📌 Ankle Coronal MRI Essentials

https://youtube.com/shorts/9DtdVm0Wst4

 

Medial Malleolus Level to Plantar Foot — What to Teach, What to See

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1. Medial Malleolus Level: The Key Coronal Slice

This mid-to-posterior coronal slice is a high-yield teaching view, allowing simultaneous evaluation of the tarsal tunnel, peroneal tendons, and major ankle ligaments.

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Medial Side — Tarsal Tunnel (Anterior → Posterior)

Use the classic mnemonic “Tom, Dick, And Very Nervous Harry.”

• Tibialis Posterior Tendon (TP) – most anterior, immediately behind the medial malleolus
• Flexor Digitorum Longus (FDL) – just posterior to TP
• Posterior Tibial Artery & Veins – between FDL and FHL
• Tibial Nerve – posterolateral to the vessels
• Flexor Hallucis Longus (FHL) – most posterior; muscle belly may still be seen at this level

• Flexor Retinaculum – fibrous roof of the tarsal tunnel

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Lateral Side — Peroneal Complex

• Peroneus Brevis Tendon – closest to fibula, within the retromalleolar groove
• Peroneus Longus Tendon – posterior to brevis
• Peroneus Brevis Muscle Belly – may extend distally to malleolar level (low-lying muscle belly)
• Superior Peroneal Retinaculum – stabilizes the peroneal tendons

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Ligaments Best Assessed on Coronal MRI

Medial (Deltoid Ligament Complex)
• Deep layer (Posterior Tibiotalar Ligament) – thick, striated, tibia to talus
• Superficial layer (Tibiocalcaneal Ligament) – thinner, courses toward sustentaculum tali

Lateral / Syndesmotic
• Calcaneofibular Ligament (CFL) – best evaluated on coronal images
• Posterior Talofibular Ligament (PTFL) – visible on posterior coronal slices
• Posterior Inferior Tibiofibular Ligament (PITFL)
• Interosseous membrane/ligament

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2. More Anterior/Distal Coronal Level: Quadratus Plantae Zone

This slice transitions from hindfoot to midfoot and is ideal for teaching plantar muscle layers.

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Plantar Muscles (Layered Anatomy)

1st Layer (Superficial)
• Flexor Digitorum Brevis (FDB)
• Abductor Hallucis
• Abductor Digiti Minimi

2nd Layer (Key Teaching Level)
• Quadratus Plantae (QP) – deep to FDB, inferior to calcaneus
• Corrects FDL pull (“accessory flexor”)
• Master Knot of Henry (FDL–FHL crossing) may be seen medially

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Tendons and Pulleys

• FHL – courses beneath sustentaculum tali, deep to FDL
• FDL – crosses superficially over FHL; insertion site of QP
• Peroneus Longus – turns medially through the cuboid groove (cuboid tunnel)

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Neurovascular Branching

• Medial Plantar Nerve & Vessels – between abductor hallucis and FDB
• Lateral Plantar Nerve & Vessels – between QP and FDB
→ Key pathway for Baxter’s nerve entrapment

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Ligaments & Fascia

• Plantar Fascia – thick low-signal band; central cord dominant
• Spring Ligament (Plantar Calcaneonavicular) – hammock supporting the talar head
• Long Plantar Ligament – deep to QP

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Lecture Pearls

• Magic Angle Effect – increased signal in TP or peroneal tendons near malleoli
• Accessory muscles – peroneus quartus, accessory FDL may cause mass effect
• Quadratus Plantae atrophy – suggests proximal tibial or lateral plantar nerve pathology (Baxter’s neuropathy)

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Take-Home Message

The coronal ankle MRI is not just a tendon slice.
It is a roadmap of tunnels, ligaments, and nerve pathways—
essential for understanding pain, instability, and neuropathy.

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#AnkleMRI, #TarsalTunnel, #FootAnkleRadiology, #MSKRadiology, #OrthopedicImaging, #PlantarAnatomy, #BaxtersNerve, #DeltoidLigament, #PeronealTendons, #RadiologyEducation, #Vibecase

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Visualizing MSK Radiology: A Practical Guide to Radiology Mastery
© 2022 MSK MRI Jee Eun Lee All Rights Reserved.
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📌 Ankle Coronal MRI Essentials