[Os trigonum tarsi syndrome. Role of magnetic resonance]

Abstract

Introduction: The os trigonum tarsi is an accessory bone of the foot localized posterolateral to the lateral tubercle of talus. It is usually an asymptomatic condition. However, particular activities such as ballet, soccer, or football may cause repeated stress and chronic microtraumas to the hindfoot, resulting in the os trigonum syndrome. Pain is typically localized anterior to the Achilles tendon; nevertheless, diagnosis may be very difficult because other conditions may show the same symptoms. Radiography can only demonstrate the os trigonum and its morphostructural changes, while MR imaging can also depict associated soft tissue damage. We report on 9 cases of os trigonum tarsi syndrome studied with MR imaging.

Material and methods: Nine patients with the os trigonum tarsi syndrome were submitted to MRI. All the examinations were performed with the patients in supine recumbency with the injured foot in neutral position and then in forced plantar flexion. Axial and sagittal T1 SE, T2* GE and FIR images were acquired. We evaluated os trigonum location and shape, signal intensity of bone, cartilages and adjacent soft tissues, and possible associated tendon injuries.

Results: No changes were found in the os trigonum location and shape. Signal intensity changes were seen in 2/9 cases. Particularly, a small area of very high signal intensity, due to necrosis, was depicted on the talar aspect in 1 case; a subchondral spot of slightly increased signal intensity, with a low-signal outline, was seen on the calcanear aspect in another case. Disruption of the cartilaginous synchondrosis between the accessory navicular bone and the posterior tibial aspect was observed in 7/9 patients. Tenosynovitis of the flexor hallucis longus was associated in 6/9 patients. Pseudoarthrosis with irregular bone margins and high-signal spots within the cartilage was found in 3 cases. Finally, fluid effusion surrounding the os trigonum and adjacent soft tissues was always detected.

Discussion and conclusions: The os trigonum syndrome may result from chronic microtraumas. Indeed, forced plantar flexion may cause os trigonum compression between the posterior aspect of the tibial malleolus and the calcaneus, with disruption of the synchondrosis with the lateral tubercle of talus. Joint inflammation may be associated with possible development of pseudoarthrosis. Other possible complications are related to vascular changes which may lead to bone necrosis. Furthermore, the particular anatomical site of the os trigonum may sometimes cause compression to the flexor hallucis longus tendon, resulting in severe tenosynovitis. MR imaging allows complete morphostructural assessment because it depicts the margins and the signal intensity of bone and ligaments on the 3 spatial planes. Particularly, sagittal T2 images best demonstrate the cartilage changes indicating synchondrosis disruption. This condition may cause abnormal mobility of the accessory bone with possible impingement with the posterior aspect of the tibia, or hypomobility due to pseudoarthrosis. Forced plantar flexion acquisitions are particularly useful in this condition because they can demonstrate the mechanism of injury.