The document discusses the prevalence and diagnostic challenges of isolated posterior inferior tibiofibular ligament (PITFL) injuries and their management in foot and ankle trauma. It includes case studies showcasing symptomatic relief through ultrasound-guided corticosteroid injections and emphasizes the importance of prompt diagnosis to reduce morbidity. The document also highlights the role of various imaging modalities, particularly MRI, in accurately diagnosing ligament injuries.

1. Foot & Ankle Trauma
Radiology
1
Dr W J Rennie
Musculoskeletal Radiologist
Leicester Royal Infirmary

2. Structure
• Some difficult Radiographs
• Important often missed fractures
• High Resolution High Quality MRI
• Tendon/Ligament Anatomy
• The Car Principle in MR Imaging!
• Foot Imaging
• The PITFL injury! The Leicester Theory!
2

3. 3
Man who stand on
street corner with
hands in pockets,
not feeling crazy,
feeling nuts.

4. Modalities
• Radiographs
• Cross sectional Imaging
• CT
• MRI
• Ultrasound
• Unclear Medicine
4

5. Stress Fractures
5

6. Stress Fractures
6

7. Occult Fractures
7

8. Occult Ankle Fractures
8

9. Occult Fractures
9

10. Coalition
10

11. 11

12. 12

13. 13

14. 14

15. 15
Man who eat
many prunes get
good run for his
money!

16. Tendon Injuries
16

17. Tendon Injuries
17

18. Ankle- Lateral Ligaments
• Syndesmotic
Ligaments-
AITFL/PITFL
• ATFL
• CFL
• PTFL
18

19. Ankle PITFL
19

20. Lateral Ligaments- CFL
20

21. Lateral Ligaments-PTFL
21

22. Lateral ligaments-ATFL
22

23. Axial- Syndesmotic ligaments
23

24. Syndesmotic injuries
24

25. Medial Tendons
• Tibialis Posterior
• Flexor Digitorum
Longus
• A
• V
• N
• Flexor Hallucis Longus
25

26. Medial Structures
26

27. Lateral Tendons
• Peroneus
Longus
• Peroneus
Brevis
27

28. Peroneii Pathology
28

29. Coronal Plane
29

30. 30
Courtesy of Prof H Umans
Lennox Hill Imaging centre NY

31. 31
Courtesy of Prof H Umans
Lennox Hill Imaging centre NY

32. 32

33. Ultrasound
• Extension of
Physical
examination
• Sonographic
Mulder’s Sign
• Forefoot
squeeze
33

34. MRI
• Remember!
• Not ALL are
EQUAL!!
• Animal Farm
Rules apply!
34

35. MRI
35
• Remember!
• Not ALL are
EQUAL!!
• Animal Farm
Rules apply!

36. Avoid the Ford!
• Open Low field
Strength 0.3T
MRI
• Non Diagnostic
for the
indications!
36
Courtesy of Prof H Umans
Albert Einstein Medical School NY
USA

37. Isolated Posterior high ankle
sprain- Case series
1Botchu R, 2Allen P, 1Rennie WJ
Leicester Royal Infirmary,
Leicester, UK

38. Introduction
• Ligament injuries of the ankle are a
common injury
• The daily incidence in USA is 23000, 5600
in UK and 1600 in Netherlands
• Syndesmostic injuries form a subset
• Early diagnosis allows appropriate
management decreasing morbidity and
enabling quick return to sport

39. Introduction
• AITFL is ruptured in almost all cases of
high ankle sprain
• PITFL is the strongest of the syndesmotic
ligaments and hence is always associated
with other ligamentous injuries
• Isolated PITFL injury has not previously
been reported

40. Aim
• We present a case series of isolated PITFL
injury

41. Normal PITFL

42. Case 1
• 36 year old male presented with 8 month history of
dull posterior and postero-lateral right ankle pain.
• No specific trauma
• Pain during push off phase of gait cycle
• Good Range of movement
• Tender posterior joint line

44. Case 1
• MRI- Oedema within PITFL and tibial enthesis with
thickening of fibres
• Physiotherapy and orthotics did not help
• US guided corticosteroid injection with
symptomatic relief
• No recurrence at 8months follow up.
• X ray normal
44

45. Case 2
• 42 year old female with 3 months of ankle
pain
• No specific trauma
• Good Range of movement
• Tenderness at inferior syndesmosis

47. Case 2
• MRI- Oedema within PITFL and tibial enthesis
with thickening of fibres
• US guided corticosteroid injection with good
symptomatic relief
• No recurrence at 8 months follow up.
47

48. Case 3
• 44 year old female with 2 years dull ankle pain
• Pain exaggerated while walking on uneven
surface
• Clinical tenderness along posteromedial ankle

50. Case 3
• MRI- edema within PITFL
• Physiotherapy and orthotics- no relief
• US guided corticosteroid injection with good
symptomatic relief
• No recurrence at 1 year follow up.
50

51. Discussion
• Ankle sprain is common and correlates to a
quarter of all musculoskeletal injuries, accounting
for 10 % of the workload in A&E
• 800 ankle sprains and 110 severe ankle sprains
per day in AE in UK

52. Discussion
• 25% of foot ball injuries and 50% of basket ball
injuries.
• Associated with chronic ankle pain and instability
• Incidence higher among adolescent females
especially athletes
52

53. Distal tibiofibular syndesmosis-
parts
• Interosseous membrane
• AITFL
• PITFL
• Inferior transverse ligament
• Interosseous ligament

54. PITFL
• Triangular multifascicular ligament
• Spans - Lateral malleolus to distal tibial
posterior margin
• Wide tibial attachment and compact fibular
attachment.
• Superficial PITFL- minor contribution to
ankle instability(9%)
• Deep PITFL and AITFL- Major stabilisers

55. Mechanism of injury
• External rotation and abduction of
dorsiflexed ankle- AITFL injury
• External rotation and abduction of
hyperdorsiflexed ankle- AITFL and PITFL
injury
• Adduction of hyperdorsiflexed ankle-
Isolated PITFL injury.

56. Isolated PITFL Injury
• Supra-malleolar pain
• Clinical tenderness – posterior distal tibio-
fibular syndemsosis (over PITFL)
• High index of suspicion
• MRI- Thickening and edema of PITFL
• Sprain- grade 1 or grade 2
• MRI- Good sensitivity(100%) and
specificity (94-100%)
• Chronic injury may result in calcification

57. Management
• Symptomatic
• Orthotics
• Analgesics
• US guided injection of corticosteroids.

58. Management
• PITFL injuries require relatively longer
duration of treatment and rehabilitation
due to altered biomechanics in comparison
to standard ankle sprains.
58

59. Message
• Isolated PITFL injuries are rare.
• Prompt diagnosis and appropriate
management helps to decrease morbidity
and enable quick return to sport.

60. References
• Nyanzi CS, Langridge J, Heyworth JRC, Mani R. Randomized controlled study of ultrasound therapy in the
management of acute lateral ligament sprains of the ankle joint. Clinical Rehabilitation 1999 13:16-22
• Bridgman SA, Clement D, Downing A, Walley G, Phair I, Maffulli N. Population based epidemiology of ankle sprains
attending accident and emergency units in the West Midlands of England, and a survey of UK practice for severe
ankle sprains. Emerg Med J 2003;20:508–510.
• Williams G, Jones M, Amendola A. Syndesmotic ankle sprains in athletes. Am J Sports Med. 2007; 35(7):1197-207.
• Ebraheim NA, Taser F, Shafiq Q, Yeasting RA. Anatomical evaluation and clinical importance of the tibiofibular
syndesmosis ligaments. Surg Radiol Anat. 2006; 28(2):142-9.
• Norkus SA, Floyd, RT. The Anatomy and Mechanisms of Syndesmotic Ankle Sprains. Journal of Athletic
Training 2001; 36(1):68-73.
• Boonthathip M, Chen L, Trudell DJ, Resnick DL. Tibiofibular syndesmotic ligaments: MR arthrography in cadavers
with anatomic correlation. Radiology. 2010; 254(3):827-36.
• Beumer A, Valstar ER, Garling EH, Niesing R, Ginai AZ, Ranstam J, Swierstra BA. Effects of ligament sectioning on
the kinematics of the distal tibiofibular syndesmosis: a radiostereometric study of 10 cadaveric specimens based on
presumed trauma mechanisms with suggestions for treatment. Acta Orthop. 2006; 77(3):531-40.
• Press C, Gupta A, Hutchinson M. Management of ankle syndesmosis injuries in the athlete. Curr Sports Med Rep.
2009; 8(5):228-33.
• Oae K, Takao M, Naito K, Uchio Y, Kono T, Ishida J, Ochi M. Injury of the tibiofibular syndesmosis: value of MR
imaging for diagnosis. Radiology. 2003;227(1):155-61.
• Brown K, Morrison W, Schweitzer M, Parellada J, Nothnagel H. MRI findings associated with distal tibiofibular
syndesmosis injury. AJR Am J Roentgenol. 2004; 182(1):131-6.
• Amendola A, Williams G, Foster D. Evidence-based approach to treatment of acute traumatic syndesmosis (high
ankle) sprains. Sports Med Arthrosc Rev 2006 ;( 14):232-236.
• Jones MH, Amendola A. Syndesmosis sprains of the ankle: a systematic review. Clin Orthop Relat Res. 2007;

61. 61
Structure
• Some difficult Radiographs
• Important often missed fractures
• High Resolution High Quality MRI
• Tendon/Ligament Anatomy
• The Car Principle in MR Imaging!
• Foot Imaging
• The PITFL injury! The Leicester Theory!
3

62. Thank You
62