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This is a 23-year-old girl who's had

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two prior sprains and now complains

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of anterolateral pain, bimalleolar pain,

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and has some additional symptoms

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that include some clicking and some

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discomfort in the anterolateral ankle region.

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Let's look at her sagittal T1 first.

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And I usually like to put up

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the, the sagittals together.

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So I'll do that real quickly and get a,

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just a quick idea of what's going on.

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We've got edema in multiple bony areas.

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The posterior malleolus, the talus.

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The edema's not really, not that dramatic.

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A little bit of edema in the fibula

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and in the medial malleolus.

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So the bimalleolar symptomatology

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may play heavily into this case or not.

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But there are some correlative MR

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anatomic and signal findings that fit.

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Thank you.

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But that may not be her primary problem,

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because they're not that dramatic.

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So let's keep looking around, and I'm going

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to put up my axial, because I know that

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she's had innumerable sprains and strains.

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In fact, I'm going to put up both axials,

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because I'm a comparative kind of guy,

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and I like to look at my water-weighted

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image and my fat-weighted image together.

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As a quick reminder, this is a T2-weighted image.

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It's water-weighted, but

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it's not that water-weighted.

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It's not as water-weighted as the PD Spur, and

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we know that because the bones aren't that black.

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I'm also going to blow up my sagittal T1,

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and I'm going to start to scroll around,

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and right away I see that she's got multiple

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bone fragments distal to the fibula.

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Now, it's not uncommon to have an os

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subfibular, which would be a single,

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round, smooth structure below the fibula,

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and by itself, doesn't produce symptoms.

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But in this case, we've got one,

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two, possibly three and four, or at

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least three abnormal bone fragments.

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And let's keep scrolling.

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We've got this funny-looking, oval,

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almost meniscoid-looking structure.

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It's got a very curvilinear look to it.

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And that is very problematic and leads

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us to the correct diagnosis in this case,

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which is a mixture of this hyalinized

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fibroinflammatory tissue and bone, seen in

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our axial projection, in a very specific

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locus called the anterolateral fibular gutter.

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So this patient has, let's scroll a little

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bit for you to see, we're up high, looks

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pretty good, anterior tibiofibular ligament.

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We're in the low ankle.

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Let's go to the anterior talofibular ligament.

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It looks horrible.

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And these anterior and lateral ligaments

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form the anterior boundary of this

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space known as the fibular gutter.

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And the roof is formed by the tibia.

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The lateral aspect is formed by the fibula.

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The base will be formed by the talus.

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And it's this space right in

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here as we follow it up and down.

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So let's scroll it again

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and follow it up and down.

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Here we are down a little bit lower.

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Here's the space.

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Here we are a little, little bit higher.

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Here is still the space.

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I'll color it in again.

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A little less of the space remaining.

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It's somewhat triangular in its configuration.

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But we've got a meniscoid looking area of

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signal alteration that when we look at the

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T2-weighted image looks like a dark triangle,

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unfortunately with some bone buried inside.

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So this condition called anterolateral

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fibular gutter impingement syndrome

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was described by Wolin in 1950 as a hyalinized

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curvilinear meniscoid structure composed of

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fibroinflammatory tissue that not only produces

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mechanical problems because it doesn't allow the

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bones to move properly between one another

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in plantar flexion, inversion, eversion, and

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rotation, but it also can produce clicking

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and catching in itself and, and cause pain.

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The mechanism for this type of

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impingement syndrome is an inversion,

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but often there's a forced plantar

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component with some supination involved.

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Spurs and bodies are an integral part of this

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disease and have to be commented on because

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they play heavily into the repair and the

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resection of this tissue that has to take place.

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This, in a young girl,

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an example of the meniscoid lesion

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in anterolateral fibular

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gutter impingement syndrome.