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This is a 48 year old, a man,

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young man at 48 with posterior ankle pain for two years,

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worsening over time, no history of prior surgery.

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So I'm gonna start out now, when I, when I look at an ankle, uh,

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because I'm an old school radiologist from the days of the Jurassic period,

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I like to look at something that is very radiographic since I grew up in the era

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of radiography and ct. So I like to start with a sagittal,

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like a lateral radiograph.

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And I get a lot of information from that on almost every structure.

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Now, for those of you that don't do a lot of foot and ankle, um, first of all,

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Mr is a terrific modality here because you can put the foot and ankle in the

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center of the bore. So no matter the field strength,

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you can get excellent image, quality, contrast,

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and spatial resolution at any field. Strength from 0.18 up to 17.

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If you're familiar with the anatomy, the sagittal should po should pose,

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no threat to you should be very comfortable for you.

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And you can go at this one of several ways. You can go at it by compartment,

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anterior, posterior, medial, or lateral.

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I teach a lot of my colleagues and fellows that I, that I work with to use a,

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a tissue approach, muscles, tendons, ligaments, cartilage,

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which means you have to learn what the key ligaments are.

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You also have to learn what the mechanisms of injury are.

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To know what you're looking for.

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You have to understand what the appearance of cartilage is by age,

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and that takes a little bit of studying and time and experience.

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But I think that's a, that's a great way to approach it by tissue.

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So I might go joint low ligaments, high ligaments,

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subor ligaments show part ligaments. So you see,

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I even divide up the ligaments into various subsets,

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and I'm not expecting you to do it right from the get-go.

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But as you get more and more experienced, your library,

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your mental library within each subset is going to expand,

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preventing you from missing things.

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So we've been directed to the posterior aspect of the ankle right away by the

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history, which is terrific. And right away,

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you see some signal here in the calcaneus. Now, another thing I try and,

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and, and teach my, my fellows is, is that,

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you know, an MR can be like a bone scan. You're looking for hotspots.

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I mean,

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one of the problems with MR is it sees so much and you have to learn how to

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correlate what you see with the history without being an overread.

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On the other hand,

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the MRI directs you to the area of potential clinical interest

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because of the swelling and mr sensitivity to it,

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be it in the soft tissue or the skeleton.

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So always like to go to the area that's most swollen. Now,

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don't get enjoyment, bias. In other words,

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you enjoy making the finding right away and you forget about everything else.

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Also known as satisfaction bias. So you gotta,

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you gotta really kind of scroll around and look at everything on your checklist.

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But since this is a readout of limited number of cases,

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I'm not gonna be able to take you through the entire checklist.

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But we're gonna start out with this tendon, the achilles tendon,

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the longest, uh, tendon in the body. Now,

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one way to think about the tendons is in the foot.

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1, 2, 3, 4, 1 Achilles,

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two peroneus longest and brevis three, the medial group,

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the posterior tibial tendon, the flexor digitorum,

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and the flexor hales. And finally four anterior,

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the extensor digitorum, the extensor hales, the tibialis anterior,

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and the peroneus queu 1, 2, 3, 4.

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So we're on tendon number one in the back. So what's,

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what's on our Achilles checklist? We have a checklist of skeleton,

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cartilage, ligaments, tendons, bone articular, et cetera.

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We're gonna break that down. We already broke down ligaments for you.

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We already broke down tendons for you.

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Now we're just gonna focus on this tendon. What is our Achilles checklist?

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Well, how does the myo tendonous junction look? Pretty good.

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How does the distal Achilles look? Well,

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maybe not so good. So now it's time for a question.

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Let's call up our polling question. Which of the following is true?

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There's a haggling lesion, a B,

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there's a show part problem C, there's an Achilles tear.

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D, there's a planter fascial tear, E,

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a, B, and C. Almost half of you got it right.

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You did not get satisfaction bias. You did not.

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Half of you did not focus simply on the Achilles. It is true.

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There is a halan lesion. It's right here.

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It's this little point sticking up usually in the post sedl

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calcaneus. It is true, there is an Achilles tear.

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It's an under surface delamination tear where the upper footprint is

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coming off the Achilles. The lower footprint remains present,

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but there's also an old fracture of the anterior process

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of the calcaneus consistent with a prior show part injury.

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There's the rest of the fracture and the hypertrophic deformity,

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which is where the bifurcate ligament of the show part system lives.

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There is a calcan cuboid lateral component to the bifurcate,

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which is right here. That's scarred.

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And there's a component that goes to the navicular,

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which is this little floppy thing, which is torn.

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So those are two components of the show part.

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Here's the short and long planter ligaments.

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Those are also components of the show part.

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There's the dorsal Taylor navicular ligament, which is thickened and scarred,

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which is very common with advancing age with a dorsal spur.

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That's part of the show part system.

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There's also a dorsal lateral calcan cuboid ligament, I'm not gonna show you,

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but also part of the show. Part system is the spring ligament complex.

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Let's take a look at that.

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Here

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We are down low. There's a sedl component of the spring ligament.

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Let's see if I can get it here for you. Right there.

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There's the sedl component of the spring ligament.

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And then here is another component. Let's see if I can get that for you.

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Down a little lower.

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Here we go. Here is the medial plantar component,

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and here's the infra lateral longitudinal component. So you have one component,

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two components, and the third component, which is right here,

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the sedl component. So three components of the spring,

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the short plantar, the long plantar, the dorsal Taylor navicular.

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And most importantly,

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the show part is injured with a fracture of the anterior process of the

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calcan affecting the medial and lateral components of the bifurcate ligament.

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But back to the Achilles, which is where we started.

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So we're back to our Achilles checklist. Myo tends junction. Okay,

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upper tendon, normal lower tendon,

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hypertrophic tendonopathy footprint de laminated in the upper half

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from the calcan attached to the lower half surrounding swelling,

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known as peritonitis, supra calcan, bursitis,

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yes, check Halan deformity, yes,

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check macro retraction,

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no check kegers space swelling. Yes,

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check reactive and edema of the calcan. Yes,

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check. And it's true, there is no planter fasciitis.

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So the answer to that question was false.

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So this patient has an achilles tear,

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a haggling deformity, a prior chopard injury,

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and we shared some interesting and important ligamentous anatomy

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of the show part system.