MRI of the foot

Muhammad Ali, MB BS; Tim S. Chen, MD; John V. Crues, III, MD

I
n an article published in the August
2006 issue of this journal, the authors
reviewed magnetic resonance imag-
ing (MRI) of the ankle. This article will
present a review of the use of MRI in the
evaluation of the foot, detailing bone and
cartilage abnormalities as well as sinus
tarsi pathology. The discussion will
address the evaluation of the foot in hind-
foot, midfoot, and forefoot subsections.

Foot MRI technique

Depending on the clinical question,
MRI of the foot should be tailored to
a hindfoot, midfoot, or forefoot exami-
nation. For hind- and midfoot, a 12- to
14-cm field of view is applied. For the
forefoot, a 10- to 12-cm field of view is
used to image the smaller peripheral
joints in detail.
Positioning
Similar to the ankle, the foot is placed in
a neutral position for high-field-strength
scanners and in approximately 30˚ plan-
tar flexion for extremity scanners.
Pulse sequences
The pulse sequences for the mid-
and forefoot are T1-weighted (T1W) in
the coronal and axial planes, short tau
inversion recovery (STIR) in the coro-
nal and sagittal or axial planes, and T2-
weighted (T2W) in the coronal plane.
Dr. Ali and Dr. Chen are Fellows in Mus-
culoskeletal Radiology, RadNet Manage-
ment, Los Angeles, CA. Dr. Crues is the
Medical Director of RadNet Management,
and a Volunteer Clinical Professor of Medi-
cine, University of California–San Diego
School of Medicine, San Diego, CA.
For the evaluation of a mass or the
diabetic foot, we add T1W sequences
before and after intravenous (IV) con-
trast (gadolinium chelate) administra-
tion. On low-field-strength scanners,
these are performed without fat satura-
tion; on high-field-strength scanners, fat
saturation is applied. Precontrast fat-
suppressed images are essential to avoid
the pitfall of pseudoenhancement of
a mass on fat-saturated postcontrast
images when compared with the non–
fat-suppressed precontrast images. This
is because of a narrow dynamic range of
the contrast display on the fat-saturated
images when compared with those with-
out fat saturation.
Bone and cartilage abnormalities
Trauma
The talus is a relatively common site
for osteochondral injury (Figure 1). The
middle third (in the sagittal plane) of the
lateral border and the posterior third of
the medial border of the talar dome are
the common locations.1 In our anecdotal
experience, the middle third of the
medial talar margin is a more common
site than the posterior third. The MRI
classification of osteochondral injuries
was presented by Hepple et al2 and
stages the talar injuries according to the
severity of the injury and the degree of
the osteochondral fragment instability.2,3
Fluid between the osteochondral frag-
ment and the underlying bone, displace-
ment of the fragment, and a fragment
size >1 cm are signs of an unstable
osteochondral fragment. Unstable or
necrotic osteochondral fragments are
treated surgically with drilling and curet-
tage. Conservative treatment is preferred
when the overlying cartilage is intact
and the fragment is stable.4
Talar neck fractures can lead to
avascular necrosis (AVN) of the proxi-
mal fragment. Stress fractures can oc-
cur in the talus but are less common
than calcaneal stress injuries.
Calcaneus stress fractures can have a
diffuse or ill-defined geographic mar-
row edema pattern (Figure 2). A low-
signal fracture line, usually in a vertical
orientation, may be visible. Complex

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 MRI OF THE FOOT

A B C

FIGURE 1. A talar dome osteochondral injury. (A) A sagittal T1-weighted image shows a low-signal osteochondral injury in the talar dome. (B) A
sagittal short tau inversion recovery image shows high signal in the talar dome, which is compatible with granulation tissue in the osteochondral
defect. (C) A coronal T2-weighted image shows the medial talar dome osteochondral defect.

A B

FIGURE 2. A calcaneus stress fracture.

(A) A T1-weighted image shows ill-
defined low signal in the posterior cal-
caneus. No discrete fracture line is
noted. (B) A corresponding short tau
inversion recovery image clearly re-
veals marrow edema associated with
trabecular stress fracture.

FIGURE 3. Talocalcaneal coalition.

(A) A sagittal T1-weighted image A B C
shows eburnation and irregularity of
the articulating surfaces (arrow) in
the middle talocalcaneal facet joint
in this patient with fibrous coalition.
(B) A coronal proton-density fat-
saturated image shows that the joint
line slopes medially (arrow) instead
of the normal lateral downslope.
(C) An oblique coronal proton-
density image in another patient
shows bony coalition of the middle
talocalcaneal facet (arrow). Again,
medial downsloping of the joint
plane is seen.
calcaneal fractures secondary to a verti- lar coalition. Osseous, fibro-osseous, fibrous bridging. Medial downsloping
cal fall mechanism are best evaluated fibrous, and fibrocartilaginous forms of the sustentaculum tali articulating
with computed tomography (CT).4 have been described. MRI findings in- surface (Figure 3) instead of the normal
clude a direct bony connection or (in the lateral slope and presence of a dorsal
Congenital case of nonosseous coalition) irregular- talar spur (not to be confused with the
Coalition of the middle talocalcaneal ity and eburnation of the articulating physiologic, more proximal dorsal spur
joint is second only to calcaneonavicu- surfaces and visualization of low-signal at the capsular insertion) are useful

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MRI OF THE FOOT

FIGURE 4. Calcaneonavicular coali-

A B
A B
C tion. (A) A sagittal T1-weighted image
shows irregularity and eburnation of
the articulating surfaces in this patient
with fibrous coalition of the calcaneo-
navicular joint (arrow). (B) An axial
short tau inversion recovery image
shows marrow edema (arrow) in the
navicular adjacent to the fibrous
coalition. (C) An axial proton-density
image in another patient shows bony
coalition (arrow) between the anterior
process of the calcaneus and the
navicular.
in their second or third decade. They
occur in a subarticular location and have
high signal on T2W images and low sig-
nal on T1W images because of their car-
tilaginous nature. Low-signal foci of
chondroid calcifications and linear low-
signal septations may be present.

Miscellaneous pathology
Navicular osteochondrosis (Köhler’s
disease) is seen in younger patients (3 to
7 years of age). Fragmentation and low
signal on T1W and T2W images are seen.7
It must not be confused with the frag-
mented appearance of nonunited ossifica-
tion centers. In adults, AVN secondary
to trauma can occur (Muller-Weiss dis-
ease).8 There is collapse and low signal of
the bone on all pulse sequences. Bony
changes seen with subtalar instability
and inflammatory arthropathies are dis-
cussed with sinus tarsi pathology.

Sinus tarsi pathology

The sinus tarsi contain 3 ligaments
extending from the talus to the calcaneus.
The lateral-most is the continuation of the
FIGURE 5. Calcaneal lipoma. (A) An axial T1-weighted image shows a large fat-signal mass in inferior extensor retinaculum. The cervi-
the calcaneus (lipoma), with central low-signal fluid secondary to cystic change. (B) The fatty
component of the lipoma is not discernable on this axial short tau inversion recovery image
cal ligament has a striated appearance. It
because of fat nulling. Only the central fluid component is seen. extends from the talar neck to the body of
the calcaneus in an oblique anteroposte-
ancillary findings.5,6 Calcaneonavicular bone cysts, and chondroblastomas. Lipo- rior direction, providing stability to the
coalition (Figure 4) is the most common mas have characteristic fat signal. They subtalar joint. The interosseous ligament
of the tarsal coalitions.5,6 As with other can have central calcification or cystic is the most medial of the 3. It extends
sites, it can be osseous or nonosseous. focus that appears as signal void or fluid from the talus to the calcaneus in an
An elongated anterior process of the signal, respectively (Figure 5). Bone oblique mediolateral direction (Figure 6).
calcaneus (anteater nose sign) may be cysts in calcaneus are more common in The ligaments limit the inversion of the
present. the older age group (>20 years). They hindfoot and play an important role in
have fluid signal and are located in the maintaining the stability of the subtalar
Neoplastic calcaneus body more inferiorly as com- joint. The sinus tarsi is predominantly
Some of the more common masses in pared with the chondroblastomas. Chon- filled with fat and also contains blood
the calcaneus include lipomas, solitary droblastomas are more common in men vessels and nerve endings.9,10

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A B C
A B
FIGURE 7. A patient with symptoms of sinus tarsi
syndrome. (A) This sagittal T1-weighted image
shows low-to-intermediate signal tissue replacing
the normal fat in the sinus tarsi. The ligaments
are not seen. (B) A coronal T2-weighted image
shows edema in the sinus tarsi (arrow). Normal
ligaments are not visible. This is compatible with
a tear of the sinus tarsi ligaments. (C) Another
patient with sinus tarsi edema. In this case, the
short tau inversion recovery coronal image
shows erosive changes in the talus and calca-
neus in addition to edema. This patient has
rheumatoid arthritis.
The ligaments can be torn secondary subchondral sclerosis with or without
to acute trauma or more commonly by subchondral edema can be seen. Poste-
chronic recurrent microtrauma. This rior talocalcaneal facet is involved to a
can lead to subtalar instability with greater degree. Normal fat signal in the
resulting degenerative changes in the sinus tarsi is replaced with edema or
joint. Articular surface irregularity and fluid signal. There is associated nonvi-
December 2006 www.appliedradiology.com
MRI OF THE FOOT
FIGURE 6. Anatomy of sinus
tarsi ligaments. (A) This sagit-
tal T1-weighted image (T1WI)
shows the cervical ligament
(arrow) extending from the
talar neck to the calcaneus.
(B) A coronal T1WI of the inter-
osseous ligament (encircled) in
the sinus tarsi. Note the normal
fat in the sinus tarsi. (C) An
interosseous ligament (arrow)
is seen on this more medial
sagittal T1WI.
A
FIGURE 8. Plantar fascitis. (A) A sagittal T1-
weighted image shows thickening and indis-
tinctness of the plantar fascia. (B) The more
sensitive sagittal short tau inversion recovery
image shows the same, with better depiction
of the mild associated edema in the adjacent
tissues (arrow).
sualization of the torn sinus tarsi liga-
ments (Figure 7).
Ankle, subtalar, and tarsal joints can
be affected by inflammatory arthrop-
athies (Figure 7), such as Reiter’s dis-
ease, or crystal deposition disease, such
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MRI OF THE FOOT

A B

FIGURE 9. Plantar fascia partial

tear. (A) A sagittal short tau inver-
sion recovery image shows partial
discontinuity in the plantar fascia
fibers (arrow) and waviness of the
torn fibers. The plantar fascia is
also thickened. (B) A coronal T2-
weighted image reveals that the
medial cord of the plantar fascia is
diffusely thick. There is focal fluid
replacing the torn fibers of the fas-
cia (arrow).

A B C

FIGURE 10. Plantar fibroma. (A) A coronal T1-weighted image shows a large low-signal mass that involves the medial cord of the plantar fascia
(arrows). (B) The mass is persistently low to intermediate in signal on this coronal T2-weighted image, which is typical for a plantar fibroma. (C) In
this sagittal short tau inversion recovery image, the mass shows intermediate signal.

adjacent subcutaneous edema. Edema

A B C may also be seen in the calcaneus at
the insertion site of the plantar fascia
(Figure 8). It is associated with a plantar
calcaneal spur in approximately 50%
of cases.
Tears of the plantar fascia occur most
commonly in the midportion of the fas-
cia. This is more distal to the typical loca-
tion of plantar fasciitis (Figure 9). They
can be partial or complete. Trauma is the
usual etiology. Discontinuity and wavi-
ness of the fascial cords with adjacent
FIGURE 11. Lisfranc ligament tear. (A) On this axial T2-weighted image, normal signal and ori-
soft tissue edema are seen on the MRI.11
entation of the Lisfranc ligament (arrow) can be seen. (B) An axial T1-weighted image in a patient Plantar fibromatosis is nodular
with a Lisfranc ligament tear shows an absence of the normal low-signal band (arrow). (C) An fibrous proliferation of the plantar fas-
axial short tau inversion recovery image at the same level as (B) shows marrow edema in the cia. The appearance can vary from a
base of the second metatarsal and the anterolateral corner of the medial cuneiform. Fluid is replacing well-circumscribed low-signal lesion on
the torn Lisfranc ligament (arrow).
all pulse sequences to a locally invasive
as gout. MRI can reveal inflamed syno- Hindfoot pathology lesion with ill-defined borders and inter-
vium in addition to the bony erosions and Plantar fasciitis is most pronounced mediate signal (Figure 10). This is a dif-
edema. Masses, such as ganglion cysts within 2 to 3 cm of the calcaneal attach- ficult lesion to treat because of its
and lipomas, can occur and lead to pain ment. It manifests as a smooth thicken- tendency to recur following local resec-
from compression of nerve endings.9,10 ing (>4 mm) of the plantar fascia, with tion.11-13 Differential diagnoses include

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MRI OF THE FOOT

A B

FIGURE 12. Synovial sarcoma. (A) A sagittal T1-weighted image shows a lobulated low-to-intermediate signal mass (arrows) that involves the tarsal
bones and the base of the metatarsal (arrowhead). (B) A sagittal T2-weighted image shows high signal in the same mass (arrows). Smooth, lobulated
margins underrepresent the aggressive nature of this neoplasm and can sometimes be misleading.

A B

FIGURE 13. Neuropathic changes. (A) A sagittal T1-weighted image shows disorganization of the talonavicular joint with fragmentation, sub-
chondral eburnation, and synovial thickening. There is mild inferior “sagging” of the talar head (arrow). Irregularity of the talar dome is also
noted. (B) A sagittal short tau inversion recovery image shows a subchondral cyst in the navicular. The marrow edema in this case is centered
on the joint, which supports the diagnosis of neuropathic joint over osteomyelitis in this diabetic patient.

soft tissue masses (such as giant cell
tumor) and sarcomatous neoplasm (such
as synovial sarcoma and fibrosarcoma).
A well-circumscribed appearance and
homogenous low-signal characteristics
suggest fibromatosis.14-16
Osseous abnormalities of the hind-
foot were discussed earlier.
Midfoot pathology
Trauma
A traumatic tear of the Lisfranc liga-
ment (a short bandlike ligament that
extends from the plantar anterolateral
corner of the medial cuneiform to the
plantar posteromedial corner of the
base of the second metatarsal) is an
important injury (Figure 11).17 It can
lead to instability and progressive dis-
organization of the Lisfranc joint.
Additionally, there can be loss of the
medial longitudinal arch. The rupture
of the ligament fibers is more common
than is the avulsion fracture at the bony
attachments.17-19 It is an important diag-
nosis, since early internal fixation may
give the ligament a chance to heal and
can help to avoid the need for future
arthrodesis. Even with early interven-
tion, the success rate is <50%.
The tarsal bones are a common site
of trabecular stress injury. Marrow ed-
ema with a lack of a clear fracture line is
present.
The flexor hallucis longus (FHL)
tendon is prone to tendinosis and tears
at the knot of Henry. The mechanism
is chronic repetitive friction with the
flexor digitorum longus (FDL) tendon
from activities like jogging.20 This is
analogous to the intersection syndrome
between the first and second extensor

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A C
FIGURE 14. Osteomyelitis. (A) A coronal short
tau inversion recovery (STIR) image shows focal
B fluid signal in the deep soft tissues of this diabetic
patient (small arrow). This finding could be a
small abscess or just inflammatory tissue. A skin
ulcer is barely visible (big arrow). (B) A contrast-
enhanced coronal T1-weighted image (T1WI)
shows enhancement in the inflammatory tissue.
A small nonenhancing area is consistent with an
abscess (small arrow). The ulcer (big arrow) is
also better visualized. This shows the value of
intravenous contrast administration in the evalu-
ation of a diabetic foot. (C) An axial STIR image
in the same patient shows high signal in the
metatarsal (arrow). The corresponding T1WI
(not shown) exhibited low signal. These findings
are consistent with osteomyelitis.
A C
B detection of neuropathic changes is very
FIGURE 15. Anatomy of the plantar capsu-
loligamentous complex of the metatarsopha-
langeal joint. (A) A sagittal short tau inversion
recovery (STIR) image shows the plantar
plate (arrow) attachment to the base of the
proximal phalanx. (B) A sagittal STIR image in
a plane more lateral to the plantar plate
reveals the hallux sesamoid (arrows) in the
flexor hallucis brevis tendon. (C) An axial T1-
weighted image shows the two hallux sesa-
moids (arrows) with a normal marrow signal.
December 2006 www.appliedradiology.com
MRI OF THE FOOT
compartment tendons in the wrist. The
medial plantar nerve branches can get
entrapped between the knot of Henry and
the abductor hallucis muscle, leading to
first and second toe plantar dysesthesias.
Neoplastic
Synovial sarcoma is a malignant neo-
plasm with predilection for the foot. It is
predominantly seen in patients between
the ages of 15 and 40 years. It is an ag-
gressive neoplasm with a posttreatment
5-year survival rate of approximately
55%.21,22 Local recurrence and pulmonary
and bone metastasis are common. On
MRI, it appears as a well-defined mass
with a heterogeneous low signal on T1W
images. On T2W images, it has a hetero-
geneous high signal (Figure 12). Cystic
areas are common. Fluid-fluid levels can
be present in close to 20% of cases. Foci
of calcifications can lead to areas of low
signal on T2W images. Heterogeneous
enhancement is seen with IV contrast ad-
ministration. It usually displaces the adja-
cent structures rather than invading them.
Sometimes a small size, slow growth, and
well-circumscribed appearance can lead
to an erroneous diagnosis of a benign
mass.23 Other soft tissue neoplasm, benign
and malignant primary bony neoplasm,
and, less commonly, metastasis can all
involve the midfoot.
Arthropathy
The Lisfranc and Chopart (intertarsal)
joints are commonly disrupted in neuro-
pathic arthropathy (Charcot joint). Rapid
destruction of the joints and bones is the
rule if protective measures are not taken
early in the process. Therefore, early
important. Signs on MRI include tear of
the Lisfranc ligament and edema in the
tarsal and metatarsal bones adjacent to
the joints. Loss of normal bony relation-
ship and articular and osseous destruction
are advanced findings (Figure 13).24-26
A common clinical question is the dif-
ferentiation between osteomyelitis and a
neuropathic joint. Certain findings (such
as the presence of more focal involvement
of the bones, skin ulcers, sinus tracts, and
abscess) are more suggestive of infection
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MRI OF THE FOOT

(Figure 14). In early neuropathic joint,

A B the signal abnormalities are centered on
the joint. However, a clear distinction be-
tween infection and neuropathic changes
is not always possible with imaging.
The midfoot is often involved in
arthropathies such as gout and rheuma-
toid arthritis. The findings on MRI in-
clude erosions, bone marrow edema,
and synovitis. In the absence of a correl-
ative history, these can be confused with
osteomyelitis. Degenerative changes
in the midfoot can be seen with altered
mechanics or can be posttraumatic.

Forefoot pathology
FIGURE 16. A metatarsophalangeal (MTP) collateral ligament injury. (A) An axial T1-weighted Trauma
image of the first MTP joint shows an indistinct and intermediate-signal medial collateral liga- “Turf toe” refers to a capsuloligamen-
ment (long arrow). Compare this with the normal low-signal lateral collateral ligament (small
arrow). (B) An axial short tau inversion recovery image shows a grade 2 sprain of the medial
tous injury of the metatarsophalangeal
collateral ligament (arrow). (MTP) joint of the first toe. The mecha-
nism of injury includes anterior thrust of
the metatarsal head in a hyperextended
A B joint with a relatively fixed great toe. This
is common in sports played on synthetic
turf, like football, hence the name turf
toe. There is stretching and tearing of the
plantar capsule and tearing of the plantar
plate. The plantar plate is a fibrocartilagi-
nous structure that extends from the
metatarsal neck to the base of the proxi-
mal phalanx. It reinforces the plantar
capsule and also attaches the hallux
sesamoid bones to the base of the proxi-
mal phalanx (Figure 15). Discontinuity
FIGURE 17. Freiberg’s infraction. (A) An axial T1-weighted image shows deformity and col- of the plantar plate and focal edema and
lapse of the second and third metatarsal heads (arrows). Repetitive microtrauma is the pro- fluid is seen. Associated proximal dis-
posed underlying etiology. (B) Axial short tau inversion recovery images show the marrow placement of the hallux sesamoids may
edema from trabecular bone injury in the second metatarsal head and the associated collapse be seen.27,28
of the second and third metatarsal heads (arrows).
Collateral ligament tears are also more
common in the great toe. Varus or valgus
A B force is the usual etiology. Edema and
discontinuity of the medial or lateral col-
lateral ligaments is present (Figure 16).
The MTP collateral ligament tear is
more common than that of the interpha-
langeal joints.29
Hallux sesamoids can be involved with
fractures, AVN, and sesamoiditis sec-
ondary to inflammatory arthropathies or
osteomyelitis. The medial sesamoid is
FIGURE 18. Pressure lesion. (A) A sagittal T1-weighted image shows a low-signal ill-defined more commonly involved with trauma,
soft tissue signal just below the metatarsophalangeal joint (arrow). It has a flat appearance
and does not have a masslike morphology. (B) A coronal T2-weighted image shows the same
and lateral sesamoid tends to get AVN.
lesion with intermediate signal and without a masslike contour. The location and MR charac- Replacement of the normal marrow fat
teristics in this diabetic patient are consistent with a pressure lesion. signal with edema signal can be seen.

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 MRI OF THE FOOT

A A

FIGURE 20. A giant cell tumor of the tendon

sheath. (A) A coronal T1-weighted image
shows a low-signal mass (arrow). The mass is
inseparable from the flexor tendons. (B) On a
coronal short tau inversion recovery image, the
mass is persistently low in signal (arrow)—
a finding that is consistent with a giant cell
FIGURE 19. Morton neuroma. (A) A coronal T1-weighted image (T1WI) without fat saturation tumor of the tendon sheath.
(low-field scanner) shows an intermediate-signal-intensity mass (arrows) in the plantar aspect “March fracture” is a stress fracture of
of the second web space. (B) A coronal T1WI without fat saturation after the administration of
the metatarsal neck.27 The name comes
intravenous contrast shows diffuse enhancement in the Morton neuroma (arrows). On high-
field scanners, fat saturation is desirable because it increases the conspicuity of the mass. from its common occurrence in military
recruits. It is predominantly seen with
activities that place excessive stress on the
A B metatarsals, such as ballet dancing and
gymnastics. Marrow edema and adjacent
soft tissue edema are seen in early stages.
Periosteal thickening is present in the
subacute stage as a healing response.

Neoplastic
Pressure lesions are fibrofatty lesions
that occur in the subcutaneous fat. These
typically develop at the load-bearing
bony prominences, including the plantar
aspects of the first and fifth metatarsal
heads or below the calcaneal tuberosity.
These lesions are of low signal on T1W
images and of variable signal (intermedi-
ate-to-high signal) on T2W images. They
can have fat in the interstices. Sometimes
FIGURE 21. Gout. (A) An axial T1-weighted image shows a low-signal gouty tophus eroding the they can develop central cystic changes.
adjacent bone (arrow) to form the typical punched-out erosion with an overhanging edge. (B) An They generally lack the well-defined
axial short tau inversion recovery (STIR) image at a slightly different slice position shows the morphology of a mass, and their appear-
bone erosions. The signal of the gouty tophus tissue is heterogeneously intermediate on STIR. ance is that of an ill-defined fibrotic
The signal of the tophi on fluid-weighted sequences is typically low to intermediate. tissue (Figure 18). The characteristic
Freiberg’s infraction of the metatarsal most popular theories of the etiology. It is location and interspersed fat in the lesion
heads is characterized by fissuring, osteo- more common in young women and may favor the diagnosis and help differentiate
necrosis, and eventual collapse of the be secondary to the wearing of high heels. it from a neoplasm.24
subchondral bone (Figure 17). The sec- In its acute stage, there is a marrow Morton neuroma is a focal perineural
ond and third metatarsal heads are most edema pattern. In its chronic phase, there fibrosis of the plantar interdigital nerves.
commonly affected.27 Repetitive micro- is deformity of the metatarsal head and It is not a true neuroma. The most com-
trauma and vascular compromise are the associated degenerative arthritis. mon location is the third and fourth web

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MRI OF THE FOOT
spaces between the plantar aspects of the
metatarsal heads.30-32 It is more common
in women, and, once again, the wearing
of high heels is implicated as a causative
factor. Other etiologic possibilities in-
clude the compression of the nerves by
the intermetatarsal ligament or a dis-
tended intermetatarsal bursa. Pain in the
web space with or without radiation to
the toes is the usual presenting symptom.
These are small lesions that are nearly
isointense to the muscles on T1W
images, are intermediate to high in signal
on T2W images, and can be isointense
to fat (Figure 19). Fat-suppressed IV
contrast-enhanced T1W images give the
highest lesion conspicuity because of
intense lesion enhancement. It can be a
mobile lesion and can change positions
in the intermetatarsal space.32
A giant cell tumor of the tendon sheath
is a relatively common benign lesion. It is
a focal form of extra-articular pigmented
villonodular synovitis. It is low in signal
on T1W images and is low-to-intermedi-
ate signal on T2W images (Figure 20).
Other masses, such as foreign body
granulomas, ganglion cysts, and malig-
nant neoplasms (like synovial sarcomas
or metastasis) can all occur in the fore-
foot location.
Arthropathy
The MTP joint of the great toe is the
characteristic location for gout. Monoar-
ticular involvement is common but not
the rule. Gouty tophi cause characteristic
erosions with punched-out, overhanging
edges of the periarticular bones. They
also occur at extra-articular locations
with associated osseous erosions. Tophi
have low signal intensity on T1W images
and low-to-intermediate signal intensity
on T2W images (Figure 21).33 Variable
enhancement is seen with IV contrast
administration. Septic arthritis should
always be considered in the differential
diagnosis of monoarthritis. Rheumatoid
arthritis and Reiter’s disease are other
common arthropathies in the forefoot.
Osteoarthritis commonly involves the
first MTP joint as well.
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Conclusion
MRI is the imaging modality of choice
for evaluation of musculoskeletal pathol-
ogy, including the soft tissue and osseous
trauma, neoplasms, and inflammatory
pathology. Compared with CT, MR pro-
vides a superior contrast resolution and
exquisite detail of soft tissue structures. It
also surpasses CT in the evaluation of tra-
becular bone injury. The strengths of MRI
in evaluating various foot pathologies
have been briefly reviewed in this article.
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