Distal tibia and calcaneum and stress fractures

Case contributed by Dai Roberts


Ongoing ankle and hindfoot pain, non-responsive to physiotherapy.

Patient Data

Age: 30 years
Gender: Female

Moderate bone marrow edema is evident in the distal tibia and posterior calcaneum, which are associated with predominantly linear areas of low T2 weighted signal with high T2 signal periosteal reaction surrounding the posterior tibia.   Findings in keeping with stress fractures.  

In addition, there is a moderate ankle joint effusion, a type 2 os naviculare and the spring ligament recess is noted.

Annotated study


Annotated images, identifying the spring ligament recess (purple arrow), the medioplantar oblique band of the spring ligament complex (green arrow), and the inferoplantar longitudinal band of the spring ligament complex (orange arrow). 

Case Discussion

Stress fractures most often occur when there is abnormal stress on normal bone, in particular excess exercise or a sudden change in training or weight-bearing activity.  They occur in characteristic locations such as the distal tibia and posterosuperior calcaneum, with imperfectly linear fracture lines surrounded by bone marrow edema.  

The spring ligament recess is an important anatomical feature to identify when reporting MRI of the foot and ankle, so to prevent misinterpreting this normal structure for a spring ligament tear. 

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