Review of running injuries of the foot and ankle: clinical presentation and SPECT-CT imaging patterns

Abstract

Distance running is among the fastest growing sports, with record registration to marathons worldwide. It is estimated that more than half of recreational runners will experience injuries related to the practice of their sport. Three-phase bone scintigraphy is a very sensitive tool to identify sports injury, allowing imaging of hyperemia, stress reaction, enthesopathy and fractures, often before abnormalities can be detected on conventional anatomical modalities. In this article, we review the most common running related injuries and their imaging findings on bone scintigraphy with SPECT-CT.

Keywords: Bone scintigraphy; SPECT; SPECT-CT; enthesopathy; running; sports injury; stress fracture.

Figure 1

Plantar blood pool (A) images demonstrate relatively symmetrical activity in both feet. Delayed plantar bone images (B) show mildly increased uptake in the right 5th metatarsal and cuboid bone area. Maximal intensity projection (C) and axial (D) SPECT-CT images localize the uptake in the fifth proximal metatarsal, consistent with a stress fracture.

Figure 2

Posterior blood pool image (A) shows hyperemia in the posterior aspect of the right calcaneus and plantar aspect of the left calcaneus. Delayed posterior (B) and lateral images of the right (D) and left (E) foot demonstrate increased uptake in a similar distribution. Sagittal and axial SPECT-CT images of the left foot (C) demonstrate increased activity at the calcaneal tuberosity consistent with plantar fasciitis. Sagittal and axial SPECT-CT images of the right foot (F) show increased uptake at the Achilles’ insertion site in the calcaneus, consistent with Achilles enthesopathy.

Figure 3

Posterior (A) and lateral (C) blood pool images demonstrate mild increased uptake over the left malleoli, consistent with mild hyperemia. Delayed planar posterior (B), lateral (D) and axial SPECT-CT (E) images show focal increased activity at the inferior aspect of medial malleolus, suggestive of malleolar periostitis due to posterior tibialis tendinosis. Sagittal PD fat suppressed weighted image (F) from subsequent MRI confirmed edema with mild tendinosis of the inframalleolar portion of the posterior tibial tendon (arrow).

Figure 4

Focal increased uptake on delayed plantar image (B) and SPECT-CT (C) in the tibial sesamoid bones bilaterally without significantly increased activity on blood pool images (A), attributed to sesamoiditis. In this case, the focal increased uptake in the right talus corresponds to remote talar fracture. SPECT-CT (D) images of a different patient demonstrates focal increased uptake with associated fracture of the left tibial sesamoid bone.

Figure 5

Posterior and lateral blood pool images (A) demonstrate hyperemia in the right lateral malleolar region. Delayed planar posterior and lateral images (B) and SPECT-CT image (C) show focal increased uptake over the lateral calcaneus, indicating peroneal tendonitis. Lateral calcaneal exostosis shown on CT (C) is likely related to long standing tenosynovitis.

Figure 6

Posterior and lateral blood pool images (A) demonstrate hyperemia in the right ankle joint area. Delayed posterior and lateral planar images (B) show increased uptake in the right ankle laterally. Coronal and axial SPECT-CT images (C) localize the area of uptake to the tibio-fibular interosseous region, representing a syndesmotic sprain.

Figure 7

Posterior and lateral blood pool images (A) demonstrate hyperemia in the left ankle joint area. Delayed posterior and lateral (B) images show a similar distribution of activity. Sagittal and axial SPECT-CT images (C) localize the area of uptake in the subarticular region and talar dome, consistent with talar osteochondral lesion.

Figure 8

Lateral x-ray of the left ankle (A) shows well-corticated ossicle located posteriorly to the talus, consistent with an os trigonum. Sagittal and axial CT images (B) with corresponding sagittal and axial SPECT-CT images (C) of the left ankle show focal increased uptake in the os trigonum, consistent with os trigonum syndrome.

Figure 9

Sagittal and axial CT images (B) of the left ankle with corresponding SPECT-CT images (C) show focal increased activity in an ossicle located posteriorly to the talus. Review of lateral left ankle plain film (A) acquired 2 years before the bone scintigraphy shows a Stieda process (arrow). These findings are in keeping with a fractured Stieda process.