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 Table of Contents  
REVIEW ARTICLE
Year : 2018  |  Volume : 13  |  Issue : 5  |  Page : 43-47

Ultrasound of ankle and foot in rheumatology


Departments of Radiodiagnosis and Rheumatology, Max Superspeciality Hospital, New Delhi, India

Date of Web Publication1-Aug-2018

Correspondence Address:
Dr. Amit Kumar Sahu
Max Superspeciality Hospital, Saket, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0973-3698.238201

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  Abstract 


Ankle and foot are frequent joints to be involved in arthritis. These joints, being superficial in nature, can be easily accessed by ultrasound. Other advantages of ultrasound are its easy availability, portability, and repeatability. Tenosynovitis, synovitis, tendinosis, bursitis, and enthesopathy are common findings in inflammatory arthritis, which can be easily evaluated by ultrasound. Follow-up and treatment response can also be evaluated with less cost to the patient. High-frequency (7–15 MHz) linear probes with availability of color and power Doppler are ideal for scanning the ankle and foot. Systematic evaluation is the primary requirement for a proper assessment. Ankle is evaluated compartment wise with specific positing for anterior, posterior, medial, and lateral compartments. Foot is evaluated according to the midtarsal joints and metatarsophalangeal and interphalangeal joints. Structured base evaluation of the compartments and joints should be done and the pathologies were noted. Thus, ultrasound of the ankle and foot is a very useful and easily available modality for identifying and distinguishing different rheumatological pathologies such as tendinitis, tenosynovitis, synovitis, bursitis, and enthesopathy of the ankle and foot.

Keywords: Ankle, foot, Rheumatology, Synovitis, Tenosynovitis, Ultrasound


How to cite this article:
Sahu AK, Rath PD, Aggarwal B. Ultrasound of ankle and foot in rheumatology. Indian J Rheumatol 2018;13, Suppl S1:43-7

How to cite this URL:
Sahu AK, Rath PD, Aggarwal B. Ultrasound of ankle and foot in rheumatology. Indian J Rheumatol [serial online] 2018 [cited 2021 Dec 9];13, Suppl S1:43-7. Available from: https://www.indianjrheumatol.com/text.asp?2018/13/5/43/238201




  Introduction Top


Ankle and foot are frequently involved in arthritis, though they are more commonly involved in trauma.[1] Because of the complex anatomy of the soft-tissue structures, it is difficult to assess the distribution and localization of the lesion by clinical examination.[2] The clinical examination may also undermine the pathology in case of subclinical stage or if minimally involved by disease process.[2] Radiography is limited by its information on soft tissue as well as bony involvement. Magnetic resonance imaging though has high resolution is limited by real-time examination, expensiveness, and repeatability. Easy availability, portability, and repeatability are the greatest advantages of ultrasound. Apart from being cost-effective, it also has a high sensitivity for detection of soft-tissue abnormalities of ankle and foot.[3]


  Ultrasonography Imaging Characteristics of the Normal Anatomical Structures Top


  • Bony cortex – Hyperechoic and regular with posterior acoustic shadowing [2]
  • Joints – Hypoechoic space between bony cortex and capsule [2]
  • Tendons and Ligaments – Fibrillar pattern on longitudinal scan and punctate pattern on transverse scan [2]
  • Bursae – Usually visualized when distended with fluid and has hyperechoic wall with hypoechoic fluid within them [2]
  • Plantar fascia – Hyperechoic fibrillar band
  • Vessels – Hypoechoic with positive Doppler signal
  • Nerves – Fascicular pattern.



  Indications Top


Rheumatological indications for the ultrasonography (USG) of ankle and foot are:

  • Joint – Effusion, synovitis
  • Tendon – Tenosynovitis, tendinosis, tear, erosion, enthesopathy
  • Bursa – Bursitis
  • Bone – Erosion, osteophytes
  • Others – Subcutaneous nodules, tophus in gout, ganglion cyst.



  Ultrasound Scanning Technique Top


High-quality USG machines equipped with 7–15 MHz linear probes with availability of color and power Doppler are ideal for scanning the ankle and foot.[3],[4] A systematic scanning protocol is recommended to assess the important anatomical structures of anterior, medial, lateral, and posterior ankle compartments and the midtarsal and foot joints using multiplanar and dynamic approach. A gel pad should be created on the examined part and the transducer placed gently so as not to create pressure compression on the examined structures. Routine practice of comparing the same structures with contralateral normal side is advisable.


  Anterior Ankle Top


Ultrasound technique

The patient was seated on examination bed with knee flexed at 45° so that the plantar surface lies flat on the bed. The transducer was kept in axial and longitudinal planes to assess the anterior ankle joint space and the tendons in their full length [Figure 1].
Figure 1: Anterior ankle – The patient was positioned with knee in 45° flexion and plantar surface flat on the examination bed. Long-axis position of the transducer as demonstrated by the box

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Anatomy assessed

  • Anterior tibiotalar joint [Figure 2].
  • Tibialis anterior tendon [Figure 3]
  • Extensor hallucis longus tendon
  • Extensor digitorum longus tendon
Figure 2: Normal anterior ankle showing the distal tibia, the talus, and the anterior tibiotalar joint (arrow)

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Figure 3: Long-axis view of the normal tibialis anterior tendon showing hyperechoic fibrillar pattern

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  Medial Ankle Top


Ultrasound technique

The patient was seated with plantar surface of the foot rolled internally or in a “frog-leg” position. Alternatively, the patient may lie supine with the foot rotated slightly laterally. Place the short axis of transducer behind the medial malleolus and assess the complete length of the medial compartment tendons [Figure 4].
Figure 4: Medial ankle – “Frog-leg” position for assessment of medial ankle placing the transducer inferior to the medial malleolus (box)

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Anatomy assessed

Figure 5: Short-axis oblique view showing the medial compartment tendons of ankle. TPT = Tibialis posterior tendon, FDLT = Flexor digitorum longus tendon, FHLT = Flexor Hallucis longus tendon

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  Lateral Ankle Top


Ultrasound technique

The patient was seated with knee flexed at 45° and the leg slightly tilted medially. Place the short axis of transducer behind the lateral malleolus and assess the complete length of the peroneal tendons [Figure 6].
Figure 6: Lateral ankle – Medial tilt of the leg for assessment of lateral ankle placing the transducer inferior to the lateral malleolus (box)

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Anatomy assessed

Figure 7: Short-axis view of peroneus longus tendon (PLT) and peroneus brevis tendon (PBT) in the lateral compartment of ankle

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  Posterior Ankle Top


Ultrasound technique

The patient was in prone position, with the foot hanging freely at the end of the examination bed [Figure 8]. Place the transducer over the Achilles tendon in short axis and assess the full length of the tendon up to the myotendinous junction. Turn the transducer into long axis to assess the tendon attachment to calcaneum.
Figure 8: Posterior ankle – Prone position of the patient with foot hanging at the end of the examination bed. Transducer position over the Achilles tendon (blue box) and over the plantar fascia (black box)

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Anatomy assessed

  • Achilles tendon [Figure 9]
  • Kager's fat pad
  • Posterior aspects of tibiotalar joint and talocalcaneal joint
  • Plantar fascia.
Figure 9: Long-axis (a) and short-axis (b) views of the normal Achilles tendon showing normal echogenic fibrillar pattern

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  Examination of Foot Top


Ultrasound technique

The patient position is the same as in assessing the anterior ankle, that is, the patient was seated on examination bed with knee flexed at 45°, so that the plantar surface lies flat on the bed [Figure 10]. Multiplanar assessment of the foot joints is performed by placing the transducer in short axis and long axis.[2]
Figure 10: The patient was positioned with knee 45° flexion and plantar surface flat on the examination bed for assessment of mid tarsal joints (blue box) and metatarsophalangeal joint (black box)

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Anatomy assessed

  • Mid tarsal joints
  • Metatarsophalangeal joints
  • Interphalangeal joints.



  Pathologies Top


Joint effusion

Anechoic fluid distension of the joint is compressible by the traducer during dynamic examination.[2],[3] [Figure 11]. Normal amount of fluid is present in the ankle joint. When the anterior–posterior dimension of the fluid pocket in anterior ankle recess is >3 mm, it is pathological.[5]
Figure 11: Joint effusion – Fluid is seen in the anterior tibiotalar joint space (arrow)

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Synovitis

When the intra-articular tissue shows soft-tissue thickening, echogenicity and is less compressible or noncompressible.[2] It may show power Doppler signal, suggesting activity.

Tenosynovitis

Thickening of the tendon with decreased echogenicity and loss of normal fibrillar pattern. There may be thickening of the tendon sheath with the presence of surrounding fluid and may also show power Doppler signal [Figure 12] and [Figure 13].[3]
Figure 12: Posterior tibial tendon is thickened with an interstitial split (arrow in [a]) and high-grade-power Doppler signal (b) suggesting tendinosis with tear

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Figure 13: Achilles tendinosis – Long-axis view of Achilles tendon showing thickening at its calcaneal attachment (arrow) with loss of normal fibrillar pattern

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Bursitis

Fluid distension of the bursa with or without septations and echogenicity [Figure 14]. Peripheral and internal power Doppler signal may also be exhibited.
Figure 14: Bursitis – Fluid distended bursa over lateral malleolus showing internal septae and echogenicity

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Enthesopathy

Thickening of tendon at its bony attachment with loss of normal fibrillar pattern and decreased echogenicity. There may also be the presence of enthesophytes and power Doppler signal too.

Plantar fasciitis

Thickening of the plantar fascia (>4 mm) at its calcaneal attachment with decreased echogenicity and occasional power Doppler signal [Figure 15].[5]
Figure 15: Plantar fasciitis – Diffusely thickened plantar fascia (long axis) with decreased echogenicity

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Gout

It is commonly seen at the first metatarsophalangeal joint in the form of bone erosions, synovial thickening, echogenic synovium with tophus, and power Doppler signal [Figure 16]. Other joints of the foot and ankle may also be involved.
Figure 16: Gout – Long axis (a) and short axis (b) of first metatarsal showing erosion in the metatarsal head as focal breaks in cortical hyperechoic outline seen in two perpendicular planes, with overhanging edge in the subarticular location (arrows) with adjacent synovitis (arrowheads)

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  Conclusion Top


Ultrasound of the ankle and foot is very useful and easily available modality for identifying and distinguishing different rheumatological pathologies such as tendinitis, tenosynovitis, synovitis, bursitis, and enthesopathy of the ankle and foot.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
De Maeseneer M, Marcelis S, Jager T, Shahabpour M, Van Roy P, Weaver J, et al. Sonography of the normal ankle: A target approach using skeletal reference points. AJR Am J Roentgenol 2009;192:487-95.  Back to cited text no. 1
    
2.
Micu MC, Nestorova R, Petranova T, Porta F, Radunovic G, Vlad V, et al. Ultrasound of the ankle and foot in rheumatology. Med Ultrason 2012;14:34-41.  Back to cited text no. 2
    
3.
Park JW, Lee SJ, Choo HJ, Kim SK, Gwak HC, Lee SM, et al. Ultrasonography of the ankle joint. Ultrasonography 2017;36:321-35.  Back to cited text no. 3
    
4.
Beggs I, Bianchi S, Bueno A, Cohen M, Court-Payen M, Grainger A, et al. European society of musculoskeletal radiology. Ankle. Musculoskeletal Technical Guidelines. VI. 2016.  Back to cited text no. 4
    
5.
Fessell DP, Vanderschueren GM, Jacobson JA, Ceulemans RY, Prasad A, Craig JG, et al. US of the ankle: Technique, anatomy, and diagnosis of pathologic conditions. Radiographics 1998;18:325-40.  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14], [Figure 15], [Figure 16]



 

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  In this article
Abstract
Introduction
Ultrasonography ...
Indications
Ultrasound Scann...
Anterior Ankle
Medial Ankle
Lateral Ankle
Posterior Ankle
Examination of Foot
Pathologies
Conclusion
References
Article Figures

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