valgus severity.
CONCLUSION. Extraarticular lateral hindfoot impingement is associated with ad-
vanced posterior tibial tendon tears and increased MRI hindfoot valgus angle. Peroneal ten-
don subluxation likely represents an end stage of lateral impingement in patients with poste-
rior tibial tendon dysfunction.

P
osterior tibial tendon dysfunc- Soft-tissue repair alone in patients with
tion is the most common cause of posterior tibial tendon dysfunction may lead
acquired flatfoot and hindfoot to unsatisfactory surgical outcome and per-
valgus and may lead to medial sistent lateral ankle pain. Calcaneal osteoto-
Keywords: ankle, impingement syndrome, MRI, posterior
and, with advanced disease, lateral ankle my is often necessary to correct the hindfoot
tibial tendon
pain [1, 2]. This lateral ankle pain has been valgus and lateral hindfoot impingement [1].
DOI:10.2214/AJR.08.2215 attributed to extraarticular lateral hindfoot Therefore, early detection of impingement is
impingement including talocalcaneal (be- beneficial for successful surgical results.
Received December 7, 2008; accepted after revision tween the lateral talus and calcaneus) [3, 4] To the best of our knowledge, the MRI ap-
January 5, 2009.
and subfibular (between the calcaneus and pearance of lateral hindfoot impingement has
1Department of Radiology, Sunnybrook Health Sciences fibula) impingement [5–11] (Fig. 1). In addi- not been reported. The purpose of this study
Centre, 2075 Bayview Ave., Rm. AG 278, Toronto, ON tion, lateral ankle pain in patients with poste- was to describe the MRI features of this ex-
M4N 3M5, Canada. Address correspondence to rior tibial tendon dysfunction has been at- traarticular impingement and to correlate its
A. Donovan (andrea.donovan@sunnybrook.ca).
tributed to sinus tarsi pathology, fibular stress presence with grading of posterior tibial ten-
2
Department of Radiology, New York University Hospital fractures [12], and lateral adventitial bursa don tear and severity of hindfoot valgus in
for Joint Disease, New York, NY. [13]. Several models of acquired hindfoot patients with posterior tibial tendon tears.
deformity suggest that lateral hindfoot im-
AJR 2009; 193:672–678
pingement is related to a lateral shift of Materials and Methods
0361–803X/09/1933–672 weight bearing from the talar dome to the Patient Population
lateral talus and fibula [14] as well as to talo- Institutional review board approval was grant-
© American Roentgen Ray Society calcaneal joint subluxation [15]. ed and informed consent was waived for this ret-

672 AJR:193, September 2009


Fig. 1—Schematic drawings
show lateral extraarticular
talocalcaneal and subfibular
hindfoot impingements.
A, Normal hindfoot valgus (≤ 6°)
and no lateral impingement.
B, Hindfoot valgus angle is
measured at intersection of
line along medial calcaneal wall
and line parallel to longitudinal
axis of tibia. With progressive
hindfoot valgus there is first
abnormal contact between
lateral talus and calcaneus
(red) resulting in talocalcaneal
impingement.
C, Subsequent abnormal
contact between both lateral
talus and calcaneus (red) as
well as between calcaneus
and fibula (orange) produces
combined talocalcaneal–
subfibular impingement.

A B C

rospective HIPAA-compliant study. A radiology slightly different, the MRI protocol in most patients smaller than the adjacent flexor digitorum longus
database was retrospectively reviewed to identify consisted of two sagittal acquisitions (T1-weight- tendon); grade III, complete tendon discontinuity.
patients with an MRI diagnosis of a posterior tibi- ed spin-echo images and inversion recovery); two The MRI hindfoot valgus angle was measured
al tendon tear over an approximately 5-year period axial acquisitions (T1-weighted or intermediate- on the most posterior coronal image that included
from January 2003 to March 2008. The search was weighted and T2-weighted fast spin-echo, with or the tibia and calcaneus by intersecting a line along
performed with the keywords “posterior tibial ten- without fat suppression); a single coronal plane (T1- the long axis of the tibia and a line along the medi-
don,” “tibialis posterior tendon tear” (or “posterior weighted or intermediate-weighted or T2-weighted al wall of the calcaneus (Fig. 1). This measurement
tibial tendon tear”), “rupture,” and “tendinosis.” fast spin-echo with fat suppression). T1-weighted is a modification from previously described radio-
The initial group of 198 patients was ultimately images were acquired with TR range/TE range of graphic and CT angle measurement techniques
limited to patients with evidence of posterior tibial 400–700/10–20, intermediate-weighted images [18, 19]. The medial, rather than the lateral, calca-
tendon tears based on MR image review. Patients were obtained with TR range/effective TE range neal wall was selected because it had less variabil-
with minimal tendinosis or isolated tenosynovitis of 2,500–3,800/34–38, T2-weighted fast spin-echo ity and fewer bony protuberances. Hindfoot valgus
were excluded. Additional exclusion criteria in- images were acquired with a TR range/effective on MRI was defined as abnormal in cases with a
cluded navicular posterior tibial tendon tear, prior TE range of 2,000–6,000/60–90, and inversion re- tibiocalcaneal angle > 6° [19].
posterior tibial tendon surgery, and incomplete or covery images were obtained with a TR range/ef- MRI criteria for lateral hindfoot impingement,
unavailable studies on our PACS. fective TE range of 4,600–7,200/16–35, all with an using all imaging planes, were based on previously
The study group was composed of 75 patients: inversion time of 150 milliseconds. Additional pa- described CT criteria for osseous impingement [20]
45 women, 30 men, mean age 58 years (age range, rameters included 12–20 × 9–20 field of view range, and on previously described MRI criteria for soft-
29–90 years) with MRI evidence of a posterior tib- 256–512 × 128–256 matrix range, 4–5 mm slice thick- tissue and osseous ankle impingement syndromes
ial tendon tear. Medical records were reviewed and ness with 1.0–1.5 mm intersection gap, and echo- at other locations [21–23]. Lateral talocalcaneal and
the clinical details recorded included patient age, train length of 4–8. subfibular impingements were defined as signal and
sex, involved side, and clinical indication for the morphologic alterations or direct contact at the op-
MRI study. MRI studies were evaluated by con- MRI Interpretation posing surfaces of the lateral talus and calcaneus
sensus by two musculoskeletal radiologists with 22 The following MRI features were recorded: grade and at the fibula and calcaneus, respectively. Spe-
and 1 years of experience, respectively. The read- of posterior tibial tendon tear, MRI hindfoot valgus cifically, the images were evaluated for the presence
ers were not blinded to the clinical information. angle, lateral hindfoot impingement, peroneal ten- of marrow edema, cystic changes, or sclerosis at
don dislocation, and lateral malleolar bursa. Poste- the opposing osseous surfaces of the talus and cal-
MRI Technique rior tibial tendon tears were graded on a I–III scale caneus or the fibula and calcaneus and the presence
The ankle MRI studies were performed on sev- on the basis of previously described classification of soft-tissue entrapment at those locations.
eral different 1.5-T MR units (n = 73) and an open systems [16, 17]: grade Ia, thickened tendon with The peroneal tendons and lateral malleolar bur-
0.2-T (n = 2) MR unit. Patients were placed in the no or a small amount of longitudinal splits; grade sa were examined in all patients. The peroneal
supine position, with the ankle in mild (20°) plan- Ib, thickened tendon with a large amount of longi- tendons were defined as subluxed or dislocated
tar flexion. Although the imaging protocols were tudinal splits; grade II, attenuated tendon (equal or when the tendons were partially out or lateral to

AJR:193, September 2009 673


TABLE 1: Hindfoot Valgus Grading proportion having grade II (n = 6, 8%) and ings (70%) within a group of seven patients.
Scheme Based on grade III (n = 7, 9%) tears. This patient group size was based on statisti-
Measured Coronal An abnormal MRI hindfoot valgus angle cal power calculation.
Tibiocalcaneal Angle (> 6°) was present in the majority of patients Most patients had mild (n = 31, 41%) or
Hindfoot (n = 70, 93%) (Table 1). MRI hindfoot val- moderate (n = 25, 33%) hindfoot valgus (Fig.
Valgus Tibiocalcaneal No. of Cases gus angle was further categorized, using 10° 2C). Severe hindfoot valgus was present in a
Severity Angle (°) (%) increments as mild (7–16°), moderate (17– minority of patients (n = 14, 19%).
Normal ≤6 5 (6.7) 26°), and severe (> 26°). The threshold an-
Mild 7–16 31 (41.3) gles of 16° and 26° used in the definitions MRI Appearance of Lateral
were chosen to optimize the statistical power Hindfoot Impingement
Moderate 17–26 25 (33.3)
of the study for detecting an association be- There were 28 cases (37%) with later-
Severe > 26 14 (19.7) tween the hindfoot valgus classification and al hindfoot impingement. These included
the frequency of talocalcaneal or subfibular isolated talocalcaneal impingement (n = 6,
the fibular groove, respectively [24]. Lateral ad- impingement. Specifically, the threshold an- 21%), isolated subfibular impingement (n =
ventitial bursa was defined as disproportionate, gle of 16° was used to distinguish mild from 8, 29%), and combined talocalcaneal–sub-
focal subcutaneous edema or a discrete collection moderate hindfoot valgus based on a receiv- fibular impingement (n = 14, 50%).
with fluid signal characteristics in the lateral peri- er operating characteristic (ROC) analysis to MRI features of talocalcaneal impinge-
malleolar fat. Cases with circumferential subcuta- assess the MRI hindfoot valgus angle as a ment (n = 20) included marrow edema (n =
neous ankle edema were excluded. predictor for a finding of impingement. The 20, 100%) or cystic changes (n = 19, 95%)
ROC analysis showed that the threshold val- (Figs. 2A and 2B) or sclerosis (low T1 and
Statistical Analysis ue of 16° resulted in a diagnostic test with the low T2 marrow signal; n = 3, 15%) (Figs.
The Cochran-Armitage trend test was used to highest average of sensitivity and specificity. 3A and 3B) at the opposing surfaces of the
correlate the prevalence of talocalcaneal or subfib- Similarly, a threshold angle of 26° provided lateral talar process and the lateral wall of
ular impingement, peroneal subluxation–disloca- the highest prevalence of impingement find- the calcaneus. At the calcaneus, the marrow
tion, and lateral adventitial bursa with grading of
posterior tibial tendon tear. An exact Mann-Whit-
ney test was used to compare subjects with and
without talocalcaneal or subfibular impingement,
peroneal dislocation, or lateral adventitial bursi-
tis with the measured MRI hindfoot valgus angle.
Fisher’s exact test was used to evaluate associa-
tions among these findings. Statistical computa-
tions were performed using SAS version 9.0 (SAS
Institute). Statistical significance was defined as a
p value less than 0.05.

Results
Distribution of Grading of Posterior Tibial A B
Tendon Tear and Hindfoot Valgus Angle
Clinical history of posterior tibial ten-
don dysfunction was provided for the major-
ity of patients (n = 45, 60%). Evaluation of
MR images showed the largest proportion of
patients having grade Ia (n = 26, 35%) and
grade Ib (n = 36, 48%) tears, and a smaller

Fig. 2—60-year-old man with lateral ankle pain.
A and B, Sagittal T1-weighted fast spin-echo (A) and
sagittal inversion recovery (B) images show cystic
changes and marrow edema at lateral talar process
(solid arrows) and opposing lateral calcaneus (open
arrows).
C, Coronal T2-weighted fast spin-echo fat-saturated
image shows moderate hindfoot valgus angle of
22°. Lateral calcaneal marrow edema (star) and
subcutaneous edema (arrow) are noted.
D, Axial T2-weighted fast spin-echo fat-saturated
image shows type Ia posterior tibial tendon tear with
mild morphologic irregularity and increased tendon
size (arrow).
C D



Fig. 3—65-year-old woman with clinical history of
posterior tibial tendon dysfunction.
A and B, Sagittal T1-weighted fast spin-echo (A) and
sagittal inversion recovery weighted (B) sequences
show signal alterations at opposing osseous contact
surfaces of talus and calcaneus, representing
sclerosis (solid arrows) and marrow edema (open
arrows, B).
C and D, Sagittal T1-weighted fast spin-echo (C) and
sagittal inversion recovery weighted (D) images
show subfibular soft-tissue abnormality depicted by
hypointense T1 and both hyper- and hypointense T2-
weighted signal (arrowheads).

A B
tion. There was a positive association be-
tween tendon subluxation and the presence
of impingement (p = 0.006); the former was
identified only in cases of impingement and
mostly with combined talocalcaneal–subfib-
ular impingement (n = 4, 80%). Also, per-
oneal tendon subluxation was seen only with
moderate or severe hindfoot valgus; a sig-
nificant positive association was present be-
tween hindfoot valgus severity and peroneal
tendon subluxation (p = 0.010).

Association Between Lateral Hindfoot
Impingement and Lateral Malleolar Bursa
Lateral adventitial bursa was present in 11
C D of 28 patients (39%) with lateral impinge-
ment (Fig. 5). There was no significant asso-
findings were mainly seen at the junction of ular impingement and severity of posterior ciation between the presence of lateral malle-
the calcaneal tuberosity with the anterior tibial tendon tear (p = 0.020) (Table 2). Com- olar bursa and hindfoot valgus impingement
process of the calcaneus. The predominant bined talocalcaneal–subfibular impingement or hindfoot valgus severity.
pattern was cystic changes with surrounding was seen in 12% (n = 8/62) of grade I, 33%
marrow edema (n = 16, 80%). (n = 2/6) of grade II, and 57% (n = 4/7) of Discussion
MRI findings of subfibular impingement grade III posterior tibial tendon tears. In our study, lateral hindfoot impinge-
(n = 22) most commonly included low T1 ment was more common in patients with ad-
and predominantly low T2 signal intensity Association Between Lateral Hindfoot vanced posterior tibial tendon tear and with
soft-tissue entrapment between the calcaneus Impingement and Hindfoot Valgus Severity a greater MRI hindfoot valgus angle. These
and fibula (n = 15, 68%) (Figs. 3C, 3D, and The prevalence of impingement correlated observations parallel the clinical manifesta-
4A) or direct osseous contact between the with MRI hindfoot valgus angle (p < 0.001) tions of posterior tibial tendon dysfunction in
calcaneus and fibula (n = 6, 27%) (Figs. 4A (Table 3). The mean angle was significant- which longitudinal arch collapse progresses
and 4B) or distal fibular marrow edema (n = ly lower among subjects without MRI evi- through four stages based on the severity of
8, 36%) (Fig. 4C). In one patient, there was dence of impingement (14.1°; SD, 6.1) than the flatfoot deformity [25, 26]. In stage I, pa-
remodeling of the calcaneus and fibula with among subjects with either isolated talo- tients present with mild medial ankle pain
the formation of a “neofacet” (Fig. 4B). calcaneal impingement (26.5°; SD, 11.0) or because of posterior tibial tendon tenosyno-
combined talocalcaneal–subfibular impinge- vitis or tendinosis. In stage II, there is a tear
Association Between Lateral Hindfoot ment (27.1°; SD, 7.0) (p < 0.001). In addition, of the posterior tibial tendon with loss of nor-
Impingement and Grading of Posterior Tibial the mean angle was significantly greater in mal alignment of the foot. However, the flat-
Tendon Tear combined talocalcaneal–subfibular impinge- foot deformity is mobile. In contrast, stage III
There was a trend for the prevalence of lat- ment compared with isolated talocalcaneal represents severe incompetence of the poste-
eral hindfoot impingement to increase with impingement (p = 0.031) or isolated subfibu- rior tibial tendon and progression to a fixed
grading of posterior tibial tendon tear (p = lar impingement (p = 0.020). flatfoot deformity. Finally, in stage IV, there
0.052). Impingement was seen in 32% (n = is additional valgus angulation of the talus at
20/62) of grade I, 50% (n = 3/6) of grade Association Between Lateral Hindfoot Impingement the tibiotalar joint [25, 26]. Although medial
II, and 71% (n = 5/7) of grade III posterior and Peroneal Subluxation–Dislocation ankle pain is the presenting symptom in early
tibial tendon tears. Furthermore, there was a Peroneal tendon subluxation was seen in stages of posterior tibial tendon dysfunction,
significant positive association between the five (7%) of the 75 patients (Fig. 4). There lateral ankle pain related to hindfoot val-
presence of combined talocalcaneal–subfib- were no cases of peroneal tendon disloca- gus and lateral impingement predominates



Fig. 4—83-year-old woman with history of
posterior tibial tendon dysfunction and lateral
ankle pain, depicted by marker, showing combined
talocalcaneal–subfibular impingement.
A, Coronal T1-weighted fast spin-echo image shows
cystic changes and sclerosis at opposing talus and
calcaneus (white arrows). Intermediate-signal soft
tissue is entrapped between fibula and calcaneus
(black arrow).
B, More posterior coronal T1-weighted fast spin-
echo image illustrates direct osseous contact
between fibula and calcaneus (arrow) with calcaneal
“neofacet” (star). Hindfoot valgus angle, formed by
intersection of line along medial calcaneal wall and
line parallel to long axis of tibia, is increased (32°).
C, Coronal T2-weighted fat-suppressed image
depicts fibular marrow edema (star).
D, Axial proton density–weighted fast spin-echo
image illustrates peroneal tendon subluxation (black
arrow) and grade III posterior tibial tendon tear
(arrowhead). Direct contact between fibula and
calcaneus (white arrows) is also identified.

A B
the MRI studies were not weight bearing, it
may still be useful for assessing anatomic
distortions [27]. Future studies with recently
introduced weight-bearing MRI capabilities
[28] may aid in correlating our MRI hindfoot
valgus grading scale with weight-bearing ra-
diographs and with clinical stages of poste-
rior tibial tendon dysfunction.
To the best of our knowledge, this study
provides the first description of the MRI fea-
tures of lateral hindfoot impingement. The
most common manifestations of talocalca-
neal impingement were cystic changes and
edema in the lateral process of the talus and
the lateral calcaneus. Imaging features of
subfibular impingement included extensive
soft-tissue thickening between the fibula and
the calcaneus. We believe this may be related
to entrapment of fat and even the calcaneo-
C D
fibular ligament between the two bones, with
TABLE 2: Association of Grading of Posterior Tibial Tendon Tear With the development of fat atrophy and fibrosis
Lateral Hindfoot Impingement [21]. Less frequent findings in subfibular im-
Grading of Posterior Tibial Tendon Tear pingement included fibular tip marrow ede-
Lateral Hindfoot Impingement Ia (n = 26) Ib (n = 36) II (n = 6) III (n = 7) p ma and contact between the fibula and cal-
caneus, occasionally with the formation of a
No impingement 18 (69.2) 24 (66.7) 3 (50.0) 2 (28.6) 0.052
calcaneal neofacet.
Impingement 8 (30.8) 12 (33.3) 3 (50.0) 5 (71.4) It is important to distinguish marrow ede-
Isolated talocalcaneal 1 (3.8) 5 (13.9) 0 (0) 0 (0) 0.804 ma involving the fibula in subfibular impinge-
ment from that related to a fibular stress frac-
Isolated subfibular 3 (11.5) 3 (8.3) 1 (16.7) 1 (14.3) 0.788
ture [29]. Both fibular marrow abnormalities
Combined talocalcaneal–subfibular 4 (15.4) 4 (11.1) 2 (33.3) 4 (57.1) 0.020 occur with increased frequency in hindfoot
Note—Data in parentheses are percentages. valgus and lateral impingement [12, 27]. The
location of marrow edema may be a helpful
in long-standing posterior tibial tendon dys- fined as 6° or less based on CT measure- distinguishing feature. Fibular stress frac-
function [14] and often necessitates osseous ments [19]. We developed a grading scheme tures typically involve the distal fibular shaft,
correction of the foot deformity [5]. for hindfoot valgus severity based on MRI whereas fibular tip edema is likely the result
Clinical or radiographic grading scales measurement of the coronal tibiocalcaneal of direct osseous contact with the calcaneus.
for hindfoot valgus severity are lacking, al- angle. Although the hindfoot valgus angle is If fibular edema is related to impingement,
though the normal angle was previously de- likely underestimated in our study because then edema may be seen in the adjacent por-



TABLE 3: Association of Hindfoot Valgus With Lateral Hindfoot combined talocalcaneal–subfibular impinge-
Impingement ment. To the best of our knowledge, these re-
Hindfoot Valgus lationships have not been described previous-
ly in the literature. Interestingly, MR images
Normal Mild Moderate Severe
Lateral Hindfoot Impingement (n = 5) (n = 31) (n = 25) (n = 14) p illustrating peroneal tendon dislocation in pa-
tients with severe hindfoot valgus secondary
No impingement 5 (100.0) 29 (93.5) 12 (48.0) 1 (7.1) < 0.001
to posterior tibial tendon dysfunction have
Impingement 0 (0) 2 (6.5) 13 (52.0) 13 (92.9) been published previously without addressing
Isolated talocalcaneal 0 (0) 1 (3.2) 2 (8.0) 3 (21.4) 0.039 this association [32]. Peroneal tendon disloca-
Isolated subfibular 0 (0) 1 (3.2) 4 (16.0) 3 (21.4) 0.034 tion has also been observed in patients with
congenital calcaneovalgus deformity [33].
Combined talocalcaneal–subfibular 0 (0) 0 (0) 7 (28.0) 7 (50.0) < 0.001
It is possible that the proximity of the calca-
Note—Data in parentheses are percentages. neus to the fibula with advanced posterior tib-
ial tendon dysfunction leads to crowding and
subsequent displacement of the peroneal ten-
dons of the retromalleolar groove.
There were several limitations to our
study. First, the retrospective design and the
case selection methodology may have intro-
duced bias by excluding patients with early
clinical posterior tibial tendon dysfunction
and normal MRI studies. This may have re-
sulted in falsely high MRI prevalence of lat-
eral impingement in our patient population.
Second, the readers were not blinded to the
grading of posterior tibial tendon tears and
were aware of the null hypothesis, and image
review was performed by consensus. Third,
access to patients’ clinical history and surgi-
cal correlation was restricted, and the MRI
criteria for impingement were established in
A B the absence of clinical correlation. Fourth,
Fig. 5—74-year-old woman with history of fall and MRI finding of severe hindfoot valgus and lateral adventitial the true degree of hindfoot valgus could not
bursa formation. be assessed because our MRI studies were
A and B, Coronal (A) and axial (B) T2-weighted fat-suppressed fast spin-echo images show lateral adventitial not weight bearing, and correlation with
bursa (stars). Severe hindfoot valgus (40°) is present as measured by tibiocalcaneal angle in coronal plane.
Posterior tibial tendon is thickened in keeping with grade Ia tear (arrow, B).
standing radiographs was not available. Fi-
nally, our study described associations be-
tween posterior tibial tendon tear severity,
tion of the calcaneus, which would be absent advanced posterior tibial tendon tears. Im- hindfoot valgus severity, and lateral hindfoot
in a stress fracture. pingement was seen in only 32% of cases with impingement; causal relationships between
Aside from posterior tibial tendon dys- grade I posterior tibial tendon tears but in 71% these findings cannot be established.
function, there are several additional causes of cases with grade III posterior tibial tendon In summary, the MRI features of lateral
of hindfoot valgus, such as healed intraartic- tears. Furthermore, combined talocalcaneal– hindfoot impingement including osseous and
ular calcaneal fractures [30], neuropathic ar- subfibular impingement was seen in a minor- soft-tissue abnormalities were more com-
thropathy [31], and inflammatory arthritides ity of cases with grade I posterior tibial tendon monly seen in patients with advanced pos-
[12], which may lead to extraarticular im- tears (12%), whereas a higher percentage was terior tibial tendon tears and with a greater
pingement. The radiologist should be famil- seen with grade II (33%) and grade III (57%) MRI hindfoot valgus angle. Peroneal ten-
iar with these different entities when encoun- posterior tibial tendon tears. don displacement, previously not described
tering patients with lateral ankle pain and A positive association was also seen be- in association with posterior tibial tendon
with MRI features of lateral impingement. tween impingement and hindfoot valgus se- dysfunction, may also be encountered with
Our data support previous studies showing verity. Moreover, the mean MRI hindfoot advanced hindfoot valgus and lateral im-
that talocalcaneal impingement may represent valgus angle was significantly greater in pingement. Thus, grading of posterior tibial
an earlier stage of posterior tibial tendon dys- combined talocalcaneal–subfibular impinge- tendon tears and assessment of hindfoot val-
function than subfibular or combined talocal- ment compared with isolated talocalcaneal gus angles on MRI may aid in the detection
caneal–subfibular impingement [20]. We not- or isolated subfibular impingement. of early lateral impingement. Further study
ed an increased prevalence of impingement, Our study noted a significant association is needed to correlate MRI findings of lateral
particularly the more advanced, combined between peroneal tendon subluxation and hindfoot impingement with clinical grading
talocalcaneal–subfibular impingement, with moderate or severe hindfoot valgus as well as of posterior tibial tendon dysfunction, lateral



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