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Comparison of high resolution ultrasonography with clinical findings in patients with ankle pain

Kunwarpal Singh
Kunwarpal Singh
, 
Chuni Lal Thukral
Chuni Lal Thukral
, 
Kamlesh Gupta
Kamlesh Gupta
 e 
Avtar Singh
Avtar Singh
   | 31 gen 2019
Journal of Ultrasonography's Cover Image
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Article Category: original-paper
Pubblicato online: 31 gen 2019
Pagine: 316 - 324
Ricevuto: 29 lug 2018
Accettato: 31 dic 2018
DOI: https://doi.org/10.15557/jou.2018.0046
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© 2018 Kunwarpal Singh et al., published by Sciendo
This work is licensed under the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.

Fig. 1.

US image of a 27-year-old male patient with a history of road side accident 3 days back shows thickened anterior talofibular ligament (ATFL) in the neutral position (arrow in A ). Stress maneuver shows thickened ATFL (green arrow in B ) with non-visualization of fibers near its fibular end (red arrow); suggestive of grade III tear. Surrounding free fluid is also seen, appearing as anechoic area (marked with an asterisk)
US image of a 27-year-old male patient with a history of road side accident 3 days back shows thickened anterior talofibular ligament (ATFL) in the neutral position (arrow in A ). Stress maneuver shows thickened ATFL (green arrow in B ) with non-visualization of fibers near its fibular end (red arrow); suggestive of grade III tear. Surrounding free fluid is also seen, appearing as anechoic area (marked with an asterisk)

Fig. 2.

US image of a 43-year-old male patient with a history of inversion injury 1 day back shows thickened and hypoechoic calcaneofibular ligament (CFL). Mild thinning of fibers near the fibular end is seen with surrounding small amount of free fluid; suggestive of grade II tear
US image of a 43-year-old male patient with a history of inversion injury 1 day back shows thickened and hypoechoic calcaneofibular ligament (CFL). Mild thinning of fibers near the fibular end is seen with surrounding small amount of free fluid; suggestive of grade II tear

Fig. 3.

US image of a 46-year-old male patient shows thickening of the Achilles tendon proximal to the insertion with multiple arc-like echogenic foci showing distal acoustic shadowing (arrows in A ); suggestive of calcific tendinosis. US in another female patient aged 41 years shows a large echogenic focus in the Achilles tendon near the insertion showing dense acoustic shadowing
US image of a 46-year-old male patient shows thickening of the Achilles tendon proximal to the insertion with multiple arc-like echogenic foci showing distal acoustic shadowing (arrows in A ); suggestive of calcific tendinosis. US in another female patient aged 41 years shows a large echogenic focus in the Achilles tendon near the insertion showing dense acoustic shadowing

Fig. 4.

US image of a 33-year-old female patient with a history of lateral ankle pain for the last 16 days shows thickened and hypoechoic tendon sheath around the peroneus longus and brevis tendons (red and yellow arrows in A ). Another female patient aged 48 years presented with a history of medial ankle pain. US shows tendon sheath thickening of the tibialis posterior tendon (green arrow in B and yellow arrow in C ) with increased vascularity on color Doppler imaging ( B ); suggestive of tenosynovitis. Asterisk presents free fluid ( B, D ). Point tenderness was present in both cases
US image of a 33-year-old female patient with a history of lateral ankle pain for the last 16 days shows thickened and hypoechoic tendon sheath around the peroneus longus and brevis tendons (red and yellow arrows in A ). Another female patient aged 48 years presented with a history of medial ankle pain. US shows tendon sheath thickening of the tibialis posterior tendon (green arrow in B and yellow arrow in C ) with increased vascularity on color Doppler imaging ( B ); suggestive of tenosynovitis. Asterisk presents free fluid ( B, D ). Point tenderness was present in both cases

Fig. 5.

A 34-year-old male patient presented with a history of sudden acute pain in the posterior aspect of the lower leg while running, 17 days back. US image in the sagittal plane shows thickened and hypoechoic Achilles tendon (arrow in A ). A tiny echopoor area is observed in the axial plane (arrow in B ), consistent with type 1 tear
A 34-year-old male patient presented with a history of sudden acute pain in the posterior aspect of the lower leg while running, 17 days back. US image in the sagittal plane shows thickened and hypoechoic Achilles tendon (arrow in A ). A tiny echopoor area is observed in the axial plane (arrow in B ), consistent with type 1 tear

Fig. 6.

A 19-year-old male patient presented with a history of injury with glass in the lower leg posteriorly 3 days back. US image showing thickened, hypoechoic and retracted Achilles tendon (elbow arrow in A ). Anechoic fluid is seen in gap (asterisk in A ); suggestive of type 2 tear. Another 28-year-old male patient presented with a history of injury with some sharp object in the lower leg posteriorly 7 days back. US image showing thickened, hypoechoic and retracted Achilles tendon with echogenic Kager’s fat pad seen herniating into the gap (arrow in B, C ); suggestive of type 3 tear
A 19-year-old male patient presented with a history of injury with glass in the lower leg posteriorly 3 days back. US image showing thickened, hypoechoic and retracted Achilles tendon (elbow arrow in A ). Anechoic fluid is seen in gap (asterisk in A ); suggestive of type 2 tear. Another 28-year-old male patient presented with a history of injury with some sharp object in the lower leg posteriorly 7 days back. US image showing thickened, hypoechoic and retracted Achilles tendon with echogenic Kager’s fat pad seen herniating into the gap (arrow in B, C ); suggestive of type 3 tear

Fig. 7.

US images in 2 different patients show anechoic fluid collections in the anterior recess of the tibiotalar joint (yellow arrows in A and B ). The echogenic fat pad is displaced anteriorly (elbow arrow in B )
US images in 2 different patients show anechoic fluid collections in the anterior recess of the tibiotalar joint (yellow arrows in A and B ). The echogenic fat pad is displaced anteriorly (elbow arrow in B )

Fig. 8.

A. US image in the longitudinal plane demonstrating an echogenic subcutaneous structure (yellow arrow) surrounded by a hypoechoic collection (elbow arrow). B, C. Color Doppler images in the longitudinal and transverse planes show increased local vascularity; suggestive of foreign body with surrounding granulomatous tissue. Follow-up revealed a wooden foreign body
A. US image in the longitudinal plane demonstrating an echogenic subcutaneous structure (yellow arrow) surrounded by a hypoechoic collection (elbow arrow). B, C. Color Doppler images in the longitudinal and transverse planes show increased local vascularity; suggestive of foreign body with surrounding granulomatous tissue. Follow-up revealed a wooden foreign body

Sex-wise incidence of ankle pathologies diagnosed in the study

Pathology Males Females Total
Achilles tendon tear 38 10 48
Ligament injury 38 16 54
Tenosynovitis 12 28 40
Achilles tendon calcification 8 6 14
Joint effusion 18 22 40
Miscellaneous pathologies 14 8 22

The normal tendo-ligamentous anatomy of the ankle joint

Compartment Tendons/ligaments
Anterior Anterior tibial tendonExtensor hallucis longus tendonExtensor digitorum longus tendon
Posterior Achilles tendon Plantaris tendon
Lateral Peroneus longus tendonPeroneus brevis tendon
Medial Posterior tibial tendonFlexor digitorum longus tendonFlexor hallucis longus tendon
The lateral ligament complex Anterior talofibularPosterior talofibularCalcaneofibular
The medial ligament complex TibionavicularTibiospringTibiocalcanealAnterior tibiotalarPosterior tibiotalar
Ankle syndesmosis Anterior inferior tibiofibularPosterior inferior tibiofibularInferior transverseDistal interosseous
The sinus tarsi Cervical and interosseous talocalcanealligaments Neurovascular structuresFat
The tarsal tunnel Flexor digitorum longus tendonPosterior tibial tendonFlexor hallucis longus tendonNeurovascular bundle

Various clinical tests with techniques to assess the integrity of ligaments and tendons of the ankle joint

Name of the test Technique Interpretation Ligament/tendon evaluated
Anterior drawer test An examiner uses one hand to hold the patient’s heel and the opposite hand to stabilize the anterior portion of the distal tibia and fibula. The examiner then uses the hand on the heel to pull the foot anteriorly. The test is abnormal when translation on the affected side is 3–5 mm greater than that on the normal side. Anterior talofibular ligament (ATFL)
The inversion stress test The examiner uses one hand to cup the heel of the affected foot and the opposite hand to stabilize the anterior portion of the distal tibia and fibula.The ATFL is evaluated by maximally plantarflexing the ankle and then inverting the rear foot; laxity and pain should occur. The calcaneofibular ligament is evaluated by maximally dorsiflexing the foot and then inverting the rear foot. The test is abnormal when inversion on the affected side is 10–15 degrees greater than that of the opposite side. Lateral ligaments complex
The Thompson test If the foot does not plantarflex, rupture of the Achilles tendon must be considered. Jeśli stopa nie jest w zgięciu podeszwowym, należy podejrzewać zerwanie ścięgna Achillesa. Complete rupture of the Achilles tendon

Comparison of ultrasonography and clinical findings in ankle pathologies in the study

Type of pathology (number) Positive on us (%) Positive on clinical tests (%) P value
Achilles tendon tear (48) 48 (100.0) 44 (91.7) 0.125
• Type I (18) 18 4
• Type II (14) 14 14
• Type III (10) 10 10
• Type IV (6) 6 6
Ligament injury (54) 44 (81.5) 46 (85.2) 0.815
• ATFL injury (36)
GRADE II 20 14
GRADE III 16 14
• CFL INJURY (10) 0
1. Grade II (8) 6 8
2. Grade III (2) 2 2
• PTFL injury (8) 0 8
Tenosynovitis (40) 38 (95.0) 38 (95.0) 1.00
• Tibialis posterior (16) 14 16
• Peroneus longus (12) 12 12
• Peroneus brevis (10) 10 10
• Extensor hallucis longus (2) 2 0
Achilles tendon calcification (14) 14 (100.0) 8 (57.1) 0.031
Joint effusion (40) 40 (100.0) 26 (65.0) 0.000
Miscellaneous pathologies (22) 22 (100.0) 16 (72.7.0) 0.031
• Hemangioma (8) 8 6
• Foreign body abscess (6) 6 4
• Granulomatous lesion (4) 4 2
• Soft tissue mass (4) 4 4
Total (218) 206 (94.0) 178 (82.0) 0.000
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Lingua:
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Medicine, Basic Medical Science, other
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