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Imaging of Foot and Ankle Nerve Entrapment Syndromes: From Well-demonstrated to Unfamiliar Sites¹

¹ From the Departments of Skeletal Radiology (E.M.D., X.D., A.B., M.C.T., A.C.) and Orthopaedic Surgery (H.M.), Roger Salengro Hospital, CHRU of Lille, Bd du Professeur Jules Leclercq, 59037 Lille Cedex, France; and the Department of Anatomy, Faculty of Medicine, Place de Verdun, Lille, France (X.D., H.M.). Recipient of a Certificate of Merit award for an education exhibit at the 2001 RSNA scientific assembly. Received March 11, 2002; revision requested May 3; final revision received July 30; accepted August 1. Address correspondence to E.M.D. (e-mail: philmanu@wanadoo.fr).

View larger version (26K): [in a new window]   Figure 1a.  (a) Drawing of the dorsal aspect of the foot illustrates the territories of the deep peroneal nerve (DPN), lateral plantar nerve (LPN), medial plantar nerve (MPN), sural nerve (SN), and superficial peroneal nerve (SPN). (b) Drawing of the plantar aspect of the foot illustrates the territories of the lateral calcaneal nerve (LCN), lateral plantar nerve (LPN), medial calcaneal nerve (MCN), medial plantar nerve (MPN), and sural nerve (SN).

View larger version (19K): [in a new window]   Figure 1b.  (a) Drawing of the dorsal aspect of the foot illustrates the territories of the deep peroneal nerve (DPN), lateral plantar nerve (LPN), medial plantar nerve (MPN), sural nerve (SN), and superficial peroneal nerve (SPN). (b) Drawing of the plantar aspect of the foot illustrates the territories of the lateral calcaneal nerve (LCN), lateral plantar nerve (LPN), medial calcaneal nerve (MCN), medial plantar nerve (MPN), and sural nerve (SN).

View larger version (59K): [in a new window]   Figure 2.  Drawing illustrates the PTN trifurcation. ADQM = abductor digiti quinti muscle, AHM = abductor hallucis muscle.

View larger version (104K): [in a new window]   Figure 3a.  Normal anatomy of the upper tarsal tunnel. (a) Axial spin-echo T1-weighted MR image (repetition time msec/echo time msec = 500/12) shows the lateral plantar nerve (black arrowhead), medial plantar nerve (black arrow), posterior tibial artery and veins (white arrow), flexor hallucis longus tendon and muscle (FHL), deep aponeurosis (white arrowheads), and tibia (T). (b) Corresponding transverse 13.5-MHz US scan shows the PTN branches (circled), posterior tibial artery and veins (thick white arrow), flexor digitorum longus tendon (black arrow), and posterior tibial tendon (thin white arrow).

View larger version (112K): [in a new window]   Figure 3b.  Normal anatomy of the upper tarsal tunnel. (a) Axial spin-echo T1-weighted MR image (repetition time msec/echo time msec = 500/12) shows the lateral plantar nerve (black arrowhead), medial plantar nerve (black arrow), posterior tibial artery and veins (white arrow), flexor hallucis longus tendon and muscle (FHL), deep aponeurosis (white arrowheads), and tibia (T). (b) Corresponding transverse 13.5-MHz US scan shows the PTN branches (circled), posterior tibial artery and veins (thick white arrow), flexor digitorum longus tendon (black arrow), and posterior tibial tendon (thin white arrow).

View larger version (99K): [in a new window]   Figure 4.  Normal anatomy of the lower tarsal tunnel. Axial spin-echo T1-weighted MR image (500/12) shows the posterior tibial artery and veins (thin white arrow), flexor digitorum longus tendon (thick white arrow), flexor hallucis longus tendon (black arrowhead), medial plantar nerve (black arrow), lateral plantar nerve (circled), and flexor retinaculum (white arrowheads).

View larger version (133K): [in a new window]   Figure 5a.  Tarsal tunnel syndrome in a 33-year-old man with pain radiating to the plantar aspect of the foot and toes. (a) Axial proton-density-weighted turbo spin-echo MR image (3,500/17) shows a ganglion cyst (*) in the tarsal tunnel. The cyst is responsible for compression of the medial plantar nerve branch (arrows). The lateral plantar nerve is circled. (b) Axial contrast material-enhanced fat-saturated spin-echo T1-weighted MR image (700/12) shows the ganglion cyst in the tarsal tunnel (*) surrounded by soft-tissue contrast enhancement (arrow).

View larger version (123K): [in a new window]   Figure 5b.  Tarsal tunnel syndrome in a 33-year-old man with pain radiating to the plantar aspect of the foot and toes. (a) Axial proton-density-weighted turbo spin-echo MR image (3,500/17) shows a ganglion cyst (*) in the tarsal tunnel. The cyst is responsible for compression of the medial plantar nerve branch (arrows). The lateral plantar nerve is circled. (b) Axial contrast material-enhanced fat-saturated spin-echo T1-weighted MR image (700/12) shows the ganglion cyst in the tarsal tunnel (*) surrounded by soft-tissue contrast enhancement (arrow).

View larger version (106K): [in a new window]   Figure 6.  Calcaneal fracture in a 40-year-old patient with pain radiating to the plantar aspect of the foot. Axial CT scan shows a bone fragment (arrowhead) and soft-tissue edema adjacent to the lateral plantar nerve branches (arrow). C = calcaneus.

View larger version (130K): [in a new window]   Figure 7a.  (a) Normal anatomy of the lateral and medial plantar nerves. Coronal oblique T1-weighted MR image (500/12) obtained at the level of the metatarsal bases shows the medial plantar nerve branches (circled), oblique head of the adductor hallucis muscle (thick arrow), flexor longus hallucis and flexor digitorum longus tendons (arrowheads), flexor digitorum brevis muscle (FDB), lateral plantar nerve branches (thin arrow), abductor digiti quinti muscle (ADQM), and abductor hallucis muscle (AH). 1rst M = first metatarsal. (b, c) Distal entrapment of the medial and lateral plantar nerve branches in a 60-year-old patient with plantar midtarsal pain radiating to the medial plantar aspect of the toes. Contiguous coronal T2-weighted MR images (3,500/119) show an arthrosynovial cyst (* in b) that is responsible for compression of the medial plantar nerve branches (circled in c).

View larger version (112K): [in a new window]   Figure 7b.  (a) Normal anatomy of the lateral and medial plantar nerves. Coronal oblique T1-weighted MR image (500/12) obtained at the level of the metatarsal bases shows the medial plantar nerve branches (circled), oblique head of the adductor hallucis muscle (thick arrow), flexor longus hallucis and flexor digitorum longus tendons (arrowheads), flexor digitorum brevis muscle (FDB), lateral plantar nerve branches (thin arrow), abductor digiti quinti muscle (ADQM), and abductor hallucis muscle (AH). 1rst M = first metatarsal. (b, c) Distal entrapment of the medial and lateral plantar nerve branches in a 60-year-old patient with plantar midtarsal pain radiating to the medial plantar aspect of the toes. Contiguous coronal T2-weighted MR images (3,500/119) show an arthrosynovial cyst (* in b) that is responsible for compression of the medial plantar nerve branches (circled in c).

View larger version (130K): [in a new window]   Figure 7c.  (a) Normal anatomy of the lateral and medial plantar nerves. Coronal oblique T1-weighted MR image (500/12) obtained at the level of the metatarsal bases shows the medial plantar nerve branches (circled), oblique head of the adductor hallucis muscle (thick arrow), flexor longus hallucis and flexor digitorum longus tendons (arrowheads), flexor digitorum brevis muscle (FDB), lateral plantar nerve branches (thin arrow), abductor digiti quinti muscle (ADQM), and abductor hallucis muscle (AH). 1rst M = first metatarsal. (b, c) Distal entrapment of the medial and lateral plantar nerve branches in a 60-year-old patient with plantar midtarsal pain radiating to the medial plantar aspect of the toes. Contiguous coronal T2-weighted MR images (3,500/119) show an arthrosynovial cyst (* in b) that is responsible for compression of the medial plantar nerve branches (circled in c).

View larger version (106K): [in a new window]   Figure 8a.  (a) Normal anatomy of the inferior calcaneal nerve. Axial T1-weighted MR image (400/12) shows the lateral plantar nerve (white arrowhead), flexor retinaculum (black arrowheads), inferior calcaneal nerve (black arrow), and medial calcaneal nerve and vessels (white arrow). (b, c) Suspected neuropathy of the inferior calcaneal nerve. Coronal T1-weighted MR images (500/12) of the ankle were obtained in a healthy volunteer (b) and a 55-year-old patient with posterior tibial tendinopathy, flatfoot, and painful heel (c). Note the selective fatty atrophy (arrow in c) of the abductor digiti quinti muscle (ADQM) on the pathologic MR image compared with the normal image. AH = abductor hallucis muscle, FDB = flexor digitorum brevis muscle.

View larger version (106K): [in a new window]   Figure 8b.  (a) Normal anatomy of the inferior calcaneal nerve. Axial T1-weighted MR image (400/12) shows the lateral plantar nerve (white arrowhead), flexor retinaculum (black arrowheads), inferior calcaneal nerve (black arrow), and medial calcaneal nerve and vessels (white arrow). (b, c) Suspected neuropathy of the inferior calcaneal nerve. Coronal T1-weighted MR images (500/12) of the ankle were obtained in a healthy volunteer (b) and a 55-year-old patient with posterior tibial tendinopathy, flatfoot, and painful heel (c). Note the selective fatty atrophy (arrow in c) of the abductor digiti quinti muscle (ADQM) on the pathologic MR image compared with the normal image. AH = abductor hallucis muscle, FDB = flexor digitorum brevis muscle.

View larger version (114K): [in a new window]   Figure 8c.  (a) Normal anatomy of the inferior calcaneal nerve. Axial T1-weighted MR image (400/12) shows the lateral plantar nerve (white arrowhead), flexor retinaculum (black arrowheads), inferior calcaneal nerve (black arrow), and medial calcaneal nerve and vessels (white arrow). (b, c) Suspected neuropathy of the inferior calcaneal nerve. Coronal T1-weighted MR images (500/12) of the ankle were obtained in a healthy volunteer (b) and a 55-year-old patient with posterior tibial tendinopathy, flatfoot, and painful heel (c). Note the selective fatty atrophy (arrow in c) of the abductor digiti quinti muscle (ADQM) on the pathologic MR image compared with the normal image. AH = abductor hallucis muscle, FDB = flexor digitorum brevis muscle.

View larger version (121K): [in a new window]   Figure 9.  Plantar fasciitis in a patient with heel pain who was not responding to local injection of corticosteroids and anesthetics. Coronal contrast-enhanced fat-saturated spin-echo T1-weighted MR image (700/12) shows plantar fasciitis (arrow) with soft-tissue contrast material uptake in the area of the inferior calcaneal nerve course (circled). ADQM = abductor digiti quinti muscle, FDB = flexor digitorum brevis muscle.

View larger version (119K): [in a new window]   Figure 10.  Jogger’s foot. Coronal spin-echo T1-weighted MR image (500/12) shows entrapment of the medial plantar nerve branches (circled) in a narrow space between the abductor hallucis muscle (AH) and the flexor digitorum longus and flexor hallucis longus tendons (arrow). ADQM = abductor digiti quinti muscle, FDB = flexor digitorum brevis muscle, QP = quadratus plantae muscle.

View larger version (105K): [in a new window]   Figure 11.  Normal anatomy of the sural nerve. Proximal coronal oblique spin-echo T1-weighted MR image (400/12) shows the sural nerve and vessels (thin arrow) near the peroneus brevis (arrowhead) and peroneus longus (thick arrow) tendons.

View larger version (51K): [in a new window]   Figure 12.  Drawing illustrates the normal anatomy of the superficial peroneal nerve (SPN) and deep peroneal nerve (DPN).

View larger version (105K): [in a new window]   Figure 13a.  (a) Normal anatomy of the anterior tarsal tunnel. Proton-density-weighted MR image (3,500/19) shows the anterior tibial tendon (large arrowhead), extensor hallucis longus muscle and tendon (thick arrow), inferior extensor retinaculum (small arrowheads), dorsal pedis artery, and lateral and medial terminal branches of the DPN (thin arrows). (b) Inflammatory arthritis and multiple tenosynovitis in a patient with vague foot pain and swelling. Contrast-enhanced fat-saturated T1-weighted MR image (700/12) shows tenosynovitis of the extensor digitorum longus tendon (arrowhead) and contrast material uptake surrounding the deep peroneal neurovascular bundle (arrow).

View larger version (107K): [in a new window]   Figure 13b.  (a) Normal anatomy of the anterior tarsal tunnel. Proton-density-weighted MR image (3,500/19) shows the anterior tibial tendon (large arrowhead), extensor hallucis longus muscle and tendon (thick arrow), inferior extensor retinaculum (small arrowheads), dorsal pedis artery, and lateral and medial terminal branches of the DPN (thin arrows). (b) Inflammatory arthritis and multiple tenosynovitis in a patient with vague foot pain and swelling. Contrast-enhanced fat-saturated T1-weighted MR image (700/12) shows tenosynovitis of the extensor digitorum longus tendon (arrowhead) and contrast material uptake surrounding the deep peroneal neurovascular bundle (arrow).

View larger version (113K): [in a new window]   Figure 14.  Normal anatomy of the distal DPN branches. Coronal oblique spin-echo T1-weighted MR image (400/12) shows the medial branch of the DPN (for the first dorsal space) (thick arrow) under the extensor hallucis longus tendon (arrowhead) and the lateral branch of the DPN (thin arrow), which supplies motor innervation to the extensor digitorum brevis muscle (EDB). N = navicular bone.

View larger version (100K): [in a new window]   Figure 15.  Normal anatomy of the SPN. Coronal oblique spin-echo T1-weighted MR image shows the subcutaneous SPN branches (arrowheads) and the great saphenous vein (arrow).

View larger version (102K): [in a new window]   Figure 16a.  Normal forefoot nerve anatomy. (a) Distal coronal spin-echo T1-weighted MR image (400/12) demonstrates the branches of the DPN for the first dorsal space (circled) and the branches of the SPN for the second through the fourth dorsal spaces (arrows). (b) Distal coronal spin-echo T1-weighted MR image (400/12) shows the medial dorsal (thin arrow) and medial plantar (thick arrow) hallucal nerves.

View larger version (144K): [in a new window]   Figure 16b.  Normal forefoot nerve anatomy. (a) Distal coronal spin-echo T1-weighted MR image (400/12) demonstrates the branches of the DPN for the first dorsal space (circled) and the branches of the SPN for the second through the fourth dorsal spaces (arrows). (b) Distal coronal spin-echo T1-weighted MR image (400/12) shows the medial dorsal (thin arrow) and medial plantar (thick arrow) hallucal nerves.

View larger version (111K): [in a new window]   Figure 17.  Forefoot neuropathy in a 60-year-old patient with gout. Oblique radiograph of the forefoot shows a large tophus (arrowheads). The medial dorsal and plantar hallucal nerves may become entrapped by a tophus, as in this case.

View larger version (114K): [in a new window]   Figure 18a.  Morton neuroma. (a) Coronal spin-echo T1-weighted MR image (400/12) shows the plantar interdigital nerve branches (circled). (b) Coronal spin-echo T1-weighted MR image (400/12) obtained in a different patient shows the plantar interdigital nerve branches embedded in perineural fibrosis (arrow).

View larger version (111K): [in a new window]   Figure 18b.  Morton neuroma. (a) Coronal spin-echo T1-weighted MR image (400/12) shows the plantar interdigital nerve branches (circled). (b) Coronal spin-echo T1-weighted MR image (400/12) obtained in a different patient shows the plantar interdigital nerve branches embedded in perineural fibrosis (arrow).

View larger version (81K): [in a new window]   Figure 19.  Second ray syndrome in a 43-year-old patient. Coronal fat-saturated turbo spin-echo T2-weighted MR image (3,500/119) demonstrates synovitis of the second metatarsophalangeal joint (arrowhead) and soft-tissue edema in the second plantar metatarsal space (arrows). These pathologic conditions can cause compression of the corresponding common plantar digital nerve branches.