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Assessment of Ankle Pain Caused by Different Musculoskeletal Disorders Archives of Orthopedics and Rheumatology ISSN: 2639-3654 Volume 2, Issue 1, 2019, PP: 01-21 Assessment of Ankle Pain Caused by Different Musculoskeletal Disorders. A Comparative Study between Ultrasonography and Magnetic Resonance Imaging Hend H Al Sherbeni1*, Hatem M El Azizi2, Abo El Magd M El Bohy3 1 2 *Assistant Professor,3 Rheumatology and rehabilitation Department, Faculty of Medicine, Cairo University. Professor, Radiology Department, Faculty of Medicine, Cairo University. *CorrespondingAssistant Author: Professor,Hend H Al Radiology Sherbeni, AssistantDepartment, Professor, Faculty Rheumatology of Medicine, andCairo Rehabilitation University. Department, Faculty of Medicine, Cairo University, Egypt, [email protected]. Abstract Ankle pain is a common complaint in orthopedic practice. Various imaging techniques are available for assessment of ankle joint abnormalities. However, many ankle injuries were undiagnosed by conventional radiology and needs further evaluation to diagnose ligamentous, tendinous and muscle injuries as well as osseous lesions as stress fractures, osteochondral lesions, and avascular necrosis. The aim of this study was to compare the diagnostic accuracy of both ultrasonography (US) and magnetic resonance imaging (MRI) for the assessment of pain around the ankle in different musculoskeletal disorders. Ultrasonography and MRI are two complementary tools of investigation with the former being used as primary tool of investigation and the latter is done to confirm the diagnosis and the extent of the lesion especially when surgical interference is planned. Keywords: Ankle pain, Musculoskeletal disorders, Ultrasonography, MRI. Introduction The ankle is a “hinged” joint capable of moving the is surrounded by a fibrous joint capsule. The tendons foot in two primary directions: away from the body attach the muscles of the leg to the foot wrap around the ankle both from the front and behind. A large tendon (Achilles tendon) passes behind the ankle (plantar flexion) and toward the body (dorsiflexion). and attaches at the back of the heel. The posterior It is formed by the meeting of three bones. The end of tibial tendon passes behind the medial malleolus. The both the tibia and the fibula meet the talus, to form the to attach into the foot (2). peroneal tendon passes behind the lateral malleolus ankle. The end of the tibia forms the medial portion The normal ankle joint is capable of moving the foot eof the ankle, while the end of the fibula forms the lateral portion of the ankle. The hard bony knobs on ach side of the ankle are called the malleoli. These from the neutral right-angle position to approximately 45 degrees of plantar flexion and to approximately andprovide walkin stabilityg (1) to the ankle joints, which function that move the ankle are located in the front and back as weight-bearing joints for the body during standing 20 degrees of dorsiflexion.(1). The powerful muscles Ligaments on each. side of the ankle provide stability portions of the leg. by tightly strapping the outside of the ankle (lateral Ankle pain is usually due to an ankle sprain but can malleolus) with the lateral collateral ligaments and also be caused by ankle instability, arthritis, gout, the inner portion of the ankle (medial malleolus) tendonitis, fracture, nerve compression, infection and withArchives the medialof Orthopedics collateral and ligaments. Rheumatology The ankle V2 joint . I1 . 2019poor structural alignment of the leg and/or the foot.1 Assessment of Ankle Pain Caused by Different Musculoskeletal Disorders. A Comparative Study between Ultrasonography and Magnetic Resonance Imaging Ankle pain may be associated with swelling, stiffness, All• patients were subjected to: redness, and warmth of the involved area. The pain is (3), (4), (5). • History taking. usually described as an intense dull aching that occurs upon weight bearing and ankle motion • Clinical examination of the affected ankle. Imaging tests can reveal damage to the tendons. X-ray Real time high resolution ultrasonography of both produces images of hard tissues. Ultrasonography (US) • ankles. can reveal signs of inflammation and damage to the • MRI of the affected ankle. Achilles tendon. Magnetic(6). resonance imaging (MRI) can help to show details about tissue degeneration HistoryPlain TakingX-ray of one or both ankles. and tendon ruptures Personal History During the process of the diagnosis of musculoskeletal disorders, there are several applications where both since that there are advantages and disadvantages to Present History US and MRI may be considered good alternatives. And Included: age, sex, and occupation. (7). each imaging method, of it is unclear which should be • considered for a specific indication Included: Musculoskeletal ultrasound (MSKUS) is a dynamic, Analysis of patient complaint (ankle pain): site, non-invasive procedure that allows high-resolution, onset, course, duration, and the relationship to • real-time evaluation of musculoskeletal disorders. posture. MSKUS is considered as a unique modality that is • Associated swelling, stiffness, and deformity. highly operator-dependent, patient friendly and Past History: cost-effective. It has been traditionally seen as a Loss of function. complement to MRI and has gained recognition as a Clinical Examination previous trauma. powerful diagnostic tool. The literature indicates(8). that MSKUS is now equivalent to MRI in diagnosing and evaluating many musculoskeletal disorders AllInspection patients were subjected to: Many studies have demonstrated the increased • sensitivity of MSKUS in the detection of bony erosions (9), • Skin, for scar or sinuses. (10),at numerous (11), (12). anatomical sites, including the hands, wrists, feet and shoulders in patients with RA • Swellings. • Muscle atrophy. MSKUS facilitates identification, localization and (13) , • Shape and symmetry. differentiation between synovial,(14), (15). tendinous and entheseal inflammation as well as joint, bursal PalpationPosition and movement of ankle. andAim soft of tissue Work fluid collection • Determination of the point of maximum The aim of this study was to compare the diagnostic • tenderness. accuracy of both ultrasonography and magnetic • Tendon defect. resonance imaging for the assessment of pain around thePatients ankle in andmusculoskeletal Methods disorders. Assessment of movements (active and passive) Ultrasonographicand muscle power. Examination This study included fifty patients complaining of both ankles to compare the symptomatic ankle to the unilateral ankle pain, referred to radiology department All patients had standardized ultrasonography of of Cairo University Hospitals. They included 35 females and 15 males. Their ages ranged between 18- contralateral normal side. Excess gel was used instead 602 years. Archivesof of the Orthopedics gel pad. and Rheumatology V2 . I1 . 2019 Assessment of Ankle Pain Caused by Different Musculoskeletal Disorders. A Comparative Study between Ultrasonography and Magnetic Resonance Imaging of the following devices: Ultrasound examinations were performed using one Finally the patient was asked to lie prone and rest on • his/her toes. The Achilles tendon(AT) was examined from its musculo-tendinous junction to its calcaneal • GE Logic pro6 (12 MHz). insertion in both longitudinal and transverse planes. GE Logic 3 (12 MHz). Power-Doppler imaging was used to detect tissue The ultrasonographic examination began with the hyperemia in cases of tendinopathy, enthesopathy, patient in the supine position. Longitudinal scanning synovitis,MRI Examination and inflammatory conditions. of the ankle was first performed to get an overall view of the tibiotalar joint and to detect joint effusion or intra-articular loose bodies. Then, the ankle joint All patients had MRI of the affected ankle(s) on a high syndesmosis and anterior inferior tibio-fibular field-strength scanners. ligament (AITFL) were assessed on transverse plane devices: MRI was performed using one of the following at anterolateral aspect of the distal tibia. Finally, while • the patient in the same position; individual evaluation • of the extensor tendons of the ankle was performed GE Signa HDxt (1.5 T). in both longitudinal and transverse planes starting Philips Achieva (1.5 T). from medial to lateral (tibialis anterior tendon(TA), Technique then extensor hallucis longus tendon( EHL), and most Knee coil was used in all cases. laterally, extensor digotoum Longus tendon( EDL). Positioning Thereafter, slight inversion of the foot was performed while the patient in the same position to examine the Every patient lied supine with the ankle and foot in lateral collateral ligaments and peroneal tendons. The neutral position, plantar flexion of 20 to 30 degrees has anterior talofibular ligament (ATFL) was first examined been advocated for reducing the “magic angle” artifact. in oblique transverse plane from the tip of lateral No movement was allowed during examination by malleolus, anteromedially and slightly downwards, till supportingProtocol the ankle using pads. malleolarthe talus. Then, tip downwards the calcaneofibular and slightly ligament backwards (CFL) was to examined in oblique longitudinal plane form the lateral The patients were examined by different pulse the lateral surface of the calcaneus. Regarding the sequences including T1, T2, proton density, gradient peroneal tendons, they were examined from their echo and short T1inversion recovery (STIR). The supramalleolar musculo-tendinous junction, then just examinations
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