0:00

<v ->The second case is this one right here.

0:05

It's a female patient, 39 years old

0:08

with history of ankle sprain eight months ago.

0:11

And she still feels pain

0:14

over the lateral malleolus without ankle instability.

0:18

Okay, so here we can see

0:21

we have the images

0:22

and I'd like to draw your attention

0:26

for the anterior tibiofibular ligament.

0:28

You can see that the ligament is huge, is thickened.

0:33

And look the marker is very close to the ligament.

0:38

And in this case, this is a case

0:41

of the anterolateral impingement.

0:46

The patient doesn't, she doesn't have instability.

0:50

She just have pain in this region right here.

0:56

We don't have contrast in this case,

0:58

but sometimes when we do contrast in case like that,

1:02

we can see an enhancement of the ligament

1:05

or not in the ligament but in the synovitis

1:09

that is a focal sign of virus

1:11

that is associated with cases of anterolateral impingement.

1:16

In this case, we can see a sort of,

1:20

some kind of a meniscoid morphology here of the ligament.

1:26

But what I've learned with this case is

1:30

that sometimes just on the arthroscopy,

1:34

that the tropic surgeon,

1:35

they can really show what's happening, what's going on.

1:40

And that's why arthroscopy is the gold standard.

1:42

But we can,

1:45

we can think about this diagnosis

1:47

when we see lesions like that

1:50

and talking about this lesion.

1:55

Let me just show the other images here.

1:58

So here we have a DP fat-saturated image.

2:03

Here we have a T1 coronal image,

2:07

and you can see this huge anterior tibiofibular ligament.

2:12

And let me let put the coronal,

2:14

the oblique image here.

2:18

Here is the area

2:19

of the thickened anterior tibiofibular ligament.

2:23

And in the coronal plane,

2:25

we can't see much about the ligament, it's here.

2:28

It's thickened.

2:30

And another interesting thing

2:33

about the anterolateral impingement

2:35

is that sometimes the impingement

2:39

is not caused about the anterior tibiofibular ligament

2:45

as you said,

2:46

but it can be caused by a lesion

2:51

of the anterior tibiofibular ligament,

2:54

especially the Bassett's ligament,

2:56

the last, the lower fibers

2:58

of the anterior tibiofibular ligament.

3:03

This ligament, the Bassett's ligament,

3:05

it is in this region here.

3:09

In this region here.

3:11

It's in this region there.

3:13

The lower part of the anterior tibiofibular joint.

3:17

And sometimes it is an intra-articular ligament,

3:20

and if the ligament's thickened,

3:23

it can cause a lesion of the cartilage of the talus

3:28

in this region right here.

3:30

And another interesting that I found

3:33

is that even if the Bassett's ligament, it's okay,

3:38

if you have a instability or a micro instability,

3:41

the slight movement of the talus

3:45

can get the talus very close to the Bassett's ligament.

3:50

And the patient can have some kind

3:53

of heterolateral impingement

3:56

because of this instability of the ankle.

4:00

And the cartilage of the talus starts to rub

4:06

against the anterior tibiofibular ligament,

4:11

the Bassett's ligament.

4:13

So that's another interesting thing

4:17

that I found about the anterolateral ligament.

4:20

And yeah, I think that's it for the second case.

4:24

I don't know.

4:25

Do you have any comments, Don?

4:28

<v ->Well, the only comment I have

4:30

that relates to the very last thing you're talking about,

4:32

I certainly have seen examples

4:34

of a prominent Bassett's ligament

4:37

extending pretty far immediately in front of the talus

4:41

associated with marrow edema in the talus.

4:44

One other thing that is very funny to me

4:47

is how much imaging we do

4:50

for acute ligamentous injuries of the ankle

4:53

which are generally treated conservatively,

4:56

yet it seems like almost all the times

4:58

we image them anyway with MR.

5:01

Prior to MR, that was never done.

5:03

You know, they just would treat them conservatively.

5:07

Chronic ligament problems, I can understand,

5:09

but I often wonder why we do so much MR

5:12

for sprained ankles.

5:14

<v ->Yes, I agree with you because for me,

5:17

I have the same feeling

5:18

because for the treatment of the ligaments of the ankle,

5:23

the treatment, it's almost always conservative.

5:27

And just if the treatment fails,

5:31

they go to surgery and it doesn't,

5:34

there's not a big problem

5:36

if the orthopedic surgeons, they operate the patient,

5:40

they go to surgery like in an acute setting,

5:44

or if like wait six months, one year.

5:47

So, yeah, yeah.

5:49

<v ->It's good to study the ligaments anatomy

5:53

but I don't know effectively how we can help

5:57

with the treatment of this patients.

6:00

So let's go to the next case of this, our last block.