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Ultrasound shear wave elastography of the anterior talofibular and calcaneofibular ligaments in healthy subjects

Lana H. Gimber
Lana H. Gimber
, 
L Daniel Latt
L Daniel Latt
, 
Chelsea Caruso
Chelsea Caruso
, 
Andres A. Nuncio Zuniga
Andres A. Nuncio Zuniga
, 
Elizabeth A. Krupinski
Elizabeth A. Krupinski
, 
Andrea S. Klauser
Andrea S. Klauser
 y 
Mihra S. Taljanovic
Mihra S. Taljanovic
   | 18 jun 2021
Journal of Ultrasonography's Cover Image
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Article Category: research-paper
Publicado en línea: 18 jun 2021
Páginas: 86 - 94
Recibido: 13 ene 2021
Aceptado: 26 abr 2021
DOI: https://doi.org/10.15557/jou.2021.0017
Palabras clave
© 2021 Polish Ultrasound Society. Published by Medical Communications Sp. z o.o.
This work is licensed under the Creative Commons Attribution-NonCommercial-NoDerivatives 3.0 License.

Fig. 1.

Diagram of the lateral ankle ligaments. The lateral ligamentous complex of the ankle is composed of the (1) anterior talofibular ligament (ATFL) which extends from the anterior lateral malleolus to the talar body, (2) calcaneofibular ligament (CFL) which extends from the lateral malleolar tip to the trochlear eminence of the calcaneus, and (3) posterior talofibular ligament (PTFL) which extends from the lateral tubercle of the posterior talus to the fibular malleolar fossa located at the deep surface of the lateral malleolus
Diagram of the lateral ankle ligaments. The lateral ligamentous complex of the ankle is composed of the (1) anterior talofibular ligament (ATFL) which extends from the anterior lateral malleolus to the talar body, (2) calcaneofibular ligament (CFL) which extends from the lateral malleolar tip to the trochlear eminence of the calcaneus, and (3) posterior talofibular ligament (PTFL) which extends from the lateral tubercle of the posterior talus to the fibular malleolar fossa located at the deep surface of the lateral malleolus

Fig. 2.

Positioning of the foot and ultrasound transducer for the evaluation of the (A) ATFL and (B) CFL in the long axis
Positioning of the foot and ultrasound transducer for the evaluation of the (A) ATFL and (B) CFL in the long axis

Fig. 3.

Grayscale and SWE US images of the normal ATFL in an asymptomatic volunteer obtained at rest and with stress. (A) Long axis grayscale US image of the ATFL (arrows) at rest shows normal echogenic fibrillar appearance. SWE in same region at rest (B) and with stress (C) show higher SW velocities in (c), consistent with increased stiffness in the contracted ligament with applied manual stress. Three ROIs are placed within the ATFL where the SW velocity measurements were obtained. Note the reference color bar at the side of images (B, C) defining the quantitative color elastogram with velocities ranging from 0.5–20 meters/second. Blue color denotes low, red high, and green and yellow intermediate SW velocities. SWE – shear wave elastography, SW – shear wave, T – talus, F – fibula
Grayscale and SWE US images of the normal ATFL in an asymptomatic volunteer obtained at rest and with stress. (A) Long axis grayscale US image of the ATFL (arrows) at rest shows normal echogenic fibrillar appearance. SWE in same region at rest (B) and with stress (C) show higher SW velocities in (c), consistent with increased stiffness in the contracted ligament with applied manual stress. Three ROIs are placed within the ATFL where the SW velocity measurements were obtained. Note the reference color bar at the side of images (B, C) defining the quantitative color elastogram with velocities ranging from 0.5–20 meters/second. Blue color denotes low, red high, and green and yellow intermediate SW velocities. SWE – shear wave elastography, SW – shear wave, T – talus, F – fibula

Fig. 4.

Grayscale and SWE US images of the normal CFL in an asymptomatic volunteer obtained at rest and with stress. (A) Long axis grayscale US image of the CFL (arrows) at rest shows normal echogenic fibrillar appearance. SWE in same region at rest (B) and with stress (C) show higher SW velocities in (C), consistent with increased stiffness in the contracted ligament with applied manual stress. Three ROIs are placed within the CFL where the SW velocity measurements were obtained. Note the reference color bar at the side of images (B, C) defining the quantitative color elastogram with velocities ranging from 0.5–20 meters/second. Blue color denotes low, red high, and green and yellow intermediate SW velocities. Left side of the image is proximal
Grayscale and SWE US images of the normal CFL in an asymptomatic volunteer obtained at rest and with stress. (A) Long axis grayscale US image of the CFL (arrows) at rest shows normal echogenic fibrillar appearance. SWE in same region at rest (B) and with stress (C) show higher SW velocities in (C), consistent with increased stiffness in the contracted ligament with applied manual stress. Three ROIs are placed within the CFL where the SW velocity measurements were obtained. Note the reference color bar at the side of images (B, C) defining the quantitative color elastogram with velocities ranging from 0.5–20 meters/second. Blue color denotes low, red high, and green and yellow intermediate SW velocities. Left side of the image is proximal

Fig. 5.

Ankle stress maneuvers of the ATFL and CFL. Black and white arrows show the direction of applied force. The (A) ATFL was stressed using the anterior drawer test, with the orthopedic surgeon applying an anteriorly directed force to the posterior calcaneus, while the other hand stabilized the distal tibia. The (B) CFL was stressed using the talar tilt test, with the orthopedic surgeon applying a medially directed force to invert the heel, while the other hand stabilized the tibia. Note the DataLog Boot Screen myometer used to ensure that 100 N of external force was applied to each stressed ligament
Ankle stress maneuvers of the ATFL and CFL. Black and white arrows show the direction of applied force. The (A) ATFL was stressed using the anterior drawer test, with the orthopedic surgeon applying an anteriorly directed force to the posterior calcaneus, while the other hand stabilized the distal tibia. The (B) CFL was stressed using the talar tilt test, with the orthopedic surgeon applying a medially directed force to invert the heel, while the other hand stabilized the tibia. Note the DataLog Boot Screen myometer used to ensure that 100 N of external force was applied to each stressed ligament

Fig. 6.

Inter-reader agreement for SW velocity measurements. Bland-Altman plot of the (A) ATFL and (B) CFL demonstrate good inter-reader agreement between the two radiologists for SW velocity measurements, with the majority of measurements falling within 2 standard deviations of the mean
Inter-reader agreement for SW velocity measurements. Bland-Altman plot of the (A) ATFL and (B) CFL demonstrate good inter-reader agreement between the two radiologists for SW velocity measurements, with the majority of measurements falling within 2 standard deviations of the mean

Comparison of SW velocities (m/s) of the ATFL and CFL at rest between radiologist 1 and radiologist 2, using the paired t-test

Reader 1 Reader 2 T-value P-value
ATFL Mean 2.02 2.15 2.06 0.05
SD 036 0.39
Min 1.36 1.45
Max 2.85 3.62
CFL Mean 1.98 2.02 0.4118 0.68
SD 0.51 0.43
Min 1.16 1.07
Max 3.60 3.26

Comparison of mean SW velocities (m/s) of the ATFL and CFL at rest and with stress

Rest Stress T-value P-value
ATFL Mean 2.09 3.21 7.580 <0.001
SD 0.30 0.92
Min 1.41 1.72
Max 3.17 5.97
CFL Mean 1.99 3.42 8.349 <0.0001
SD 0.36 1.09
Min 1.29 1.72
Max 2.88 8.01

Comparison of SW velocities (m/s) of the ATFL and CFL at rest and with stress using data from a single radiologist

Rest Stress T-value P-value
ATFL Mean 2.15 3.21 7.062 <0.0001
SD 0.39 0.92
Min 1.45 1.72
Max 3.62 5.97
CFL Mean 2.02 3.42 8.635 <0.0001
SD 0.43 1.09
Min 1.07 1.72
Max 3.26 8.00
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