Patterns of ankle injury in soccer: MRI clues to traumatic mechanism

Understanding the traumatic mechanisms of ankle injuries in soccer is crucial for an accurate and complete MRI diagnosis. Many ankle injuries share universal mechanisms seen in other athletic activities, but certain patterns are found to be more specific and relatively unique to soccer. Ankle impingement syndromes encountered in soccer encompass a spectrum of disorders that include anterior and posterior impingement categories, with anterior impingement representing pathology relatively specific to soccer. Lateral ligamentous sprains are one of the most common injuries; however, there is a higher rate of injuries to the medial structures in soccer as compared to other sports. Ankle fractures are uncommon in soccer while bone contusions and chondral and osteochondral injuries frequently accompany ligamentous sprains. Tendon abnormalities in soccer most commonly result from overuse injuries and typically affect peroneal tendons, posterior and anterior tibialis tendons, and Achilles tendon. Acute Achilles tendon ruptures occur in both recreational players and elite soccer athletes. Tibialis anterior friction syndrome may mimic tibial stress fractures. Long-term sequelae of acute traumatic and chronic overuse ankle injuries in professional soccer players manifest as ankle osteoarthritis that is more prevalent compared to not only the general population, but also to former elite athletes from other sports. This article examines the most common and specific injuries in soccer in order of their frequency.

Update on Ankle and Foot Impingement

Ankle impingement syndromes are a well-recognized cause of chronic ankle symptoms in both the elite athletic and general population. They comprise several distinct clinical entities with associated radiologic findings. Originally described in the 1950s, advances in magnetic resonance imaging (MRI) and ultrasonography have allowed musculoskeletal (MSK) radiologists to further their understanding of these syndromes and the range of imaging-associated features. Many subtypes of ankle impingement syndromes have been described, and precise terminology is critical to carefully separate these conditions and thus guide treatment options. These are divided broadly into intra-articular and extra-articular types, as well as location around the ankle. Although MSK radiologists should be aware of these conditions, the diagnosis remains largely clinical, with plain film or MRI used to confirm the diagnosis or assess a surgical/treatment target. The ankle impingement syndromes are a heterogeneous group of conditions, and care must be taken not to overcall findings. The clinical context remains paramount. Treatment considerations are patient symptoms, examination, and imaging findings, in addition to the patient's desired level of physical activity.

Ankle Impingement: A Critical Analysis Review

Ankle impingement presents with painful and limited range of motion with dorsiflexion or plantar flexion, originating from pathological contact between bone and/or soft-tissue structures. Diagnosis is made primarily through clinical examination with adjunct radiographs and magnetic resonance imaging, with care taken to rule out a plethora of similarly presenting pathologies. Arthroscopic surgical approaches bring satisfactory short, mid, and long-term outcomes, with the current body of evidence dominated by Level-IV studies. Minimally invasive techniques offer improvements in time to return to play and complication rates relative to open approaches. Recent advances in the arthroscopic management of ankle impingement include long-term outcome studies, novel prognostic classification systems, and strategies for concomitant lesion management.

Combined Anterolateral, Anterior, and Anteromedial Ankle Impingement in an Adolescent Soccer Player: A Case Report and Review of the Literature

A unique case of combined anterolateral, anterior, and anteromedial ankle impingement in an adolescent soccer player is presented in this article. To the best of our knowledge, this is the only report of circumferential, massive, anterior ankle impingement in children described in the literature. The importance of proper diagnosis and treatment of such a lesion is illustrated in this case report. We also emphasize that clinical examination combined with 3D computed tomography scan reconstruction is an excellent and cost-effective imaging modality that can help with the diagnosis of anterior ankle impingement. Finally, open surgical treatment showed excellent results in an elite athlete.

Anatomy of the ankle capsule: A cadaveric study

Although bony and ligamentous injuries of the ankle are well understood, little is known about the degree to which injury of the ankle capsule can be a component of such injuries. The purpose of this study was to determine the dimensions of the ankle capsule and its relationship to adjacent structures. Thirteen fresh-frozen ankle specimens were systematically dissected. Methylene blue solution was injected to identify the dimensions of the ankle capsule. External dimensions were measured as the distance from the capsular reflection to the bony margin of the ankle. Internal dimensions were measured as the distance from the capsular attachment of the distal tibia, fibula, and talus to the cartilage margin. The anterior aspect of the capsule demonstrated the most proximal capsular reflection in all specimens. The most proximal reflections of the anteromedial, anterior middle and anterolateral capsule were 10.3, 13.5, and 9.8 mm, respectively. The most proximal reflections of the posteromedial, posterior middle and posterolateral region were 8.7, 6.2, and 3.5 mm, respectively. There was no capsular reflection over the medial malleolus and less than 1 mm over the posterior lateral malleolus. There was a confluence of the capsule and ligamentous complex on the medial side, and also with the transverse tibiofibular ligament about the posterolateral ankle. The most proximal attachment of the ankle capsule was located at the anterior aspect of the distal tibia. The medial and posterolateral capsules were confluent with the ligamentous complexes of the ankle in those regions. Clin. Anat. 31:1018-1023, 2018. © 2018 Wiley Periodicals, Inc.

Prevalence and location of bone spurs in anterior ankle impingement: A cadaveric investigation

Anterior ankle impingement (AAI) results from repetitive microtrauma leading to pain and decreased dorsiflexion due to spur formation and synovial hypertrophy. Information about the prevalence of anterior spur formation in a large population, and the individual contributions of the talus and tibia to osseous impingement, is limited. A total of 670 ankle specimens from 344 individuals (n = 111 females, n = 233 males) aged 20 to 40 years at the time of death were examined. Matching tibia and talus were opposed and any spurring causing impingement was recorded. Spur locations were measured and ratios calculated to allow for inter-specimen comparison between: (1) medial-to-lateral and anterior-to-posterior spur location versus dimensions of talar neck width, and (2) medial-to-lateral spur location to dimensions of distal anterior tibial width. Differences in spur prevalence in relation to sex, race, height and age were identified by univariant and multivariable statistical analyses. Bony impingement was observed in 21% (n = 72) of specimens, with bilateral involvement in 8% (n = 27). For ankles with AAI, spurs were seen on the talus only in 61%, on the tibia only in 14%, and on both the tibia and talus in 26%. Spurs were significantly more prevalent in males (P = 0.001) and with increasing specimen age (P = 0.002). There were no significant differences related to specimen height or race. Spurs were predominately located on the anterolateral talus (78%) and the anterolateral portion of the distal tibial margin (80%). AAI was present in 21% of young osseous specimens and was significantly more prevalent in males and with increasing specimen age. Clin. Anat. 31:1144-1150, 2018. © 2018 Wiley Periodicals, Inc.

Arthroscopic debridement of anterior ankle impingement in patients with chronic lateral ankle instability

BACKGROUND

The aim of this study was to determine the functional and radiological outcomes of arthroscopic treatment of anterior ankle impingement (AAI) in patients with chronic lateral ankle instability (CAI).

METHODS

All patients with CAI between June 2012 and May 2015 were invited to participate in this investigation. All of them accepted open modified Broström repair of lateral ankle ligaments and were divided into two groups: AAI group (with anterior ankle impingement) and pure CAI group (without anterior ankle impingement). All of them were followed up using American Orthopaedic Foot and Ankle Society Score (AOFAS), Karlsson Ankle Functional Score and Tegner activity score. Ankle dorsiflexion was also examined. X-ray examination was applied to investigate anterior tibiotalar osteophytes.

RESULTS

Finally, a total of 60 patients were followed up at a mean of 37 ± 10 months, including 22 patients in the AAI group and 38 patients in the pure CAI group. Preoperatively, the AAI group had significant lower AOFAS score (62.9 ± 11.7 vs 72.9 ± 11.1; p = 0.002) and Tegner activity score (1.5 ± 0.8 vs 2.1 ± 1.0; p = 0.04) respectively when compared with the pure CAI group. The ankle dorsiflexion of the AAI group (13 ± 2.1) was also significantly lower than that of the pure CAI group (26.2 ± 2.1) (p = 0.001). However, there was no significant difference in the AOFAS score or the Karlsson score or the Tegner score or the Ankle dorsiflexion between the two groups postoperatively. The postoperative X-ray images demonstrated complete osteophyte resection in all patients, and no recurrence of osteophyte.

CONCLUSION

The functional outcome scores and dorsiflexion had significantly improved postoperatively. Combined treatment of chronic ankle instability and anterior ankle impingement produced satisfactory surgical outcomes in patients with CAI accompanied by anterior ankle impingement symptom.

MR Imaging of Impingement and Entrapment Syndromes of the Foot and Ankle

Impingement is a clinical syndrome of chronic pain and restricted range of movement caused by compression of abnormal bone or soft tissue within the ankle joint. It usually occurs following a sprain injury or repetitive microtrauma causing haemorrhage, synovial hyperplasia, and abnormal soft tissue interposition within the joint. MR imaging is particularly valuable in being able to detect not only the soft tissue and osseous abnormalities involved in these syndromes, but also a wide variety of other potential causes of ankle pain and instability that also may need to be addressed clinically.

Heterotopic ossification after total ankle replacement: The role of prosthesis alignment

BACKGROUND

The aetiology of heterotopic ossifications (HO) after total ankle arthroplasty (TAR) remains controversial. The aim of the study was to evaluate the prevalence and localisation of HO and the effect of alignment.

METHODS

88 TARs with a series of radiological controls and follow-up of 36 months were evaluated. Frontal and sagittal alignment parameters (alfa and beta angle defined by Hintermann) and tibial coverage were evaluated.

RESULTS

The prevalence and grading of HO increased over time, mostly in the posterior gutter. Varus alignment correlated with HO increase in the ventral and lateral gutters the first year. A dorsally located rotational centre correlated with total HO growth and HO in the posterior gutter. These correlations were not detected after 3 years, as HO were seen in all prostheses, regardless of alignment.

CONCLUSIONS

HO grow over time with a prevalence up to 100% after 3 years. TAR alignment correlates with gutter-specific HO formation within the first year.

Ankle impingement

Ankle impingement is a syndrome that encompasses a wide range of anterior and posterior joint pathology involving both osseous and soft tissue abnormalities. In this review, the etiology, pathoanatomy, diagnostic workup, and treatment options for both anterior and posterior ankle impingement syndromes are discussed.

Accessory Anterolateral Talar Facet in Populations With and Without Symptoms: Prevalence and Relevant Associated Ankle MRI Findings

OBJECTIVE

The purpose of this study was to determine the prevalence of and relevant findings associated with the accessory anterolateral talar facet, which may have a role in talocalcaneal impingement and sinus tarsi syndrome, on ankle MR images of persons with and those without symptoms.

SUBJECTS AND METHODS

In this case-control study, three observers independently reviewed 1.5-T or 3-T MR images of 110 ankles with symptoms in 100 consecutively registered patients (age range, 16-79 years; mean, 41.5 years) and limited 1.5-T MR images of 104 age-, sex-, and side-matched ankles in 104 volunteers without symptoms for the presence of an accessory anterolateral talar facet, calcaneal cortical thickness, subjacent talar or calcaneal cystic and bone marrow edema-like changes at the angle of Gissane, and sinus tarsi fat obliteration.

RESULTS

An accessory anterolateral talar facet was present in 36 (32.7%) ankles with symptoms versus 27 (26.0%) symptom-free ankles (p = 0.297). Interobserver agreement was almost perfect (κ = 0.851; 95% CI, 0.772-0.929) for the detection of accessory anterolateral talar facet and substantial for the detection of sinus tarsi fat obliteration (κ = 0.671; 95% CI, 0.427-0.915). The angle of Gissane was significantly smaller in persons with an accessory anterolateral talar facet, either with or without symptoms (p < 0.0001). Subjacent talar (p = 0.003) and calcaneal (p = 0.033) bone marrow edema-like change and sinus tarsi fat obliteration (p = 0.034) were significantly more frequent in persons with accessory anterolateral talar facet, but chronic reactive osseous changes at the angle of Gissane were not (p > 0.05).

CONCLUSION

The higher prevalence of the MRI finding of an accessory anterolateral talar facet in ankles with symptoms is not statistically significant. This facet may be associated with subjacent talar bone marrow edema-like change on MR images of individuals with and those without symptoms and with sinus tarsi fat obliteration in individuals with symptoms.

Incidence of Intracapsular Placement When Inserting Medial Talar Body Schanz Pins: An Anatomic Study

OBJECTIVES

Medial talar body pins may be inserted to provide points of fixation in the hindfoot when applying external fixators. Because of the proximity to the ankle joint, there is a risk of intracapsular pin placement. We hypothesized that intracapsular placement is common when inserting medial talar body pins.

METHODS

Medial talar body pins were inserted in 12 fresh frozen cadaver ankles. Arthrography of each ankle was then performed to determine whether the pin was intracapsular. Each pin was then removed, and fluoroscopy was repeated to evaluate for contrast extravasation from the pin insertion site. The distance from the apex of the talar head to the anterior extent of the ankle capsule was measured to determine a safe area for extracapsular pin placement.

RESULTS

Arthrograms of all 12 ankles demonstrated that the pins were intracapsular. After pin removal, there was contrast extravasation from the pin insertion site in all specimens. Contrast was present in the pin tract in all specimens. Mean distance from the talar head to the anterior ankle capsule was 20.95 ± 4.8 mm (range, 12.2-27.3 mm) on the lateral view and 15.5 ± 1.8 mm (range, 12.4-20.0 mm) on the anteroposterior view of the foot.

CONCLUSIONS

There is a high rate of intracapsular pin placement when inserting medial talar body pins. Pin placement within the joint capsule risks seeding a sterile joint with bacteria and fistula formation when the pin remains in place for prolonged periods. For this reason, talar body pins should be avoided in temporizing external fixation frames.

Arthroscopic treatment of anterior ankle impingement: a prospective study of 46 patients with 5-year follow-up

BACKGROUND

Midterm outcomes after arthroscopic debridement in patients with anterior ankle impingement without osteoarthritis are currently unclear.

PURPOSE

To assess the functional and radiological outcomes after arthroscopic treatment of anterior ankle impingement with a minimum 5-year follow-up in patients without osteoarthritis.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

From September 1999 to March 2006, a consecutive series of eligible patients without ankle osteoarthritis and with anterior ankle impingement, who had persistent ankle pain and activity restrictions despite at least 6 months of nonoperative management, underwent standardized arthroscopic debridement and followed uniform postoperative management. Patients were assessed preoperatively and at 6 weeks, 6 months, and 12 months and then at 1-year intervals after surgery until a minimum of 5 years' follow-up had been achieved, with weightbearing ankle dorsiflexion, Foot Functional Index (FFI), and plain radiography including Scranton and McDermott classification (SMC) grade and tibial osteophyte size.

RESULTS

A total of 46 patients (42 male, 4 female) were prospectively assessed, with a mean age at surgery of 29 years (range, 16-44 years) and a mean follow-up duration of 5.1 years (range, 5.0-7.5 years). Preoperative ankle radiographs demonstrated a median SMC grade of 2 and a mean tibial osteophyte size of 5.1 mm. At a minimum of 5 years postoperatively, patients demonstrated limited improvement in ankle dorsiflexion (mean, 24.7° [preoperatively] vs 27.0° [final follow-up]; P = .049); however, they demonstrated substantial improvement in the FFI (mean, 20.5 [preoperatively] vs 2.7 [final follow-up]; P < .001). Postoperatively, 84% of patients showed a recurrence of radiological osteophytes, with plain radiographs at final follow-up demonstrating no significant difference in the SMC grade (P = .107) or tibial osteophyte size (P = .212) compared with preoperative imaging. There was no significant effect of patient age, sex, body mass index, or SMC grade at the time of surgery on any of the postoperative outcome measures.

CONCLUSION

In this prospective outcome study of 46 patients without osteoarthritis managed arthroscopically for anterior ankle impingement, the functional outcome scores had significantly improved at 5 years postoperatively despite a recurrence of radiographic osteophytes.

Arthroscopic treatment of ankle anterior bony impingement: the long-term clinical outcome

BACKGROUND

Arthroscopic treatment of anterior ankle bony impingement provides good results, with a tendency to decrease over time. The purpose of this study was to analyze the factors affecting long-term results.

METHODS

Eighty consecutive patients with a mean age of 37.3 years were treated between 2000 and 2004. Impingement lesions were identified according to Scranton-McDermott classification. Preoperative ankle osteoarthritis was documented by van Dijk scale upon the x-rays. Bone spurs were analyzed and classified according to location and size. The associated chondral lesions were classified following the International Cartilage Repair Society (ICRS) criteria. Patient data, foot morphology, and previous traumas were recorded. Patients were evaluated after a mean of 104.6 months follow-up with the American Orthopaedic Foot and Ankle Society (AOFAS) scale. The influence of different factors on outcomes was statistically analyzed.

RESULTS

The mean preoperative AOFAS score was 50.9, while at follow-up it was 70.7 (P < .05). The different grades of Scranton-McDermott impingement classification did not affect the results, but the different grades of van Dijk scale significantly affected the result but not the preoperative stage. Tibial localized spurs had better outcome at follow-up. The grade of the chondral lesions significantly affected the outcome. Other factors negatively affecting the results were age, cavus foot morphology, and history of previous ankle fracture.

CONCLUSION

Arthroscopic treatment provides overall good results, but the long-term presence of associated conditions such as chondral lesions, advanced age, and previous trauma are relevant as prognostic factors. Based on these results, a new classification for bony impingement syndrome system is proposed.

LEVEL OF EVIDENCE

Level IV, case series.

Anterior ankle impingement after tendo-Achilles lengthening for long-standing equinus deformity in residual poliomyelitis

BACKGROUND

This study was performed to investigate anterior ankle impingement after tendo-Achilles lengthening for long-standing equinus deformity in patients with residual poliomyelitis and to investigate whether the severity of preoperative equinus deformity affected the occurrence of symptomatic anterior impingement.

METHODS

Twenty-seven consecutive patients (mean age, 43.8 ± 9.4 years) with residual poliomyelitis who underwent tendo-Achilles lengthening for equinus foot deformity were included. On lateral foot-ankle weight-bearing radiographs, the tibiocalcaneal angle, plantigrade angle, and McDermott grade were measured and the presence of anterior blocking spur was evaluated.

RESULTS

Eleven patients (40.7%) had anterior ankle impingement on radiographic findings preoperatively and 24 patients (88.9%) at latest follow-up. There was a significant difference in McDermott grade between preoperative and latest follow-up (P < .001). There were significant differences in tibiocalcaneal angle and plantigrade angle between the patients with anterior ankle pain and without anterior ankle pain (P = .006 and .011, respectively) and between the patients with anterior blocking spur and without anterior blocking spur (P = .005 and .010, respectively).

CONCLUSIONS

Most patients with residual poliomyelitis had anterior ankle impingement after tendo-Achilles lengthening for long-standing equinus deformity, and the presence of symptomatic anterior ankle impingement was significantly associated with the severity of the equinus deformity. Therefore, for residual poliomyelitis patients with severe long-standing equinus deformity, surgeons should consider the possibility of a subsequent anterior procedure for anterior impingement after tendo-Achilles lengthening.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

A new osteophyte segmentation algorithm using partial shape model and its applications to rabbit femur anterior cruciate ligament transection via micro-CT imaging

Osteophyte is an additional bony growth on a normal bone surface limiting or stopping motion at a deteriorating joint. Detection and quantification of osteophytes from CT images is helpful in assessing disease status as well as treatment and surgery planning. However, it is difficult to distinguish between osteophytes and healthy bones using simple thresholding or edge/texture features due to the similarity of their material composition. In this paper, we present a new method primarily based active shape model (ASM) to solve this problem and evaluate its application to anterior cruciate ligament transection (ACLT) rabbit femur model via CT imaging. The common idea behind most ASM based segmentation methods is to first build a parametric shape model from a training dataset and apply the model to find a shape instance in a target image. A common challenge with such approaches is that a diseased bone shape is significantly altered at regions with osteophyte deposition misguiding an ASM method and eventually leading to suboptimum segmentations. This difficulty is overcome using a new partial ASM method that uses bone shape over healthy regions and extrapolates it over the diseased region according to the underlying shape model. Finally, osteophytes are segmented by subtracting partial-ASM derived shape from the overall diseased shape. Also, a new semi-automatic method is presented in this paper for efficiently building a 3D shape model for an anatomic region using manual reference of a few anatomically defined fiducial landmarks that are highly reproducible on individuals. Accuracy of the method has been examined on simulated phantoms while reproducibility and sensitivity have been evaluated on CT images of 2-, 4- and 8-week post-ACLT and sham-treated rabbit femurs. Experimental results have shown that the method is highly accurate ( R2 = 0.99), reproducible (ICC = 0.97), and sensitive in detecting disease progression (p-values: 0.065,0.001 and < 0.001 for 2- vs. 4, 4- vs. 8- and 2- vs. 8-weeks, respectively).

Proximal tibial osteophytes and their relationship with the height of the tibial spines of the intercondylar eminence: paleopathological study

OBJECTIVE

Tibial spiking (i.e., spurring of tibial spines), eburnation, and osteophytes are considered features of osteoarthritis. This investigation employed direct inspection of the medial and lateral tibial plateaus in paleopathological specimens to analyze the frequency and morphological features of osteoarthritis and to define any relationship between the size of osteophytes and that of the intercondylar tibial spines.

MATERIALS AND METHODS

A total of 35 tibial bone specimens were evaluated for the degree of osteoarthritis and presence of eburnation. Each plateau was also divided into four quadrants and the presence and size of bone outgrowths were recorded in each quadrant. The "medial/lateral tibial intercondylar spine index" for each specimen was calculated as follows: (medial/lateral intercondylar tibial spine height)/(anteroposterior width of the superior tibial surface). The relationships between medial and lateral tibial height indexes with the degree of osteoarthritis were then tested.

RESULTS

Osteophytes were observed more frequently in the anterior quadrants of both tibial plateaus than in the posterior quadrants (29 vs 16 for the medial tibial plateau [p = 0.01] and 28 vs 20 for the lateral tibial plateau [p = 0.04]). Eburnation was seen more frequently in the posterior regions of both tibial plateaus than in the anterior regions (17 vs 5, p < 0.01). In specimens with no signs of osteoarthritis the lateral intercondylar tibial index was significantly lower than that in specimens with some degree of osteoarthritis (p = 0.02). The medial intercondylar tibial index of the specimens with no signs of osteoarthritis was not significantly different from that of the specimens with some degree of osteoarthritis (p = 0.45). There was a positive correlation between the lateral spine height index and the overall grading of osteoarthritis, (r = 0.6, p < 0.01). In the anteromedial and posteromedial quadrants of the lateral tibial plateau, the association between the lateral intercondylar tibial spine index and the grade of osteophytes was 0.5 (p < 0.01) and 0.7 (p < 0.01) respectively.

CONCLUSION

Spiking of the lateral tibial intercondylar spine is associated with osteophyte formation and osteoarthritis. Eburnation occurs mainly in the posterior parts of the tibial plateaus while osteophytes arise mainly in the anterior parts. These findings suggest that stresses occurring in the flexed knee may contribute to many of the morphological abnormalities of osteoarthritis.