Imaging Anatomy of the Ankle in Normal and Pathological States: A Clinically Focused Pictorial Review.

This narrative pictorial review presents the imaging anatomy of the ankle in normal and pathologic states and emphasizes practical, clinically oriented correlations. The ankle is a compound synovial joint complex in which osseous architecture, ligamentous systems (lateral collateral, deltoid, and syndesmotic), and tendon compartments interact within a compact space to provide stability and motion during gait and sport. This anatomical complexity underlies a broad spectrum of traumatic and degenerative conditions, including lateral ankle sprains, syndesmotic injury, osteochondral lesions of the talus, tendinopathy/rupture, and post-traumatic osteoarthritis, that are highly prevalent in clinical practice. Normal imaging anatomy provides the baseline for detecting disease: radiographs remain indispensable for initial assessment, ultrasound offers dynamic tendon-ligament evaluation, CT delineates osseous architecture and alignment, and MRI affords comprehensive soft-tissue and osteochondral characterization. Emerging techniques - weight-bearing CT and high-resolution isotropic or quantitative MRI, with MR arthrography when indicated - improve detection of subtle instability and early cartilage or capsuloligamentous injury. Evidence informing this review was derived from a non-systematic search of MEDLINE/PubMed, Embase, Scopus, and the Cochrane Library (January 1990-September 2025; last update 12 September 2025), prioritizing studies from the past two decades while retaining seminal references. By coupling descriptive imaging anatomy with representative traumatic and degenerative patterns, the review aims to support diagnostic accuracy, multidisciplinary communication, and evidence-based management of ankle disorders.