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Mostovoy A, Chang T. Peroneal Pathology in the Athlete. Clin Podiatr Med Surg 2023; 40:139-155. [PMID: 36368839 DOI: 10.1016/j.cpm.2022.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
The peroneal tendons play a critical role in stabilizing the foot and ankle especially in athletes with high demands on lateral ankle strength. A complete understanding of the anatomy of the lateral ankle as well as a careful physical examination is imperative to diagnosing peroneal pathology, which is commonly misdiagnosed and can lead to chronic pain and inability to perform high level sport. Although low-demand patients do well with a conservative approach, most high-demand athletes will benefit from surgical intervention.
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Affiliation(s)
- Amelia Mostovoy
- St. Mary's Medical Center, Graduate Medical Office, 450 Stanyan Street, San Francisco, CA 94117, USA.
| | - Thomas Chang
- Redwood Orthopedic Surgery Associates, 208 Concourse Boulevard #1, Santa Rosa, CA 95403, USA
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2
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Sconfienza LM, Adriaensen M, Albano D, Alcala-Galiano A, Allen G, Aparisi Gómez MP, Aringhieri G, Bazzocchi A, Beggs I, Chianca V, Corazza A, Dalili D, De Dea M, Del Cura JL, Di Pietto F, Drakonaki E, Facal de Castro F, Filippiadis D, Gitto S, Grainger AJ, Greenwood S, Gupta H, Isaac A, Ivanoski S, Khanna M, Klauser A, Mansour R, Martin S, Mascarenhas V, Mauri G, McCarthy C, McKean D, McNally E, Melaki K, Messina C, Mirón Mombiela R, Moutinho R, Olchowy C, Orlandi D, Prada González R, Prakash M, Posadzy M, Rutkauskas S, Snoj Ž, Tagliafico AS, Talaska A, Tomas X, Vasilevska Nikodinovska V, Vucetic J, Wilson D, Zaottini F, Zappia M, Obradov M. Clinical indications for image-guided interventional procedures in the musculoskeletal system: a Delphi-based consensus paper from the European Society of Musculoskeletal Radiology (ESSR)-part VI, foot and ankle. Eur Radiol 2021; 32:1384-1394. [PMID: 34432122 PMCID: PMC8794903 DOI: 10.1007/s00330-021-08125-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2021] [Accepted: 06/07/2021] [Indexed: 01/10/2023]
Abstract
Objectives Clarity regarding accuracy and effectiveness for interventional procedures around the foot and ankle is lacking. Consequently, a board of 53 members of the Ultrasound and Interventional Subcommittees of the European Society of Musculoskeletal Radiology (ESSR) reviewed the published literature to evaluate the evidence on image-guided musculoskeletal interventional procedures around this anatomical region. Methods We report the results of a Delphi-based consensus of 53 experts from the European Society of Musculoskeletal Radiology who reviewed the published literature for evidence on image-guided interventional procedures offered around foot and ankle in order to derive their clinical indications. Experts drafted a list of statements and graded them according to the Oxford Centre for evidence-based medicine levels of evidence. Consensus was considered strong when > 95% of experts agreed with the statement or broad when > 80% but < 95% agreed. The results of the Delphi-based consensus were used to write the paper that was shared with all panel members for final approval. Results A list of 16 evidence-based statements on clinical indications for image-guided musculoskeletal interventional procedures in the foot and ankle were drafted after a literature review. The highest level of evidence was reported for four statements, all receiving 100% agreement. Conclusion According to this consensus, image-guided interventions should not be considered a first-level approach for treating Achilles tendinopathy, while ultrasonography guidance is strongly recommended to improve the efficacy of interventional procedures for plantar fasciitis and Morton’s neuroma, particularly using platelet-rich plasma and corticosteroids, respectively. Key Points • The expert panel of the ESSR listed 16 evidence-based statements on clinical indications of image-guided musculoskeletal interventional procedures in the foot and ankle. • Strong consensus was obtained for all statements. • The highest level of evidence was reached by four statements concerning the effectiveness of US-guided injections of corticosteroid for Morton’s neuroma and PRP for plantar fasciitis. Supplementary Information The online version contains supplementary material available at 10.1007/s00330-021-08125-z.
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Affiliation(s)
- Luca Maria Sconfienza
- Unit of Diagnostic and Interventional Radiology, IRCCS Istituto Ortopedico Galeazzi, Via Riccardo Galeazzi 4, 20161, Milan, Italy. .,Dipartimento di Scienze Biomediche per la Salute, Università degli Studi di Milano, Milan, Italy.
| | - Miraude Adriaensen
- Department of Medical Imaging, Zuyderland Medical Center, Sittard-Geleen, Heerlen, Brunssum, Kerkrade, the Netherlands
| | - Domenico Albano
- Unit of Diagnostic and Interventional Radiology, IRCCS Istituto Ortopedico Galeazzi, Via Riccardo Galeazzi 4, 20161, Milan, Italy.,Sezione di Scienze Radiologiche, Dipartimento di Biomedicina, Neuroscienze e Diagnostica Avanzata, Università degli Studi di Palermo, Palermo, Italy
| | | | - Georgina Allen
- St Luke's Radiology Oxford Ltd, Oxford, UK.,University of Oxford, Oxford, UK
| | - Maria Pilar Aparisi Gómez
- Department of Radiology, Auckland City Hospital, Auckland, New Zealand.,Department of Radiology, Hospital Vithas Nueve de Octubre, Valencia, Spain
| | - Giacomo Aringhieri
- Diagnostic and Interventional Radiology, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Alberto Bazzocchi
- Diagnostic and Interventional Radiology, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
| | | | - Vito Chianca
- Ospedale Evangelico Betania, Napoli, Italy.,Clinica di Radiologia EOC IIMSI, Lugano, Switzerland
| | - Angelo Corazza
- Unit of Diagnostic and Interventional Radiology, IRCCS Istituto Ortopedico Galeazzi, Via Riccardo Galeazzi 4, 20161, Milan, Italy
| | - Danoob Dalili
- School of Biomedical Engineering & Imaging Sciences, King's College London, London, UK
| | | | | | - Francesco Di Pietto
- Dipartimento di Diagnostica per Immagini, Pineta Grande Hospital, Castel Volturno, Italy
| | | | | | - Dimitrios Filippiadis
- 2nd Department of Radiology, University General Hospital "ATTIKON" Medical School, National and Kapodistrian University of Athens, Haidari, Athens, Greece
| | - Salvatore Gitto
- Dipartimento di Scienze Biomediche per la Salute, Università degli Studi di Milano, Milan, Italy
| | | | | | | | - Amanda Isaac
- School of Biomedical Engineering & Imaging Sciences, King's College London, London, UK.,Guy's and St Thomas' Hospitals, London, UK
| | - Slavcho Ivanoski
- Department of Radiology, Special Hospital for Orthopedic Surgery and Traumatology, St. Erazmo -, Ohrid, North Macedonia.,Ss. Cyril and Methodius University of Skopje, Skopje, North Macedonia
| | | | - Andrea Klauser
- Department of Radiology, Medical University Innsbruck, Innsbruck, Austria
| | - Ramy Mansour
- Oxford Musculoskeletal Radiology, Oxford University Hospitals, Oxford, UK
| | | | - Vasco Mascarenhas
- Hospital da Luz, Musculoskeletal Imaging Unit, Lisbon, Portugal.,AIRC, Advanced Imaging Research Consortium, Lisbon, Portugal
| | - Giovanni Mauri
- Division of Interventional Radiology, Istituto Europeo di Oncologia, Milan, Italy.,Department of Oncology and Hemato-Oncology, University of Milano, Milan, Italy
| | | | - David McKean
- Buckinghamshire Healthcare NHS Trust, Aylesbury, UK
| | | | - Kalliopi Melaki
- Department of Radiology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Carmelo Messina
- Unit of Diagnostic and Interventional Radiology, IRCCS Istituto Ortopedico Galeazzi, Via Riccardo Galeazzi 4, 20161, Milan, Italy
| | | | - Ricardo Moutinho
- Hospital da Luz, Musculoskeletal Imaging Unit, Lisbon, Portugal.,Hospital de Loulé, Loulé, Portugal
| | - Cyprian Olchowy
- Department of Oral Surgery, Wroclaw Medical University, Wroclaw, Poland
| | - Davide Orlandi
- Department of Radiology, Ospedale Evangelico Internazionale, Genoa, Italy
| | | | - Mahesh Prakash
- Post Graduate Institute of Medical Education & Research (PGIMER), Chandigarh, India
| | | | - Saulius Rutkauskas
- Department of Radiology, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Žiga Snoj
- Institute of Radiology, University Medical Centre Ljubljana, Zaloska 7, 1000, Ljubljana, Slovenia.,Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Alberto Stefano Tagliafico
- Department of Health Sciences, University of Genova, Genoa, Italy.,IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | | | - Xavier Tomas
- Radiology Dpt. MSK Unit. Hospital Clinic (CDIC), University of Barcelona (UB), Barcelona, Spain
| | | | - Jelena Vucetic
- Radiology Department, Hospital ICOT Ciudad de Telde, Las Palmas, Spain
| | | | | | - Marcello Zappia
- Department of Medicine and Health Sciences, University of Molise, Campobasso, Italy.,Varelli Institute, Naples, Italy
| | - Marina Obradov
- Department of Radiology, Sint Maartenskliniek, Nijmegen, The Netherlands
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A Systematic Review of the Efficacy of Corticosteroid Injections of Tendon Sheaths, Excluding Stenosing Tenosynovitis of the Wrist and Hand. Am J Phys Med Rehabil 2021; 100:683-688. [PMID: 33017344 DOI: 10.1097/phm.0000000000001609] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVE Corticosteroid injections into tendon sheaths are common in clinical practice for treatment of a variety of tendon disorders. Previous systematic reviews have been performed on injections for stenosing tenosynovitis (DeQuervain tenosynovitis and trigger finger), but little high-level evidence remains for other tendon sheath injections. This systematic review analyzes the available literature on improvements in pain and function after these injections. DESIGN This systematic review of MEDLINE and Embase databases, as well as article bibliographies, examined studies of adult tendon sheath injections, excluding DeQuervain and trigger finger injections. Studies with and without comparison groups were examined. Risk of bias assessment was additionally performed. RESULTS Abstracts from 1293 records were screened, and 187 full-text articles were reviewed. Seven articles met final inclusion criteria, of which five were prospective trials and none were compared with a placebo. The proximal biceps, peroneal, finger flexor, and posterior tibialis tendons were explicitly examined. All articles reported at least short-term improvements in pain, and some reported improvement in function. CONCLUSIONS Low-quality studies exist that suggest tendon sheath injections may provide at least short-term improvement in pain. Controlled studies are required to fully demonstrate efficacy.
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The accuracy of an injection technique for Flexor hallucis longus tendon sheath: A cadaveric study. Foot Ankle Surg 2020; 26:334-337. [PMID: 31122874 DOI: 10.1016/j.fas.2019.04.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Revised: 03/13/2019] [Accepted: 04/09/2019] [Indexed: 02/04/2023]
Abstract
BACKGROUND Corticosteroid injections are used in the conservative treatment of Flexor hallucis longus (FHL) tendinopathy. Studies for imaging guided injection are done, however, the accuracy of blind injection has not yet been studied. PURPOSE The aim of this study was to determine the accuracy of a blind injection technique into the FHL tendon sheath. HYPOTHESIS We hypothesize that a blind injections technique into the FHL tendon sheath based on clinical examination has a high accuracy. STUDY DESIGN Descriptive cadaveric study. METHODS Ten ankles of human cadavers were blindly injected with radiologic contrast mixed with methylene blue into the FHL tendon sheath. After injection, a CT scan of each ankle was performed to evaluate the location of contrast material. CT scans were reviewed by an experienced musculoskeletal radiologist blinded to the procedure. Anatomic dissection was undertaken to assess the location of the injection fluid. RESULTS In nine ankles the radiological contrast was injected in the FHL tendon sheath. In one cadaver there was a technical problem and was therefore excluded. CONCLUSION This study shows that the FHL tendon sheath can be blindly injected based on only clinical examination with high accuracy. LEVEL OF EVIDENCE Descriptive cadaveric study.
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Fram BR, Rogero R, Fuchs D, Shakked RJ, Raikin SM, Pedowitz DI. Clinical Outcomes and Complications of Peroneal Tendon Sheath Ultrasound-Guided Corticosteroid Injection. Foot Ankle Int 2019; 40:888-894. [PMID: 31068007 DOI: 10.1177/1071100719847629] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The treatment of symptomatic peroneal tendinopathy and tears traditionally begins with nonsteroidal anti-inflammatory drugs, activity modification, physical therapy, and immobilization, with surgery typically reserved for those failing nonoperative treatment. Ultrasound-(US)-guided peroneal tendon sheath (PTS) corticosteroid injection is an additional nonoperative modality, but limited data exist on its safety and efficacy. The purpose of this study was to assess clinical outcomes following US-guided PTS corticosteroid injection for chronic tendinopathy or tears. METHODS We retrospectively identified patients who had undergone US-guided PTS corticosteroid injection for pain due to peroneal tendinopathy, tears, or subluxation at our institution from 2012 to 2018. Underlying diagnosis was based on clinical examination, magnetic resonance imaging (MRI) results, and/or intraoperative findings, when available. Medical record data were supplemented by e-mail or telephone follow-up. Collected information included patient age, sex, body mass index (BMI), smoking status, workers' compensation status, prior surgeries about the foot and ankle, duration of symptoms prior to injection, perceived improvement in pain following injection and its duration, number of injections, progression to surgery, and any adverse outcomes of injection. We identified 96 patients (109 injections). Thirty-seven (38.5%) had previous foot and ankle surgery, with 17 (17.7%) having surgery specifically on the peroneal tendons. RESULTS Twenty-four of 96 (25%) progressed to have surgery on their peroneal tendons following injection. Following injection, 38/87 (43.7%) of patients reported 0-1 weeks of pain relief, 11/87 (12.6%) 2-6 weeks, 6/87 (6.9%) 7-12 weeks, and 32/87 (36.8%) greater than 12 weeks. Preinjection duration of symptoms was associated with postinjection duration of pain relief (P=.036). There were 2 reported complications (1.8%): 1 case of self-limited sural nerve irritation and 1 of peroneus longus tear progression. CONCLUSION Our study demonstrates US-guided PTS corticosteroid injection was safe and relatively effective in patients with symptomatic peroneal tendon tears or tendinopathy, including those who had undergone prior surgery, and may be considered in a comprehensive protocol of nonoperative management. LEVEL OF EVIDENCE Level IV, case series.
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Affiliation(s)
| | - Ryan Rogero
- 1 Rothman Orthopaedic Institute, Philadelphia, PA, USA.,2 Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
| | - Daniel Fuchs
- 1 Rothman Orthopaedic Institute, Philadelphia, PA, USA
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ACR Appropriateness Criteria ® Chronic Ankle Pain. J Am Coll Radiol 2018; 15:S26-S38. [PMID: 29724425 DOI: 10.1016/j.jacr.2018.03.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Accepted: 03/04/2018] [Indexed: 12/26/2022]
Abstract
Chronic ankle pain is a common clinical problem whose cause is often elucidated by imaging. The ACR Appropriateness Criteria for chronic ankle pain define best practices of image ordering. Clinical scenarios are followed by the imaging choices and their appropriateness. The information is in ordered tables with an accompanying narrative explanation to guide physicians to order the right test. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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Sirlyn Q. Ultrasound evaluation of adult-acquired flatfoot deformity: Emphasis on the involvement of spring ligament. Australas J Ultrasound Med 2017; 20:83-90. [PMID: 34760477 PMCID: PMC8409874 DOI: 10.1002/ajum.12050] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Adult-acquired flatfoot deformity (AAFD), a condition commonly caused by tibialis posterior tendon (TPT) dysfunction, has recently been recognised to encompass a spectrum of other deformities, including the disruption of the spring ligament complex. This case series reviews eight examples of chronic AAFD, outlines the sonographic assessment of the TPT and spring ligament and depicts various abnormalities of the TPT and spring ligament that are relevant to AAFD. The importance to always include the spring ligament during the assessment of AAFD will be addressed, as misdiagnosis of the involvement of the spring ligament could lead to inappropriate operative management.
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Fritz J, Miller TT. Sonography and fluoroscopy guidance for percutaneous musculoskeletal procedures. Skeletal Radiol 2017; 46:225-226. [PMID: 27928581 DOI: 10.1007/s00256-016-2552-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Accepted: 11/28/2016] [Indexed: 02/02/2023]
Affiliation(s)
- Jan Fritz
- Russell H. Morgan Department of Radiology and Radiological Science, Section of Musculoskeletal Radiology, Johns Hopkins University School of Medicine, 601 North Caroline Street, JHOC 3140A, Baltimore, MD, 21287, USA.
| | - Theodore T Miller
- Department of Radiology and Imaging, Hospital for Special Surgery, 535 E 70th St, New York, NY, 10021, USA
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Abstract
Arthroscopy of the ankle is used in the treatment and diagnosis of a spectrum of intra-articular pathology including soft tissue and osseous impingement, osteochondral lesions, arthrofibrosis, and synovitis. To help identify the correct pathology, imaging techniques are often used to aid the surgeon in diagnosing pathology and determining best treatment options. This article discusses the use of imaging in various ankle pathologies.
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Affiliation(s)
- Sean T Grambart
- Carle Physician Group, Department of Orthopedics, 1802 South Mattis Avenue, Champaign, IL 61821, USA.
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Braito M, Wöß M, Henninger B, Schocke M, Liebensteiner M, Huber D, Krismer M, Biedermann R. Comparison of preoperative MRI and intraoperative findings of posterior tibial tendon insufficiency. SPRINGERPLUS 2016; 5:1414. [PMID: 27625969 PMCID: PMC4996816 DOI: 10.1186/s40064-016-3114-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/28/2015] [Accepted: 08/19/2016] [Indexed: 11/24/2022]
Abstract
Background The purpose of this study was to investigate the radiological and surgical correlation between preoperative magnetic resonance images (MRI) and the intraoperative findings in patients with acquired adult flatfoot. Results The overall radiological–surgical correlation between preoperative MRI and the intraoperative findings for posterior tibial tendon insufficiency was only slight to fair in our patient’s series. Comparing the most commonly used posterior tibial tendon classification systems, the classification of Rosenberg et al. and Kong et al. showed higher interobserver agreement than our modified classification system and the classification system of Conti et al. Conclusion Further prospective studies are needed to evaluate the importance of preoperative MRI before surgical repair of posterior tibial tendon dysfunction.
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Affiliation(s)
- Matthias Braito
- Department of Orthopedics, Medical University of Innsbruck, Anichstrasse 35, Innsbruck, Austria
| | - Martina Wöß
- Department of Orthopedics, Medical University of Innsbruck, Anichstrasse 35, Innsbruck, Austria
| | - Benjamin Henninger
- Department of Radiology, Medical University of Innsbruck, Anichstrasse 35, Innsbruck, Austria
| | - Michael Schocke
- Department of Radiology, Medical University of Ulm, Albert-Einstein-Allee 7, Ulm, Germany
| | - Michael Liebensteiner
- Department of Orthopedics, Medical University of Innsbruck, Anichstrasse 35, Innsbruck, Austria
| | - Dennis Huber
- Department of Experimental Orthopaedics, Medical University of Innsbruck, Innrain 36, Innsbruck, Austria
| | - Martin Krismer
- Department of Orthopedics, Medical University of Innsbruck, Anichstrasse 35, Innsbruck, Austria
| | - Rainer Biedermann
- Department of Orthopedics, Medical University of Innsbruck, Anichstrasse 35, Innsbruck, Austria
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Rehmani R, Endo Y, Bauman P, Hamilton W, Potter H, Adler R. Lower Extremity Injury Patterns in Elite Ballet Dancers: Ultrasound/MRI Imaging Features and an Institutional Overview of Therapeutic Ultrasound Guided Percutaneous Interventions. HSS J 2015; 11:258-77. [PMID: 26788031 PMCID: PMC4712185 DOI: 10.1007/s11420-015-9442-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2014] [Accepted: 03/20/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND Altered biomechanics from repetitive microtrauma, such as long practice hours in en pointe (tip of the toes) or demi pointe (balls of the feet) predispose ballet dancers to a multitude of musculoskeletal pathologies particularly in the lower extremities. Both ultrasound and magnetic resonance imaging (MRI) are radiation-sparing modalities which can be used to confidently evaluate these injuries, with ultrasound (US) offering the added utility of therapeutic intervention at the same time in experienced hands. QUESTIONS/PURPOSES The purposes of this paper were: (1) to illustrate the US and MRI features of lower extremity injury patterns in ballet dancers, focusing on pathologies commonly encountered at a single orthopedic hospital; (2) to present complementary roles of both ultrasound and MRI in the evaluation of these injuries whenever possible; (3) to review and present our institutional approach towards therapeutic ultrasound-guided interventions by presenting explicit cases. METHODS Online searches were performed using the search criteria of "ballet biomechanics" and "ballet injuries." The results were then further narrowed down by limiting articles published in the past 15 years, modality (US and MRI), anatomical region (foot and ankle, hip and knee) and to major radiology, orthopedics, and sports medicine journals. RESULTS Performing ballet poses major stress to lower extremities and predisposes dancer to several musculoskeletal injuries. These can be adequately evaluated by both US and MRI. US is useful for evaluating superficial structures such as soft tissues, tendons, and ligaments, particularly in the foot and ankle. MRI provides superior resolution of deeper structures such as joints, bone marrow, and cartilage. In addition, US can be used as a therapeutic tool for providing quick symptomatic improvement in these athletes for who "time is money". CONCLUSION Performing ballet may cause major stress to the lower extremities, predominantly affecting the foot and ankle, followed by the knee and hip. US and MRI play complementary roles in evaluating various orthopedic conditions in ballet dancers, with US allowing for dynamic evaluation and guidance for interventions.
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Affiliation(s)
- Razia Rehmani
- />Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA
| | - Yoshimi Endo
- />Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA
| | - Phillip Bauman
- />Orthopedic Associates of New York, 315 West 57th Street, New York, NY 10019 USA
| | - William Hamilton
- />Orthopedic Associates of New York, 315 West 57th Street, New York, NY 10019 USA
| | - Hollis Potter
- />Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021 USA
| | - Ronald Adler
- />Hospital for Joint Diseases, New York University, New York, NY USA
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Donovan A, Rosenberg ZS, Bencardino JT, Velez ZR, Blonder DB, Ciavarra GA, Adler RS. Plantar tendons of the foot: MR imaging and US. Radiographics 2014; 33:2065-85. [PMID: 24224599 DOI: 10.1148/rg.337125167] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Tendon disorders along the plantar aspect of the foot may lead to significant symptoms but are often clinically misdiagnosed. Familiarity with the normal anatomy of the plantar tendons and its appearance at magnetic resonance (MR) imaging and ultrasonography (US) is essential for recognizing plantar tendon disorders. At MR imaging, the course of the plantar tendons is optimally visualized with dedicated imaging of the midfoot and forefoot. This imaging should include short-axis images obtained perpendicular to the long axis of the metatarsal shafts, which allows true cross-sectional evaluation of the plantar tendons. Normal plantar tendons appear as low-signal-intensity structures with all MR sequences. At US, accurate evaluation of the tendons requires that the ultrasound beam be perpendicular to the tendon. The normal tendon appears as a compact linear band of echogenic tissue that contains a fine, mixed hypoechoic and hyperechoic internal fibrillar pattern. Tendon injuries can be grouped into six major categories: tendinosis, peritendinosis, tenosynovitis, entrapment, rupture, and instability (subluxation or dislocation) and can be well assessed with both MR imaging and US. The radiologist plays an important role in the diagnosis of plantar tendon disorders, and recognizing their imaging appearances at MR imaging and US is essential.
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Affiliation(s)
- Andrea Donovan
- From the Department of Medical Imaging, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Ave, Room AG 278, Toronto, ON, Canada M4N 3M5 (A.D.); Department of Radiology, NYU Hospital for Joint Diseases, New York, NY (Z.S.R., J.T.B., D.B.B., G.A.C., R.S.A.); and CediMed, Medellin, Colombia (Z.R.V.)
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Poggio D, Medrano C, Asunción J. The retromalleolar compression test: a useful exploratory maneuver in the clinical evaluation of flexor hallucis longus rupture. J Foot Ankle Surg 2013; 53:117-9. [PMID: 23540758 DOI: 10.1053/j.jfas.2013.02.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2013] [Indexed: 02/03/2023]
Abstract
The clinical examination of ruptures of the flexor hallucis longus can be difficult, especially spontaneous defects that arise without a definitive history of trauma. Advanced imaging, in particular, magnetic resonance imaging, can be a useful adjunct to the clinical examination. However, we believe that a simple clinical maneuver can be used to reliably ascertain the presence of a rupture of the flexor hallucis longus.
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Affiliation(s)
- Daniel Poggio
- Foot and Ankle Unit, Orthopedic Surgery, Hospital Clínic, University of Barcelona, Barcelona, Spain.
| | - Cristina Medrano
- Foot and Ankle Unit, Orthopedic Surgery, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Jordi Asunción
- Foot and Ankle Unit, Orthopedic Surgery, Hospital Clínic, University of Barcelona, Barcelona, Spain
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Corte-Real NM, Moreira RM, Guerra-Pinto F. Arthroscopic treatment of tenosynovitis of the flexor hallucis longus tendon. Foot Ankle Int 2012. [PMID: 23199862 DOI: 10.3113/fai.2012.1108] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Tenosynovitis of the flexor hallucis longus (FHL) tendon is a condition typically found in ballet dancers and sometimes in soccer players and is related to chronic overuse. A traumatic cause for this situation, such as an ankle sprain, is considered rare. In case of failure of conservative treatment, the tendon can be surgically released, which is usually done through an open procedure. This article presents the results of an arthroscopic release of the FHL. METHODS Twenty-seven patients underwent surgery for FHL tenosynovitis over a period of 18 months. The mean age of the patients was 34 years. All patients related the onset of the condition with an ankle sprain. Eighteen patients were on worker's compensation and five had sport-related accidents. None of the patients was a professional athlete or a ballet dancer. The mean follow-up was 32 months. The outcome was measured with a satisfaction questionnaire and with the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot scoring system. RESULTS The mean postoperative AOFAS score was 89 with 70% excellent or good results. Mean satisfaction rate was 4 (range, 0 to 5); 89% of the patients would undergo the procedure again. Twenty-two patients (81%) returned to the same level of activity in work and sports. A complication rate of 18% (five patients) and reoperation rate of 4% (one patient) were found. CONCLUSION Arthroscopic release of the FHL tendon was a valid procedure. It was a minimally invasive surgery that allowed good visualization of the involved structures and yielded good results. This condition can be related to trauma and is not an exclusive disease of ballet dancers or overuse.
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Chen W, Li X, Su Y, Zhang Q, Smith WR, Zhang X, Zhang Y. Peroneal tenography to evaluate lateral hindfoot pain after calcaneal fracture. Foot Ankle Int 2011; 32:789-95. [PMID: 22049865 DOI: 10.3113/fai.2011.0789] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Lateral hindfoot pain after union of a calcaneal fracture remains a challenge to orthopaedic surgeons. This study aimed to investigate the relationship between lateral calcaneal pain, calcaneal width and peroneal tendon sheath impingement in patients with lateral hindfoot pain. MATERIALS AND METHODS Seventy-four consecutive patients with unilateral lateral hindfoot pain were identified from an institutional trauma registry. Regular followups were performed and the severity of lateral hindfoot pain was recorded. CT scans were conducted to measure calcaneal width at the level of sustentaculum tali. Bilateral peroneal tenography was performed to examine compression of the peroneal tendon sheath. The sheaths on the injured, painful side were compared to the contralateral sheath at the same level. The data was analyzed with bivariate correlation using SPSS 13.0 for Windows. RESULTS The injured calcanei were wider in all patients and the peroneus longus and brevis tendon sheaths were compressed on peroneal tenography in 68.9% (51 of 74). Statistics demonstrated significant correlations between compression of tendon sheaths and lateral hindfoot pain (Rs = 0.93, p < 0.001), and between increasing calcaneal width and lateral hindfoot pain (Rs = 0.665, p < 0.001). The severity of lateral hindfoot pain was directly correlated to tendon sheath impingement and indirectly related to calcaneal widening. CONCLUSION Calcaneal widening following fracture union was the cause of compression of the peroneal tendons. Increasing compression correlated with increasing levels of lateral pain. Our study demonstrated the utility of peroneal tenography in identifying the presence of peroneal tendon impingement in patients with lateral pain following calcaneal fractures.
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Affiliation(s)
- Wei Chen
- Department of Orthopaedic Surgery, Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, PR China
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The Accuracy of Ultrasound-Guided and Palpation-Guided Peroneal Tendon Sheath Injections. Am J Phys Med Rehabil 2011; 90:564-71. [DOI: 10.1097/phm.0b013e31821f6e63] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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Abstract
The major muscular prime movers and stabilizers of the foot and ankle originate in the mid to lower leg and send their tendons distally. Most of these tendons, with the exception of the Achilles and plantaris tendons, must negotiate a sharply curved course at the ankle and are stabilized by fibro-osseous tunnels, pulleys, or fibrous retinaculi before eventually inserting at the foot. Knowledge of specific tendon anatomy, contact points and sites of physical and vascular stress, helps to identify those regions susceptible to degeneration or tearing and to optimize the design of imaging protocols. This review covers the imaging modalities used to assess tendons about the ankle and issues related to their usage, normal tendon structure and relevant anatomy, normal imaging appearances and artifacts, and the common degenerative pathological processes which imaging can show.
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Cooper AJ, Mizel MS, Patel PD, Steinmetz ND, Clifford PD. Comparison of MRI and local anesthetic tendon sheath injection in the diagnosis of posterior tibial tendon tenosynovitis. Foot Ankle Int 2007; 28:1124-7. [PMID: 18021580 DOI: 10.3113/fai.2007.1124] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The modalities currently available to clinicians to confirm the clinical suspicion of posterior tibial tendinitis include MRI, CT, sonography, tenography, and local anesthetic tendon sheath injections. There are no reports in the literature comparing local anesthetic tendon sheath injection to MRI as tools for diagnosing posterior tibial tenosynovitis. METHODS The authors reviewed the records of all patients with stage 1 posterior tibial tendon dysfunction between the dates of September 1, 2001, to November 21, 2004. Fifteen patients (17 ankles) had a local anesthetic injection into the posterior tibial tendon sheath and MRI for clinically suspected tenosynovitis of the posterior tibial tendon. RESULTS Seventeen (100%) of 17 ankles had complete relief of symptoms after the local anesthetic tendon sheath injections. Fifteen (88%) of 17 ankles had abnormally increased fluid signal within the posterior tibial tendon sheath seen on MRI. Two of two ankles (100%), after having negative MRI findings, had complete relief with a local anesthetic tendon sheath injection. In addition, conservative treatment failed in these two patients, and they subsequently had tenosynovectomy with gross confirmation at surgery of inflammatory changes within the tendon sheath. These two patients had complete symptom relief after tenosynovectomy. CONCLUSIONS Local tendon sheath injections and MRI are both reliable diagnostic tools. Injection of the posterior tibial tendon is an accurate, safe, and sensitive modality useful in patients in whom MRI studies are negative in the face of continued clinical suspicion.
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Affiliation(s)
- Andrew J Cooper
- Department of Orthopaedic Surgery, University of Miami, Miami, FL, USA
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Messiou C, Robinson P, O'Connor PJ, Grainger A. Subacute posteromedial impingement of the ankle in athletes: MR imaging evaluation and ultrasound guided therapy. Skeletal Radiol 2006; 35:88-94. [PMID: 16362423 DOI: 10.1007/s00256-005-0049-1] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2005] [Revised: 09/08/2005] [Accepted: 09/28/2005] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To describe the use of MR imaging and efficacy of ultrasound-guided steroid injection in the diagnosis and management of athletes with clinical posteromedial impingement of the ankle. DESIGN AND PATIENTS A retrospective analysis of imaging findings on MR was undertaken in nine elite athletes with clinical posteromedial ankle impingement. MR studies from six professional athletes with posterolateral pain were also reviewed as an imaging control group. The two reviewing radiologists were blinded to the clinical details and the proportion of control and study subjects. The nine study athletes also underwent diagnostic ultrasound and ultrasound-guided injection of steroid and anaesthetic into the posteromedial capsular abnormality. Follow-up was by telephone interview. RESULTS Posteromedial capsular thickening was seen only in athletes with posteromedial impingement (7/9). Posteromedial synovitis was present in all athletes with posteromedial impingement; however, posterior and posterolateral synovitis was also seen in these athletes. Mild posteromedial synovitis was present in two control athletes. Ultrasound identified abnormal posteromedial soft tissue thickening deep to tibialis posterior between the medial malleolus and talus in all nine athletes. After injection all athletes returned to their previous level of sport, with eight of the nine not experiencing any residual or recurrent symptoms. CONCLUSION If MR imaging excludes significant coexistent abnormality, ultrasound can localise posteromedial soft tissue abnormality and guide injection therapy, allowing return to athletic activity without surgical intervention.
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Affiliation(s)
- Christina Messiou
- Department of Radiology, Leeds Teaching Hospitals, St. James University Hospital, Beckett Street, LS9 7TF Leeds, UK
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Na JB, Bergman AG, Oloff LM, Beaulieu CF. The Flexor Hallucis Longus: Tenographic Technique and Correlation of Imaging Findings with Surgery in 39 Ankles. Radiology 2005; 236:974-82. [PMID: 16118172 DOI: 10.1148/radiol.2362040835] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE To examine the use of tenography for evaluation of the flexor hallucis longus (FHL) sheath. MATERIALS AND METHODS Institutional review board approval was waived, patient consent was obtained, and the study was HIPAA compliant. Retrospective review of 192 FHL tenograms and associated surgical records identified 39 ankles in 37 patients (17 male, 20 female; mean age +/- standard deviation, 38 years +/- 13.8; range, 14-68 years) in which both tenography and surgery had been performed. Two radiologists reviewed tenographic findings, including contrast agent extravasation, synovial irregularity, stenosis, fibrous bands, sheath outpouching, extent of opacification, and communications with adjacent structures. Alterations in pain after anesthesia of the tendon sheath were also recorded. Surgical reports were reviewed. RESULTS Thirty-four of 39 tenograms were diagnostic. Some extravasation occurred in nine (45%) of 20 injections with an initial injection method and in two (11%) of 19 with a new injection technique. Synovial irregularity was present in all 34 studies (15 mild, 16 moderate, three severe). Stenoses were identified in 23 (68%) of 34 ankles, fibrous bands were seen in 16 (47%) of 34 ankles, and outpouching of the sheath above a stenosis was present in 13 (38%) of 34 ankles. Communication of the FHL sheath with the ankle, flexor digitorum longus, or subtalar joint occurred in half the cases. Most patients with pain reported relief; relief was complete (100% reduction from preprocedural pain) in eight of 27, moderate (50%-90% reduction) in nine of 27, and mild (<50% reduction) in eight of 27 patients. CONCLUSION Tenography of the FHL sheath produced diagnostic images in almost all patients and effectively demonstrated abnormalities of the tendon sheath. Pain relief with anesthetic injection helped confirm the FHL sheath as the pain generator.
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Affiliation(s)
- Jae-Boem Na
- Department of Radiology, Stanford University Medical Center, 300 Pasteur Dr, S-056, Stanford, CA, 94305-5105, USA
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Affiliation(s)
- Ken L Schreibman
- Department of Radiology, Musculoskeletal Section, University of Wisconsin, 600 Highland Ave, E3/311, Madison, WI 53792-3252, USA
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