Lateral ankle pain: what is the problem?

Transcription

1 Lateral ankle pain: what is the problem? Poster No.: C-1121 Congress: ECR 2013 Type: Educational Exhibit Authors: J. LEE, S. J. Lee, H. J. Choo, H. W. Jeong, Y.-M. Park, S. J. Choi; Busan/KR Keywords: Musculoskeletal joint, CT, MR, Ultrasound, Normal variants, Diagnostic procedure, Inflammation, Athletic injuries DOI: /ecr2013/C-1121 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 37

2 Learning objectives - Normal anatomy of the lateral ankle - Variable pathologic conditions that can cause lateral ankle pain or instability - Diagnostic US and MR imaging findings of these lesions Background Normal Anatomy - Tendon (Fig 1, 2) - Ligament (Fig 3, 4, 5) Anatomic Pitfalls - Magic angle phenomenon (Fig 6) - Increased SI within normal tendons - fibers form an angle of about 55 with the main magnetic vector - SE with short TEs or GE with short TEs and high FA - Mild plantar flexion Anatomic Variants - Morphologic Variations in the Retromalleolar Fibular Groove - Smooth & concave : 82% - Flat : 11% - Convex : 7% - Lateral dislocation, longitudinal tear of the peroneal tendons - Hypertrophy of the peroneal tubercle (Fig 7) - Peroneus Quartus Muscle (Fig 8, 9, 10) - m/c accessory muscle of the ankle - Origin : muscular portion of peroneus brevis muscle in the distal 1/3 Page 2 of 37

3 - Insertion : variable - Descends posteromedial to the peroneal tendon - Asymptomatic - Low-lying Peroneus Brevis Muscle Belly (Fig 11) - Common anatomical variation - Anomalous extension of the peroneus brevis m. into and distal to the fibular groove #Crowding of retromalleolar groove #Stretching of SPR #Longitudinal splitting of peroneus brevis tendon, tenosynovitis, and dislocation - Os Peroneum (Fig 12) - Round or oval-shaped sesamoid bone - Substance of the distal peroneus longus tendon - Calcaneocuboid joint level Images for this section: Fig. 1: Normal anatomy - ankle tendon Page 3 of 37

4 Fig. 2: Sagittal (a) and axial (b) T1-weighted MR images demonstrate normal peroneus brevis (short arrow) and peroneus longus (long arrow) tendons descending posterior to the lateral malleolus (F). The peroneus brevis tendon is mildly crescentic in configuration on the axial image. Fig. 3: Lateral view of right foot Page 4 of 37

5 Fig. 4: Normal tibiofibular ligaments. (a) Axial T1-weighted MR image obtained at the joint level demonstrates the anterior (straight arrows) and posterior (curved arrow) tibiofibular ligaments. (b) Coronal T1-weighted MR image shows the posterior tibiofibular (straight arrow) and posterior talofibular (curved arrow) ligaments. (c) Normal talofibular ligaments. Axial T1-weighted MR image depicts the anterior talofibular ligament (arrow). The posterior talofibular ligament normally demonstrates a striated pattern due to interspersed fat (*). Note the oblong shape of the talus as well as the medial indentation of the fibula (F), which represents the malleolar fossa. Fig. 5: Normal calcaneofibular ligament. (a) Axial T1-weighted MR image shows the calcaneofibular ligament (straight arrows) immediately adjacent to the peroneal tendons (curved arrow). (b) Sequential coronal T1-weighted MR images display the calcaneofibular ligament as a round, hypointense structure (arrow) extending from the lateral malleolar tip (F) to the lateral wall of the calcaneus (C). Page 5 of 37

6 Fig. 6: Magic angle effect in MRI of ankle tendons in asymptomatic subjects. Transverse oblique T1-weighted images (435/14) in supine body position with neutral position of the foot (left) and in prone body position with plantar flexion of the foot (right). a Imaging Page 6 of 37

7 plane at the inferior tip of medial malleolus (51-year-old asymptomatic woman). In supine body position (left), the PB tendon (white arrow) and the FHL tendon (black arrowhead) show diffusely increased signal due to MAE. After repositioning with plantar flexion of the foot (right) a normal dark signal is seen within the PB and FHL tendons. At this level no MAE is seen within the ATT, PTT, FDL and PL tendons. b Imaging plane just anterior to the sustentaculum tali at the level of the trochlear process of the calcaneus (37-yearold asymptomatic man). In the supine body position with neutral position of the foot (left), MAE with diffusely increased signal is visible within the PTT (white arrowhead), FDL (smallwhite arrow), PB (white arrow), PL (black arrowhead), EHL (curved white arrow) and EDL tendon (second and third tendon) (curved black arrow). In this position only the ATT and the FHL tendon have no MAE. In the prone body position with plantar flexion of the foot (right), all ankle tendons show a normal dark signal with no MAE Fig. 7: Hypertrophied peroneal tubercle in 46-year-old man. A and B. Coronal T1weighted (A) and sagittal T1-weighted (B) images reveal a bone protuberance (black arrowhead) between peroneus brevis (white arrowhead) and peroneus longus tendons (white arrow). Note peroneal tendon thickening with slightly internal hyperintense to muscle, consistent with peroneal tendinosis. C. Axial fat-suppressed intermediateweighted image reveals a split of peroneus longus tendon (arrow) and slightly hyperintense to muscle within peroneus brevis tendon (arrowhead), associated with small amount of fluid in tendon sheath. Page 7 of 37

8 Fig. 8: Drawing illustrates a peroneus quartus muscle (arrowheads) located posterior to the peroneus brevis (long straight arrow) and peroneus longus (short straight arrow) tendons. Its most common insertion site is the retrotrochlear eminence of the calcaneus (curved arrow). (Courtesy of Salvador Beltran, MD, Albons, Girona, Spain.) Page 8 of 37

9 Fig. 9: Peroneus quartus variant in 40-year-old man. A. Axial T1WI shows a split of peroneus brevis tendon (white arrow) with normal peroneus longus tendon lying posterior (arrowhead). Peroneus quartus tendon (black arrow) is posteromedial to peroneus longus tendon and lies beneath peroneal retinaculum, before insertion of peroneus quartus tendon onto lateral wall of calcaneus. B. Coronal short tau inversion recovery (STIR) image reveals longitudinal spilt of peroneus brevis tendon (arrows). Fig. 10: Peroneus quartus variant in 38-year-old man. A. US image obtained transversely to the peroneus tendon just inferior to the lateral malleolus shows the (1)peroneus brevis and (2) peroneus longus tendons running behind the lateral malleolus (LM). Note the Page 9 of 37

10 peroneus quartus muscle (PQm) located in a more posterior position and separated from the tendons by hyperechoic fat. B. Axial T1WI demonstrates normal peroneus brevis (arrowhead) and peroneus longus (white arrow) tendons descending posterior to the lateral malleolus (LM). Note the peroneus quartus muscle (black arrow) located in a more posterior position. Page 10 of 37

11 Fig. 11: Low-lying peroneus brevis muscle belly in a foot in dorsiflexion in 28-year-old woman. Axial intermediate-weighted image (TR/TE, 2587/28) shows a peroneus brevis muscle belly (arrow) below the fibular tip. Page 11 of 37

12 Fig. 12: Os peroneum fracture and full-thickness peroneus longus tendon tear in 47-yearold man. A. Oblique radiograph of the left foot shows an irregular appearance of the os peroneum with additional small osseous fragments seen at the level of the cuboid tunnel, consistent with os peroneum fracture. Note diastasis of os peroneum fragments (arrows), Page 12 of 37

13 which were separated by 13mm. B. STIR image (TR/TE, 5350/16) reveals proximal os peroneum fragment (arrowhead). The small distal fragment is not well visualized. Note the fluid signal intensity at the site of peroneus longus tendon tear (star). B= peroneus brevis tendon, C = calcaneus, Cu =cuboid bone, F =fibula, L =peroneus longus. C. US image obtained longitudinally to the peroneus longus tendon shows diastasis of os peroneum fragments (arrows). Note the loss of normal fibrillar tendon appearance and the abnormal hypoechogenicity at the site of the tendon tear (star). Page 13 of 37

14 Imaging findings OR Procedure details Peroneal tendon - Peroneal tendinosis (Fig 13) - Non-inflammatory degenerative process within the peroneal tendons - Athletes (m/c), elderly individuals, diabetics, patients with inflammatory arthritis, and individuals with displaced Fx of the lateral malleolus and calcaneus - Peroneal Tenosynovitis - Inflammation of the tendon or tendon sheath - m/c tendon disorders of the lateral ankle - Etiology - Trauma, repetitive local stress, systemic joint disorders - Peroneus Brevis Tears (Fig 14, 15, 16) - Young athletes, elderly - Associated conditions - ligamentous injuries - insufficiency of the SPR - thickening of the calcaneofibular ligament - overcrowding of the retromalleolar groove - Susceptible to degenerative tears - Peroneus Longus Tears (Fig 17) - Isolated peroneus longus tendon tears - Uncommon - Level of the cuboid tunnel - Associated with peroneus brevis tendon tears : retromalleolar groove - m/c condition of acute tears - Direct trauma or sports-related injury - Avulsion fracture of the os peroneum : Os peroneum fragment separation (# 6mm) - Degenerative chronic tears - Mechanical friction - Cuboid tunnel or a hypertrophic peroneal tubercle Peroneal Retinaculum - Dislocation and SPR Injuries - Peroneal tendon subluxation - Uncommon but not rare % of traumatic events to the ankle Page 14 of 37

15 - Peroneal tendon dislocation - One or both tendons displace from the retromalleolar groove during ankle movement or muscle contractions - Commonly a/w SPR injury - SPR injury (Fig 18, 19, 20) - Acute inversion injury to the dorsiflexed ankle or during forced dorsiflexion of the everted foot - Skiing, skating, soccer, or football - Congenital foot deformities - Shallow or convex fibular groove - Overcrowding of retromalleolar groove by the anatomic variants - Fx of the distal fibula & calcaneus - US and MRI - Peroneal tendon dislocation and SPR injuries - Dynamic US with a dorsiflexion-eversion maneuver : more helpful for detection of intermittent dislocation - Intrasheath Subluxation (Fig 21, 22, 23) - Reverse anatomic locations of brevis and longus tendons within the peroneal groove - Intact retinaculum - Two subtypes (by Raikin) - Dynamic ultrasound - Subluxation of peroneus brevis and longus tendons over each other within the peroneal groove : peroneus longus lie deep to the peroneus brevis tendon - Intact superior peroneal retinaculum while dorsiflexion and eversion maneuver Intartendinous Ganglion in PB (Fig 24) Ligment Injuries (Fig 25, 26, 27, 28) - Lateral ankle sprain % of all sports-related traumatic lesions - Anterior talofibular ligament - weakest ligament - most frequently torn - Anatomic classification (No. of affected ligaments) - 1st degree : partial or complete tear of ant. talofibular lig. - 2nd degree : partially or complete tear of ant. talofibular &calcaneofibular lig. - 3rd degree : injuries to ant. talofibular, calcaneofibular & posterior talofibular lig. - Acute rupture of the lateral collateral ligament Page 15 of 37

16 - Discontinuity, detachment, thickening, thinning, or irregularity of the ligament - Heterogeneity with increased intraligamentous SI (fat-suppressed or T2WI) - intrasubstance edema or hemorrhage - Obliteration of the fat planes around the ligament - Extravasation of joint fluid into adjacent soft tissues - Talar contusions - Chronic tear - Thickening, thinning, elongation, and wavy or irregular contour of the ligament - Residual marrow or soft tissue edema (-) - Hemorrhage (-) - Decreased SI in the fat abutting the ligaments (scarring/synovial proliferation) Impingement syndrome - Anterolateral impingement syndrome (Fig 29) - Entrapment of abnormal soft tissue in the anterolateral gutter of the ankle - Chronic lateral ankle pain - Injuries to ATF & AITF ligaments, accessory fascicle of AITF ligament - Chronic lateral instability - Repetitive synovial inflammation - Soft tissue "mass" (hypertrophic synovial tissue, fibrosis) - MRI - Abnormal soft-tissue mass or fibrous band in the anterolateral ankle gutter - Low SI on T1WI, Low-, intermediate SI on T2WI Osseous Lesions - Osteochondroma (Fig 30) - Cartilage-covered osseous excrescences - Solitary/multiple - Long tubular bone - Lower extremity > upper extremity - Metaphyseal location - Radiologic finding - Osseous protuberance arising from external surface of long tubular bone - Fracture of Os subfibulare (Fig 31) - Os subfibulare - Accessory bone located under the tip of lateral malleollus - 2.1% of individuals - Persistence of an accessory ossification center - Old non-united avulsion fractures : swelling, tenderness, painful weight bearing, painful range of motion and ankle effusion, ankle instability Page 16 of 37

17 Ganglion Cysts (Fig 32) - m/c soft tissue mass in the foot and ankle - Origin sites - tendon sheath - joint - bone (periosteal or intraosseous) - soft tissue - Intratendinous ganglion cysts of the ankle - uncommon - Etiology - not completely understood - recurrent injury to the tendon with subsequent cystic degeneration - MR imaging - Well-defined, lobulated mass located adjacent to a joint or tendon sheath - Simple or complex fluid-like signal - Rim enhancement - Fluid-filled tail that connects to the adjacent joint or tendon sheath (reliable sign) Images for this section: Page 17 of 37

18 Fig. 13: Peroneal longus tendinosis with common peroneal tenosynovitis in 65year-old man. A and B. Axial FS intermediate-weighted (A) and sagittal STIR (B) images show thickening of and increased signal intensity within the peroneal longus tendon(arrowhead). Note extensive increased signal intensity surrounding the peroneal longus and brevis tendon, compatible with extensive tenosynovitis (arrows). C. US image obtained longitudinally to the peroneus tendon shows that the peroneal longus tendon is extensively thickened and hypoechoic from the level of the lateral malleolus to the plantar surface of the foot. And fluid is demonstrated within the common peroneal tendon sheath (star). D. Color Doppler imaging shows positive flow, which means hyperemia. B=peroneus brevis tendon, L=peroneus longus, F =fibula, LM=lateral malleolus. Page 18 of 37

19 Fig. 14: Peroneus brevis tears with lateral subluxation of the peroneal tendons in 20year-old woman. A and B. axial T1WI (A) and FS intermediate-weighted (B) images reveal a fragmented peroneus brevis tendon (arrowheads) with an advanced tear and a markedly thinned central portion. There is also mild lateral subluxation of the peroneus brevis (arrowheads) and longus tendons (arrow) with the lateral split portion of the brevis located lateral to the lateral aspect of the distal fibula. Findings indicate disruption of the superior peroneal retinaculum. Note is made of a convex contour of the posterior aspect of the distal fibula (star), which may predispose to peroneal tendon subluxation. Page 19 of 37

20 Fig. 15: Peroneus brevis tears in 36-year-old woman. A. US image obtained transversely to the peroneus tendon just inferior to the lateral malleolus shows splitting of the peroneus brevis tendon in two hemi-tendons. The peroneus longus tendon is normal. B=peroneus brevis tendon, L=peroneus longus tendon, LM=lateral malleous. B. Longitudinal dynamic sonogram obtained with a dorsiflexion-eversion maneuver of the ankle shows that peroneus brevis tendon has torn longitudinally into two parts. The peroneus longus tendon is normal. PB= peroneus brevis tendon, PL =peroneus longus tendon. Page 20 of 37

21 Fig. 16: Peroneus brevis tears in 36-year-old woman. A. US image obtained transversely to the peroneus tendon just inferior to the lateral malleolus shows splitting of the peroneus brevis tendon in two hemi-tendons. The peroneus longus tendon is normal. B=peroneus brevis tendon, L=peroneus longus tendon, LM=lateral malleous. B. Longitudinal dynamic sonogram obtained with a dorsiflexion-eversion maneuver of the ankle shows that peroneus brevis tendon has torn longitudinally into two parts. The peroneus longus tendon is normal. PB= peroneus brevis tendon, PL =peroneus longus tendon. Page 21 of 37

22 Fig. 17: Peroneus longus tear in 35-year-old man. A and B, axial T1WI(A) and sagittal FS intermediate- weighted (B) image demonstrate discontinuity of the peroneus longus tendon(arrow). F =fibula. The peroneus brevis (arrowhead) is normal. Page 22 of 37

23 Fig. 18: Drawings illustrate Oden's surgical classification system for SPR injuries. A normal SPR originates from the distal fibula (A). A small fibrous ridge may be found at the attachment site. In type I injury (B), the SPR is stripped off the distal fibula, forming a pouch into which the peroneal tendons can dislocate. Type II injury (C) is a tear of the SPR at its attachment to the distal fibula. Type III injury (D) is an avulsion fracture of the SPR at its attachment to the distal fibula. Type IV injury (E) is a tear of the SPR at its posterior attachment. PB = peroneus brevis tendon, PL = peroneus longus tendon. (Reprinted, with permission, from reference 21.) Page 23 of 37

24 Fig. 19: Dislocation of the peroneus tendons and SPR Injury in 50-year-old woman. Axial T1WI shows that the peroneus brevis (arrowhead) and longus (white arrow) tendons locate lateral to lateral margin of fibula with associated retinacular tear (black arrow). Degenerative changes at the ankle joint and ligamentous injury, including anterior and posterior tibiofibular ligaments are incidentally noted. Page 24 of 37

25 Fig. 20: SPR injury with mild subluxation of the peroneus tendons in 24-year-old woman. Axial dynamic sonogram obtained with ankle dorsiflexed and everted shows partial subluxation of the peroneus tendons over fibula. This is associated with stretching and partial tearing of the peroneal retinaculum.b=peroneus brevis tendon, L=peroneus longus tendon, LM=lateral malleolus Page 25 of 37

26 Fig. 21: Classification system for intrasheath subluxation of the peroneal tendons. Page 26 of 37

27 Fig. 22: Type-A intrasheath subluxation in 34-year-old woman. Axial dynamic sonogram obtained with ankle dorsiflexed and everted shows that peroneus longus and peroneus brevis tendons have reversed their normal anteroposterior relationship, although they are still located behind lateral malleolus. B=peroneus brevis tendon, L=peroneus longus tendon, LM=lateral malleolus. Page 27 of 37

28 Fig. 23: Type-B intrasheath subluxation in 82-year-old-woman. Axial dynamic sonogram obtained with a dorsiflexion-eversion maneuver of the ankle shows that the peroneus longus tendon subluxates through a longitudinal split tear within the peroneus brevis tendon with a portion of the longus tendon coming to lie deep to the brevis tendon at this level.b=peroneus brevis tendon, L=peroneus longus tendon, LM=lateral malleolus. Fig. 24: Intratendinous ganglion cyst of peroneus brevis tendon in 52-year-old woman. A and B, Axial FS T2WI (A) and STIR (B) images reveal heterogeneous hyperintense mass (white arrowheads) involving peroneal sheath. Note internal increased signal intensity within peroneus longus tendon (arrow), which means tendinosis. Lesion blends with peroneus brevis tendon (black arrowheads) more proximally (B). C. Axial T1WI shows hypointense mass (arrowheads) involving peroneal sheath. Note internal increased signal intensity within peroneus longus tendon (arrow), which means tendinosis. Page 28 of 37

29 Fig. 25: Left heel pain for 3 week in 39 year-old- man. Axial T2WI shows tear of anterior talofibular ligament. Page 29 of 37

30 Fig. 26: Left ankle pain for 5 years in 17 year-old-man. A. PD axial MR image shows poorly delineation of anterior and posterior talofibular ligaments. Also, lateral dislocation of peroneal tendon. B. Coronal T2WI shows poorly delineation of anterior and posterior talofibular ligaments. Page 30 of 37

31 Fig. 27: Right ankle pain for 4 years in 27 year-old-man. A,B. Poorly visualized anterior inferior tibiofibular ligament on T2 axial and PD MR image. Fig. 28: Left lateral ankle pain for 4 years in 17-years-old female. A. axial MPR, B. axial T1 SPIR GD, C. FS T2WI demonstrate non-visualization of left calcaneofibular ligament. Increased SI in the peroneus brevis. Small amount of fluid in tendon sheath of peroneus. Slightly increased bone marrow SI around accessory navicular bone, suggesting accessory navicular syndrome. Page 31 of 37

32 Page 32 of 37

33 Fig. 29: MR image shows diffuse irregular thickening of the anterolateral capsular tissues (curved arrow) with no recess of fluid (straight arrow) anterior to the fibula. Fig. 30: Fig 19. Palpable mass in the left lateral malleolar area in 31-year-old woman. (A) Simple radiography, (B) axial and (C) coronal CT images show enthesophyte at left distal fibula. Osteochondroma was confirmed in the excisional biopsy Page 33 of 37

34 Fig. 31: Fig 20. Left ankle pain in 16-year-old woman for 5 months. (A) Simple ankle anteroposterior radiography, (B) axial, (C) sagittal and (D) coronal CT images show accessory bone located under the tip of lateral malleollus. Page 34 of 37

35 Fig. 32: Right ankle pain for 4 years in 27-year-old man. (A) Fat suppressed coronal T2WI shows well-defined hyperintense mass in the anterolateral recess of the ankle. (B) Coronal T1WI shows well-defined hypointense mass in the anterolateral recess of the ankle. Page 35 of 37

36 Conclusion This exhibit reviews the ultrasound and MRI features of the lateral ankle pathology and variations. In particular, ultrasound is emphasized for the dynamic evaluation of peroneal tendon subluxation and dislocation, and occult tear of the lateral ligament. After viewing this exhibit, the reader will be familiar with the imaging anatomy of the lateral ankle and be able to recognize the full spectrum of pathologies that can cause lateral ankle pain or instability. References 1. Zehava S et al. MR imaging of the Ankle and Foot. RadioGraphics 2000; 20:S153S Philip Robinson et al. Soft-Tissue and Osseous Impingement Syndromes of the Ankle: Role of Imaging in Diagnosis and Management. RadioGraphics 2002; 22: Lyndon K et al. Magnetic resonance imaging findings in anterolateral impingement of the ankle. Skeletal Radiol (2000) 29: Philip Robinson et al. Anterolateral Ankle Impingement: MR Arthrographic Assessment of the Anterolateral Recess. Radiology 2001; 221: J M Mellado et al. Accessory ossicles and sesamoid bones of the ankle and foot: imaging findings, clinical significance and differential diagnosis. Eur Radiol (2003) 13:L164-L Jose A Narvaez et al. MRI of Sports-Related Injuries of the Foot and Ankle: Part 2. Curr Probl Diagn Radiol 2003;32: L F Foo et al. Tumours and tumour-like lesions in the foot and ankle. Clinical Radiology (2005) 60, Michelle A Wessely. MR imaging of the ankle and foot--a review of the normal imaging appearance with an illustration of common disorders. Clinical Chiropractic (2007) 10, Joshua C Dubin DC et al. Lateral and syndesmotic ankle sprain injuries: a narrative literature review. Journal of Chiropractic Medicine (2011) 10, Anthony D Watson. Ankle Instability and Impingement. Foot Ankle Clin N Am 12 (2007) Xiao-Tian Wang et al. Normal Variants and Diseases of the Peroneal Tendons and Superior Peroneal Retinaculum: MR Imaging Features. RadioGraphics 2005; 25: M. Szendroi. GIANT-CELL TUMOUR OF BONE. J Bone Joint Surg [Br] 2004;86B: George Arnold et al. Normal Magnetic Resonance Imaging Anatomy of the Ankle & Foot. Magn Reson Imaging Clin N Am 19 (2011) Page 36 of 37

37 23. Jaume Llauger et al. MR Imaging of Benign Soft-Tissue Masses of the Foot and Ankle. RadloGraphics 1998; 18: Kiley D. Perrich et al. Ankle Ligaments on MRI: Appearance of Normal and Injured Ligaments. AJR 2009; 193: George Koulouris et al. Foot and Ankle Disorders: Radiographic Signs. Semin Roentgenol Oct;40(4): Personal Information Page 37 of 37