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Normal Ankle MRI Report Template
Normal ankle MRI report template: ligaments by complex, tendons by compartment, talar dome cartilage and marrow, syndesmosis, plantar fascia and sinus tarsi, with notes on osteochondral lesion and tendon-tear wording.
EXAMINATION: MRI [right/left] ankle without intravenous contrast. CLINICAL HISTORY: [indication, e.g. “Ankle pain”] COMPARISON: None available. TECHNIQUE: Multiplanar, multisequence MR imaging of the [right/left] ankle without intravenous contrast. FINDINGS: Bones and marrow: Normal marrow signal in the distal tibia, fibula, talus, calcaneus and visualized midfoot. No fracture, stress reaction or marrow edema. No osteochondral lesion of the talar dome. Articular cartilage: Preserved at the tibiotalar and subtalar joints. Ligaments: Lateral collateral complex: The anterior talofibular, calcaneofibular and posterior talofibular ligaments are intact. Deltoid complex: The superficial and deep deltoid ligaments are intact. Syndesmosis: The anterior inferior and posterior inferior tibiofibular ligaments are intact. No widening of the tibiofibular clear space. Spring ligament: Intact. Tendons: Medial: The posterior tibial, flexor digitorum longus and flexor hallucis longus tendons are intact, with normal caliber and signal. Lateral: The peroneus longus and brevis tendons are intact and normally positioned within the retromalleolar groove. The superior peroneal retinaculum is intact. Anterior: The tibialis anterior, extensor hallucis longus and extensor digitorum longus tendons are intact. Posterior: The Achilles tendon is normal in caliber and signal with a normal insertion. No retrocalcaneal bursitis. Kager's fat pad is clear. Plantar fascia: Normal thickness and signal at the calcaneal origin. Sinus tarsi: Normal fat signal. The interosseous and cervical ligaments are intact. Joints: No significant tibiotalar or subtalar joint effusion. No tarsal coalition. Soft tissues: Unremarkable. No ganglion or mass. IMPRESSION: 1. Normal MRI of the [right/left] ankle. No ligament or tendon tear, osteochondral lesion or occult fracture.
Dictation notes
- Describe a talar dome osteochondral lesion by quadrant (anterolateral or posteromedial), size, cartilage status and whether the fragment is unstable (fluid undercutting, cystic change) — stability decides between offloading and surgery.
- Peroneus brevis is the tendon that splits — a longitudinal split tear looks like a “third tendon” at the retromalleolar level; count the peroneal tendons at every axial level before calling them intact.
- Grade an ATFL sprain as intact, partial thickness or complete with the chronicity (acute edema versus thickened, scarred ligament) — chronic lateral instability is managed differently from an acute tear.
- Posterior tibial tendon pathology is graded by caliber (thickened, attenuated, ruptured) with the flatfoot sequelae (spring ligament, sinus tarsi, subtalar alignment) — a “PTT tendinosis” line alone misses the stage.
- The Achilles is reported by thickness at its thickest point and by the gap in a complete tear, measured with the foot position noted; that gap is what decides operative repair.
Related references
Weber ankle fracture quick reference
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