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We're gonna talk in the next 45

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to 50 minutes about critical tendons of the ankle and foot.

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And here I have two general objectives that I hope

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to fulfill to review the anatomy

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and normal MR imaging appearance of each of the four

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major tendon groups in the ankle and foot.

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And illustrate the major pathologic abnormalities

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that occur in these tendons.

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And I've listed some of the ones there.

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We'll be covering pretty much all of these

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in this particular lecture.

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Now this is an image, uh, that was given to me, uh,

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years ago by many patria.

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Uh, showing you the four major groups of tendons

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that we'll be concentrating on in this lecture.

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If we put an X through the transverse image

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through the distal tib

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and fibula, you can see the four quadrants

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and the major tendons that are found in each anally.

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We'll be talking about the anterior

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or extensor tendons laterally.

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We'll be talking about the perineal tendons posteriorly.

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We'll be talking mainly about the Achilles

1:09

tendon and medially.

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We'll be talking about the medial flexor tendons.

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And the reason that I've used this, uh,

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particular image supplied to me

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by many is not only does it show you the quadrants

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of these groups of tendons,

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but it gives you an idea of what their size is.

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And indeed this is an important point.

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'cause when we're looking for tendon pathology,

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be it degeneration

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or tearing, the size of the tendon becomes critical.

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So be aware of what tendons are larger

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and what tendons are smaller.

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Now whether they are oriented horizontally

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or vertically varies okay, uh, throughout their course.

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But at least you should get a general idea

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of which are the larger tendons

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and which are the smaller ones.

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Tendons are generally

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of similar size throughout their course

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with a few exceptions.

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So I want to outline those

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where you have accessory ossification centers, this may look

2:14

like a thick pendant.

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Now that's not a problem if the ossification center indeed

2:19

is ossified, but as I'll show you with one

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or two examples later on, fibro cartilaginous nodules

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may be what you see at these so-called accessory centers.

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In addition, where we have branches

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and divisions, which happen with a lot of these tendons,

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you may in fact be mistaken

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and call that pathologic thinning

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of at tendon, which it is not.

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And there's certain tendons in which this particular problem

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does produce a diagnostic dilemma.

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And then where we have osseous grooves,

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and I'm gonna show you that in a moment,

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you may have flattening of an adjacent tendon,

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which can simulate in fact tendon pathology.

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To give you an idea, let's look at this.

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Uh, this image, cadaveric specimens,

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we're looking at the posterior aspect of the distal tibia

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and fibula to point out some contour alterations

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that occur normally in this region.

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There is a prominent groove along the posterior aspect

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of the medial mais, which houses

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the tibials posterior tendon.

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And right behind it that flexor digitor longest tendon.

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There is a flattened area in this particular region

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of the distal tibia, intimate

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with the flexor lysis longest tendon.

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And indeed that is a site of pathology of that tendon.

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And then there is a second groove of variable size.

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And in this specimen, quite flat, that houses

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the peroneal tendon.

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Okay, the brevis

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and the longest, particularly the brevis, which is in front.

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This is the most variable of the grooves.

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And it's not surprising then of all the tendons,

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it's the peroneal tendons

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that most commonly will displace even dislocate at the

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level of the distal fibula.

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Let me just take a picture through that.

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Here's what it looks like.

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Tibials posterior flexor digit arm, longest flexor lysis,

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longest tendon.

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The muscle is over here. And note this groove.

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This is generally a very prominent group.

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So when you end up with problems in that particular area,

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tendinosis as shown here, penant tears not shown.

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Here, you can end up with reactive edema involving the subj

4:51

portion of the medial Malala.

4:55

There are also five ret macular.

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I'm showing you a picture of

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what they look like from the medial side over here on your

5:04

left and from the lateral side.

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On the medial side, we have the medial or flexor retula.

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On the lateral side, we have the superior

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and inferior extensor ret macula, and the superior

5:17

and inferior perineal ret macular.

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And you can see the tendons

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and the sheets that pass under these particular reac.

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I wanna emphasize one of these.

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This will come up again toward the end

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of this particular lecture.

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This is known as the medial malar sleeve,

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and it has three constituents, all right?

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And it forms an arc like region of continuous tissue. Here.

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As we look in front of the medial malus,

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we can see the attachment

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of the superficial deltoid ligament.

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You can see the similar things on these two images. Then we

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Reach this area, which is the outer periosteum attached

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to the medial maus.

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And then we can see the attachment side here

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of the flexor ret macular.

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So you could imagine perhaps some problems

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with the tali posterior tendon

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and fact, let's say it's sublux is.

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And it can strip away the reticulum as well

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as the periosteum,

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and in some cases even portions of the deltoid uh,

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ligament attachment.

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This is the medial malar sleep.