"The Role of Dynamic Ultrasound and MRI in the poorly resolving ankle sprain."

Transcription

1 "The Role of Dynamic Ultrasound and MRI in the poorly resolving ankle sprain." Poster No.: P-0007 Congress: ESSR 2013 Type: Scientific Exhibit Authors: J. M. Zietkiewicz, P. Mercouris, M. C. Marshall; Durban/ZA Keywords: Athletic injuries, Diagnostic procedure, Ultrasound, MR, Musculoskeletal soft tissue DOI: /essr2013/P-0007 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 71

2 Purpose Learning Objectives A relatively common clinical problem encountered by the sport's medicine physician is the patient with ongoing ankle pain and disability following an inversion sprain. The primary goal of the sports physician and radiologist is to establish an accurate diagnosis confidently in order to ensure appropriate treatment in a safe and timely way that does not place the patient at risk for recurrent or worsening injury (1). The learning objectives were to correlate the clinical presentation and examination with an accurate ultrasound assessment of the lateral ligamentous complex of the ankle, with associated dynamic stress assessment for ligament instability. The clinical and ultrasound examinations were followed by an ankle MRI examination, which was independently reported by an experienced MSK radiologist (12 yrs experience), blinded to the clinical assessment and ultrasound findings. Methods and Materials Materials and Methodology The study consisted of 16 patients, 6 females and 10 males aged between 15 and 47 years. All patients had suffered a recent inversion sprain. All patients had initial negative plain films for underlying fractures. Patients were assessed 6-15 weeks after their inversion injuries. History and Clinical Examination by the Sport's Physician. The clinical history included drug therapy, physiotherapy, immobilization of the ankle and infiltration. Further history included the patient's current symptoms related to the ankle injury including pain, swelling, stiffness, range of movement and feeling of instability and weakness. Page 2 of 71

3 Clinical examination included assessing for swelling, localization of tenderness, range of movement, instability testing and functional stability tests. The anterior drawer test is performed by immobilizing the patient's distal tibia with one hand while applying pressure against the back of the foot with the other hand. This test assesses the integrity of the anterior talofibular ligament (ATFL) and posterior talofibular ligament (PTFL) with a positive test being anterior talar shift against the tibia (7). The talar tilt test (varus/valgus stress) is performed by applying varus stress to the ankle by rolling the calcaneus with the patient in a relaxed supine position. This assesses the integrity of the calcaneofibular ligament (CFL) and the ATFL. The syndesmosis test (high ankle sprain test) is assessed in dorsiflexion and eversion. This test predominantly assesses the anterior inferior tibiofibular ligament (AITFL) and the amount of widening noted between the tibia and fibula during stress. The Balance Error Scoring System (BESS) attempts to challenge the sensory systems by combining a variety of stances on a firm as well as on a more unstable surface e.g. foam (5). The test requires participants to stand unsupported with their eyes closed under six conditions using a combination of two surfaces and 3 stances (double limb, single limb and tandem) (5). Errors are recorded for each stance and summed up to produce a total BESS score (5). Ultrasound Examination The Ultrasound machine used in all examinations was a Phillips iu 22 machine. A L15-7 transducer with a 15 to 7 MHz extended frequency range using a phased linear array. Ultrasound assessed the lateral ligamentous complex including the AITFL and syndesmosis, peroneal tendons and peroneal retinaculae. The ligament injury was graded I, II or III based on the following criteria (7). Grade I:Thickened ligament, which largely maintains its echo pattern. Page 3 of 71

4 Fig. 1: ATFL Grade I injury: White arrow indicates thickened ligament which largely maintains its echo pattern. References: Radiology, Lake,Smit and Partners, St.Augustine's Hospital - Durban/ZA Page 4 of 71

5 Fig. 2: CFL Grade I injury: White arrow indicates thickened ligament which largely maintains its echo pattern. References: Radiology, Lake,Smit and Partners, St.Augustine's Hospital - Durban/ZA Grade II: Thickened ligament with either focal or diffuse loss of the ligament echo pattern with some ligament irregularity indicating a partial thickness tear. Page 5 of 71

6 Fig. 3: ATFL Grade II injury: Partial thickness tear (a)grey arrow indicates hypoechoic gap. (b) White arrow indicates attenuated ligament. References: Radiology, Lake,Smit and Partners, St.Augustine's Hospital - Durban/ZA Fig. 4: CFL Grade II injury: White arrow indicates attenuated hypoechoic ligament. References: Radiology, Lake,Smit and Partners, St.Augustine's Hospital - Durban/ZA Page 6 of 71

7 Grade III: Hypoechoic gap in the ligament indicating a complete tear. Fig. 5: ATFL Grade III injury: Complete tear.large white arrow indicates ligament stump. References: Radiology, Lake,Smit and Partners, St.Augustine's Hospital - Durban/ZA A joint effusion in the anterolateral joint was considered present when the fluid measured greater than 3 mm in AP diameter (11). Page 7 of 71

8 Fig. 6: Arrow indicates large joint effusion. References: Radiology, Lake,Smit and Partners, St.Augustine's Hospital - Durban/ZA Synovial thickening of 10 mm or greater was considered significant (11). Page 8 of 71

9 Fig. 7: White arrow indicates the prominent synovial thickening in the talofibular joint. References: Radiology, Lake,Smit and Partners, St.Augustine's Hospital - Durban/ZA Pre-stress joint measurements of the anterolateral tibiotalar and calcaneofibular joints as well as the anterior tibiofibular recess were taken. Stress tests were performed in conjunction with the sports physician who had taken the clinical history and performed the clinical examination. This ensured consistency of the stress tests in all patients. Page 9 of 71

10 Fig. 8: Drawer Test: At rest. References: Radiology, Lake,Smit and Partners, St.Augustine's Hospital - Durban/ZA Page 10 of 71

11 Fig. 9: Drawer Stress test: Anterior Talar shift demonstrated under stress in keeping with instability. References: Radiology, Lake,Smit and Partners, St.Augustine's Hospital - Durban/ZA MRI Examination All 16 patients underwent an MRI ankle examination. All examinations were performed on a Siemens Magneton Aera 1.5 T unit (Version Syngo MR D11) utilizing a 16 channel foot and ankle coil. Sequences (1) PD TSE Fat Sat Axial: TR 3020 TE 24 (2) T1 TSE Axial: TR 613 TE 13 (3) T2 TSE Fat Sat Axial: TR 4050 TE 79 (4) PD TSE Fat Sat Coronal: TR 3830 TE 26 (5) T1 TSE Sagittal: TR 535 TE 13 Page 11 of 71

12 (6) PD TSE Fat Sat sagittal: TR 2979 TE 26 Slice thickness 3mm and slice gap 0,6mm. FOV 160 mm. Matrix 320 x 320. The following structures were assessed on MRI: The osteochondral elements, ligaments and tendons, synovium and joint fluid. The primary ligament complex assessed for the purposes of this study was the lateral ligament complex. The individual ligaments of the ligament complexes were assessed on MRI for alteration in morphology and signal. (1) The ligament was considered stretched or sprained if it demonstrated increased or heterogenous signal on fluid sensitive sequences and one or more of the following morphologic features: thickened or attenuated ligament, indistinct, irregular or wavy ligament margins ( 3, 9, 10). Page 12 of 71

13 Fig. 10: ATFL Grade I injury: Arrow indicates sprained ATFL. ( PD TSE FS Axial) References: Radiology, Lake,Smit and Partners, St.Augustine's Hospital - Durban/ZA Page 13 of 71

14 Fig. 11: CFL Grade I injury: Arrow indicates sprained CFL. (T2 TSE Coronal) References: Radiology, Lake,Smit and Partners, St.Augustine's Hospital - Durban/ZA (2) The ligament was considered partially torn, if in addition to the aforementioned criteria of a sprained ligament, there was incomplete interruption of the ligament (3, 9, 10). Page 14 of 71

15 Fig. 12: ATFL Grade II injury: Arrow indicates the partial thickness tear of ATFL. ( T2 TSE Axial ) References: Radiology, Lake,Smit and Partners, St.Augustine's Hospital - Durban/ZA Page 15 of 71

16 Fig. 13: CFL Grade II injury: Arrow indicates partial thickness tear of CFL. (PD TSE FS Coronal) References: Radiology, Lake,Smit and Partners, St.Augustine's Hospital - Durban/ZA (3) The ligament was classified as a complete tear, in addition to the aforementioned criteria of a sprained ligament, if there was a complete interruption of the ligament with or without fluid bridging the gap in the tear ( 3, 9, 10). Page 16 of 71

17 Fig. 14: ATFL Grade III injury: Arrow indicates stump of ATFL in keeping with a complete tear. (PD TSE FS Axial) References: Radiology, Lake,Smit and Partners, St.Augustine's Hospital - Durban/ZA Page 17 of 71

18 Fig. 15: AITFL Grade III injury: Arrow indicates torn AITF ligament.( T1 TSE Axial ) References: Radiology, Lake,Smit and Partners, St.Augustine's Hospital - Durban/ZA Page 18 of 71

19 Fig. 16: AITFL Grade III injury: Arrow indicates complete tear AITF ligament. ( PD TSE FS Axial ) References: Radiology, Lake,Smit and Partners, St.Augustine's Hospital - Durban/ZA Ligament Injury Grading Grade I: Sprained ligament (1, 3, 9, 10). Grade II: Partial thickness tear of ligament (1, 3, 9, 10). Page 19 of 71

20 Grade III: Complete tearing of the ligament (1, 3, 9, 10). Images for this section: Fig. 3: ATFL Grade II injury: Partial thickness tear (a)grey arrow indicates hypoechoic gap. (b) White arrow indicates attenuated ligament. Page 20 of 71

21 Fig. 5: ATFL Grade III injury: Complete tear.large white arrow indicates ligament stump. Fig. 4: CFL Grade II injury: White arrow indicates attenuated hypoechoic ligament. Page 21 of 71

22 Fig. 2: CFL Grade I injury: White arrow indicates thickened ligament which largely maintains its echo pattern. Page 22 of 71

23 Fig. 6: Arrow indicates large joint effusion. Page 23 of 71

24 Fig. 1: ATFL Grade I injury: White arrow indicates thickened ligament which largely maintains its echo pattern. Page 24 of 71

25 Fig. 7: White arrow indicates the prominent synovial thickening in the talofibular joint. Page 25 of 71

26 Fig. 8: Drawer Test: At rest. Page 26 of 71

27 Fig. 9: Drawer Stress test: Anterior Talar shift demonstrated under stress in keeping with instability. Fig. 10: ATFL Grade I injury: Arrow indicates sprained ATFL. ( PD TSE FS Axial) Page 27 of 71

28 Fig. 12: ATFL Grade II injury: Arrow indicates the partial thickness tear of ATFL. ( T2 TSE Axial ) Page 28 of 71

29 Fig. 14: ATFL Grade III injury: Arrow indicates stump of ATFL in keeping with a complete tear. (PD TSE FS Axial) Page 29 of 71

30 Fig. 11: CFL Grade I injury: Arrow indicates sprained CFL. (T2 TSE Coronal) Page 30 of 71

31 Fig. 13: CFL Grade II injury: Arrow indicates partial thickness tear of CFL. (PD TSE FS Coronal) Page 31 of 71

32 Fig. 15: AITFL Grade III injury: Arrow indicates torn AITF ligament.( T1 TSE Axial ) Page 32 of 71

33 Fig. 16: AITFL Grade III injury: Arrow indicates complete tear AITF ligament. ( PD TSE FS Axial ) Page 33 of 71

34 Results RESULTS: CLINICAL HISTORY AND EXAMINATION. All patients had taken non-steroidal anti-flammatory drugs. All had undergone physiotherapy. One patient had a corticosteriod infiltration. Current Symptoms: Pain 15 Swelling 5 Stiffness 3 Decreased ROM 4 Feeling of instability/weakness 5 Examination Findings: Swelling 3 Joint effusion 3 Joint line tenderness 5 ATFL tenderness 10 CFL tenderness 2 Peroneal tendon tenderness 5 Syndesmosis tenderness 3 ROM-reduced dorsiflexion 2 Stress Tests Drawer test 10 Valgus/varus 2 High ankle sprain(syndesmosis) 1 Page 34 of 71

35 Functional Stability Tests (errors in 20's) All patients who tested negative, for all three stability tests, scored 4 or less. All patients who tested positive for the anterior drawer test scored on average of 6. The patient who had positive drawer and valgus/varus stress test - scored 6. The patient with the high ankle sprain (syndesmosis) - scored 8. Ultrasound Results: ATFL Grade I----5 Grade II Grade III----1 CFL Grade I ---2 Grade II ---3 Grade III ---0 PTFL Grade I ---2 Grade II ---0 Grade III ---0 Syndesmosis 1 Avulsion fracture 2 talus Synovial thickening 6 Anterolateral 2 Posterolateral Joint effusion 5 Peroneal tendon tears 0 Page 35 of 71

36 Peroneal retinaculum 5 sprain Fig. 17: Anterior Inferior Tibiofibular ligament (a)left image :Normal ligament (b) Right image : Complete tear. References: Radiology, Lake,Smit and Partners, St.Augustine's Hospital - Durban/ZA Page 36 of 71

37 Fig. 18: Varus Valgus Stress test: At rest. References: Radiology, Lake,Smit and Partners, St.Augustine's Hospital - Durban/ZA Page 37 of 71

38 Fig. 19: Varus valgus Stress Test: No joint space widening noted during loading in keeping with stability. References: Radiology, Lake,Smit and Partners, St.Augustine's Hospital - Durban/ZA Fig. 20: Syndesmosis stress test: Syndesmosis at rest. Page 38 of 71

39 References: Radiology, Lake,Smit and Partners, St.Augustine's Hospital - Durban/ZA Fig. 21: Syndesmosis Stress Test during loading: No widening of syndesmosis noted in keeping with stability. References: Radiology, Lake,Smit and Partners, St.Augustine's Hospital - Durban/ZA Page 39 of 71

40 Fig. 22: Avulsion Fracture Talus. References: Radiology, Lake,Smit and Partners, St.Augustine's Hospital - Durban/ZA Page 40 of 71

41 Fig. 23: Varus valgus stress test: at rest. References: Radiology, Lake,Smit and Partners, St.Augustine's Hospital - Durban/ZA Page 41 of 71

42 Fig. 24: Positive Varus/Valgus Stress: Widened calcaneofibular joint during stress indicating instability. References: Radiology, Lake,Smit and Partners, St.Augustine's Hospital - Durban/ZA MRI Results: ATFL Grade I ---6 Grade II ---9 Grade III ---1 CFL Grade I Grade II ---5 Grade III ---0 PTFL Grade I ---0 Grade II ---0 Page 42 of 71

43 Grade III ---0 AITFL (syndesmosis) 1 Deltoid lig sprain 2 OCL talus 2 Avulsion fracture talus 1 Bone bruise 5 Sinus tarsi sprain 1 Joint effusion 6 Synovial thickening Anterolateral-7 Synovial thickening Posterolateral-4 Page 43 of 71

44 Fig. 25: Osteochondral Lesion Talus: PD TSE FS Coronal References: Radiology, Lake,Smit and Partners, St.Augustine's Hospital - Durban/ZA Page 44 of 71

45 Fig. 26: Bone Bruise Lateral Malleolus: PD TSE FS Coronal References: Radiology, Lake,Smit and Partners, St.Augustine's Hospital - Durban/ZA Page 45 of 71

46 Fig. 27: Bone Bruise Medial Malleolus: PD TSE FS Coronal References: Radiology, Lake,Smit and Partners, St.Augustine's Hospital - Durban/ZA Page 46 of 71

47 Fig. 28: Deep Deltoid ligament sprain: PD TSE FS Coronal References: Radiology, Lake,Smit and Partners, St.Augustine's Hospital - Durban/ZA Page 47 of 71

48 Fig. 29: Sinus Tarsi Sprain: PD TSE FS Sagittal References: Radiology, Lake,Smit and Partners, St.Augustine's Hospital - Durban/ZA Page 48 of 71

49 Fig. 30: Posterior Synovitis: T1 TSE Axial References: Radiology, Lake,Smit and Partners, St.Augustine's Hospital - Durban/ZA Page 49 of 71

50 Fig. 31: Anterior and Posterior Synovitis: PD TSE FS Sagittal References: Radiology, Lake,Smit and Partners, St.Augustine's Hospital - Durban/ZA Page 50 of 71

51 Fig. 32: PTFL striated appearance: PD TSE FS Axial. References: Radiology, Lake,Smit and Partners, St.Augustine's Hospital - Durban/ZA Page 51 of 71

52 Fig. 33: PTFL striated appearance: PD TSE FS Coronal. References: Radiology, Lake,Smit and Partners, St.Augustine's Hospital - Durban/ZA Images for this section: Page 52 of 71

53 Fig. 17: Anterior Inferior Tibiofibular ligament (a)left image :Normal ligament (b) Right image : Complete tear. Page 53 of 71

54 Fig. 18: Varus Valgus Stress test: At rest. Fig. 19: Varus valgus Stress Test: No joint space widening noted during loading in keeping with stability. Page 54 of 71

55 Fig. 20: Syndesmosis stress test: Syndesmosis at rest. Fig. 21: Syndesmosis Stress Test during loading: No widening of syndesmosis noted in keeping with stability. Page 55 of 71

56 Fig. 22: Avulsion Fracture Talus. Page 56 of 71

57 Fig. 23: Varus valgus stress test: at rest. Page 57 of 71

58 Fig. 24: Positive Varus/Valgus Stress: Widened calcaneofibular joint during stress indicating instability. Page 58 of 71

59 Fig. 25: Osteochondral Lesion Talus: PD TSE FS Coronal Page 59 of 71

60 Fig. 26: Bone Bruise Lateral Malleolus: PD TSE FS Coronal Page 60 of 71

61 Fig. 27: Bone Bruise Medial Malleolus: PD TSE FS Coronal Page 61 of 71

62 Fig. 28: Deep Deltoid ligament sprain: PD TSE FS Coronal Page 62 of 71

63 Fig. 29: Sinus Tarsi Sprain: PD TSE FS Sagittal Page 63 of 71

64 Fig. 30: Posterior Synovitis: T1 TSE Axial Page 64 of 71

65 Fig. 31: Anterior and Posterior Synovitis: PD TSE FS Sagittal Page 65 of 71

66 Fig. 32: PTFL striated appearance: PD TSE FS Axial. Page 66 of 71

67 Fig. 33: PTFL striated appearance: PD TSE FS Coronal. Page 67 of 71

68 Conclusion Lateral ankle sprains resulting from inversion injuries account for the majority of sportsrelated injuries to the ankle and are evaluated initially with a clinical assessment and routine ankle radiographs (1). The majority of ankle sprains resolve by being treated conservatively with functional rehabilitation - including bracing. (4) Advanced imaging is rarely indicated in this group (1). More problematic for the athletes and sports physicians is the condition of persistent pain that has not responded to conservative treatment and prevents the patients from returning to sport (1). It is estimated that severe injuries including distal tibiofibular syndesmosis injuries (high ankle sprain) make up between 1-20% of ankle injuries (2). The efficacy of stress radiographs in acute ankle sprains is limited because they are influenced by other factors such as patient pain, oedema, muscle spasm and radiographic technique as well as the difference in the amount of force applied to the joint (10). In addition the traditional radiographic tests do not selectively test the ligaments involved in ankle stability. In terms of the clinical examination, postural control deficits have been identified as a contributing factor to repeated episodes of instability (5). Postural stability testing provides a useful tool for objectively assessing the motor domain of neurologic function (6). The Balance Error Scoring System (BESS) was traditionally used for monitoring recovery from mild head injury. It has provided a useful screening tool following ankle injury (5, 6). Page 68 of 71

69 One possible explanation is that following an inversion stress to the ankle joint, the mechanoreceptors located within the ligaments and joint capsule are stretched. In addition decreased range of movement, pain, decreased strength often present in functionally unstable ankles following lateral sprain and these may contribute to decreased postural control (5). The ultrasound examination provides an anatomical assessment of the lateral ligament complex. Ultrasound also provides a grading of the ligament injury with further assessment of ligament integrity and ankle instability during dynamic imaging of the ankle. Ultrasound can also target specific sites of pain as indicated by the patient and often this correlates the pain to ligament attachments, underlying synovial thickening and subtle bony avulsions. Direct comparison with the opposite ankle can also be made at the time of the ultrasound examination. Ultrasound does have some limitations however, in assessing the lateral ligamentous complex. The different fasciles of the AITFL and ATFL are sometimes difficult to distinguish. The fibular attachment of the CFL is not easily visualized on patients and this visualization can be improved by applying varus stress which straightens the ligament and allows better assessment of the fibular attachment (7). The PTFL is a deeper structure in the ankle and has a striated appearance, and overgrading of the ligament injury as well as assessing the ligament integrity, is also more difficult on ultrasound. In a small number of patients an MRI examination of the ankle should be performed. A reasonable assumption on ultrasound examination and clinical examination is that almost all inversion ankle injuries follow an established injury pattern. The ATFL is the weakest ligament, followed by the CFL and the PTFL (4). Findings that indicate an MRI examination is warranted: Page 69 of 71

70 Suspected syndesmosis injury which has been found to be statistically significant with ATFL injury, bone bruise and fracture, osteochondral fracture and tibiofibular joint incongruity (2). Medial pain - the deltoid ligament, talar dome, spring ligament complex and sinus tarsi are all better assessed on MRI based on the multiplanar imaging and choice of image sequence. Suspected occult fractures. Synovial thickening - MRI demonstrates the relationship and site of synovial thickening in the anterolateral gutter and posterolateral ankle better than ultrasound (1, 8). A lack of joint effusion can make the assessment of the depth of synovial thickening difficult as well as its variable appearance on ultrasound (8). Large joint effusion - this implies more serious internal derangement of the ankle and probable synovitis. Suspected osteochondral injury - plain films can be negative and the talar dome cannot be accurately assessed on ultrasound. CONCLUSION A good clinical examination, including postural deficit testing, supplemented with a dynamic ultrasound examination is adequate in the majority of patients in the further management of the patient with ongoing ankle pain and disability following an inversion sprain. The role of MRI should be limited to assessing the ankle for secondary causes of ankle pain.these include osteochondral injuries, occult fractures, medial ligamentous complex injuries and synovial pathology, including soft tissue impingement. References References 1. Mark. S. Collins: Imaging Evaluation of Chronic Ankle and Hindfoot pain in athletes. Magn. Reson Imaging Clinics of N Am 16(2008) Brown. KW et al: MRI findings associated with distal tibiofibular syndesmosis injuries. AJR (2004) 182 (4) Kiley. D. Perick et al: Appearance of Normal and Injured ligaments. AJR : Scott. E. Campbell et al: MR Imaging of Ankle inversion injuries. Magn. Reson Imaging Clinics of N Am. 16(2008) Page 70 of 71

71 5. Carrie. L. Docherty et al: Postural Control Deficits in participants with functional ankle instability as measured by the Balance Error Scoring System. Clin. J. Sport Med Nov 2006 Volume 16 Issue 3 Pgs Tamerah. N. Hunt et al: The Reliability of the Modified Balance Error Scoring System. Clin. J. Sport Med 2009; 19: S. Bianchi and C. Martinoli: Ultrasound of the Musculoskeletal System. Chapter 16 Ankle: Pgs Springer Melanie. A. Hooper, Philip Robinson: Ankle Impingement Syndromes. Radiol Clin N Am 46 (2008) Stoller. D. W: The Ankle and Foot Chapter 5 in Magnetic Resonance Imaging in Orthopaedics and Sports Medicine, 3rd Ed. Lippincott, Williams and Wilkins. 10. Cheung. Y, Rosenberg. Z. S: MR Imaging of Ligamentous abnormalities of the ankle and foot. Magn Reson Imaging Clin North Am 2001; 9 (3): Cochet. H., Pele. E. et al: Anterolateral Ankle Impingement. Diagnostic Performance of MDCT Arthrography and Sonography. AJR : Personal Information Page 71 of 71