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 Table of Contents  
ORIGINAL ARTICLE
Year : 2016  |  Volume : 33  |  Issue : 1  |  Page : 49-53

Role of ultrasonography in assessment of tendons around ankle joint


1 Department of Radiodiagnosis, Faculty of Medicine, Benha University, Benha, Egypt
2 Department of Radiodiagnosis, Faculty of Medicine, Cairo University, Cairo, Egypt

Date of Submission29-Nov-2015
Date of Acceptance26-Jan-2016
Date of Web Publication28-Nov-2016

Correspondence Address:
Amir G Mohamed Ahmed
3 Taqsim El-Mesaha, 9 St, El-Maadi, Cairo 11728
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1110-208X.194392

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  Abstract 


Introduction Ankle injury is a common condition secondary to trauma; ultrasonography plays a big role in the assessment of a variety of musculoskeletal disorders. These improvements along with economic factors and availability have resulted in renewed interest in using ultrasound (US) as a diagnostic tool. As such, the efficacy of US has been compared with other modalities, in particular MRI, as a cost effective imaging alternative.
Context US is a rapid, accurate, and cheap diagnosing tool.
Aims The aim of this study was to show the efficacy of US as a cost effective diagnostic imaging alternative.
Settings and design Selected individuals of ankle or foot injuries by clinical examination, with no exclusion criteria. Performing real time ankle US bilaterally for each patient.
Participants and methods They will be divided into two groups: first control group which demonstrates 25 asymptomatic ankle ligaments and tendons. Second group includes 25 patients suffering from unilateral or bilateral ankle as sequelae of trauma. All patients will be subjected to history taking and real-time high-resolution ultrasonography. The procedures followed were in accordance with the ethical standards and approval by Benha University.
Statistical analysis used Parametric analysis of our results using Excel program.
Results Forty pathological entities were diagnosed by both utilized imaging modalities in 25 cases. The study included 11 cases with tendon pathology that were interpreted into 13 pathological entities by all imaging modalities. However, US missed two cases: (a) a case of partial tear of Achilles tendon; (b) a case of flexor hallucis longus tenosynovitis. US could detect all of the ligamentous lesions identified in three cases, which were interpreted as tear by MRI, likely due to US anisotropy effect.
Conclusion Ankle US is a rapid, accurate, and cost effective imaging modality.

Keywords: ankle, ankle ultrasound, real time ankle ultrasound, ultrasound could detect


How to cite this article:
Medhat RM, El-Shazly EM, Mohamed Ahmed AG. Role of ultrasonography in assessment of tendons around ankle joint. Benha Med J 2016;33:49-53

How to cite this URL:
Medhat RM, El-Shazly EM, Mohamed Ahmed AG. Role of ultrasonography in assessment of tendons around ankle joint. Benha Med J [serial online] 2016 [cited 2020 Jul 7];33:49-53. Available from: http://www.bmfj.eg.net/text.asp?2016/33/1/49/194392




  Introduction Top


Ultrasound (US) allows dynamic evaluation of tendons and muscles. In many instances, the entire length of the tendon can be assessed despite an obtuse course, whereas MRI cannot always visualize the full extent of the tendon in the true longitudinal plane. The ability of US to assess tendons is a particular strength of US, because this imaging tool is able to visualize and evaluate clearly the structure of normal tendons. It is also easy to follow tendons taking an oblique course or sudden change in orientation. Subluxation and tendon function can be assessed dynamically. In addition, dynamic imaging and compression can assist in the differentiation of tendinosis from tears [1].

US is an efficient and inexpensive alternative to MRI for evaluation of the ankle, in addition to the tendons and tendon sheaths. Other ankle structures demonstrated with US include the anterior joint space, retrocalcaneal bursa, ligaments, and plantar fascia ankle US, which allow detection of tenosynovitis and tendinitis, as well as partial and complete tendon tears. As pressure for cost containment continues, demand for US of the ankle may increase given its lower cost compared with that of MRI [2].

In most cases, a focused ankle US examination can be performed more rapidly and efficiently than MRI. Familiarity with the technique of ankle US, normal US anatomy, and the US appearances of pathologic conditions will establish the role of US as an effective method of imaging the ankle.


  Participants and methods Top


A total of 50 cases are the subject of our study. High-resolution ultrasonography was done in the Radiology Department of El-Helal Hospital. They will be divided into two groups.

Group I (control group)

They demonstrate the normal US appearance of the ankle ligaments and tendons. Sonographic examination will be done to the ankles of 25 asymptomatic volunteers with no history of ankle trauma.

Group II

It includes 25 patients suffering from unilateral or bilateral ankle as sequelae of trauma. All patients will be subjected to the following:

  • History taking
  • Real-time high-resolution ultrasonography.


Inclusion criteria

Patients were proven to have ankle or foot injuries by clinical examination.

Exclusion criteria

There were no exclusions.

The procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation.


  Results Top


Forty pathological entities were diagnosed by both utilized imaging modalities in 25 cases as shown in Chart 1.



The study included 11 cases with tendon pathology that were interpreted into 13 pathological entities by all imaging modalities. However, US missed two cases:

  • A case of partial tear of Achilles tendon
  • A case of flexor hallucis longus tenosynovitis.


[Table 1] shows the distribution of different injured tendons in 13 out of 25 ankles.
Table 1 The distribution of different injured tendons in 13 out of 25 ankles

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US could detect all of the ligamentous lesions identified at MRI (100% sensitivity for pathological ligament). However, one case was diagnosed on US as tear and was identified on MRI as stretching lesion.

Out of 12 ligamentous lesions interpreted as stretching lesion by US and subjected to MRI scanning, three cases were interpreted as tear by MRI, likely due to US anisotropy effect. The rest of the cases interpreted as stretching lesion by US, were seen on MRI to have change in signal intensity, and returned to normal sonographic appearance on follow-up scan after medical treatment and posterior slap fixation.

[Table 2] shows the distribution of different ligamentous injuries which were diagnosed by US in 16 out of 25 ankles.
Table 2 The distribution of different ligamentous injuries which were diagnosed by ultrasound in 16 out of 25 ankles

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[Table 3] and [Table 4] show correlation between sonographic and MRI findings in 18 ligamentous injuries out of 16 ankles subjected to both imaging modalities.
Table 3 Correlation between ultrasound and MRI findings in 11 ligamentous injuries diagnosed as stretching lesion by ultrasound

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Table 4 Correlation between ultrasound and MRI findings in seven ligamentous injuries diagnosed as tears by ultrasound

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Bone lesions

This group included three cases. One case with fracture medial malleolus, another one with fracture fibula and callus formation, and the third case was fissure fracture of the lateral aspect of the fibular cortex.

[Table 5] shows distribution of all 40 pathological entities.
Table 5 Distribution of all 40 pathological entities

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  Discussion Top


The development of high-frequency high-resolution modern electronic transducers has increased the possibility of ultrasonography in the detection of normal small anatomic structures and the assessment of a variety of musculoskeletal disorders. These improvements along with economic factors and availability have resulted in renewed interest in using US as a diagnostic tool. As such, the efficacy of US has been compared with other modalities, in particular MRI, as a cost effective imaging alternative [3].

Fifteen entities of tendon injuries were diagnosed in this study which represented about 36.6% of the pathological entities encountered.

Although it is the strongest tendon in the human body, all literature agreed that the Achilles tendon is the most commonly injured ankle tendon. The site of pathological findings is typically within the critical zone, a zone of relative hypovascularity 2–6 cm from the calcaneal insertion [4].

Our study coincides with this hypothesis as Achilles tendon injuries represented 53.3% of all diagnosed ankle tendon injuries and ranged in severity from tendinosis, partial tear, to complete tear.

Of the three medial ankle tendons, the tibialis posterior tendon is the most frequently affected. In our study, three cases of posterior tibial tendon pathology were diagnosed by US [5].

Of the remaining medial ankle tendons, the flexor digitorum longus tendon is rarely affected by pathologic changes, but can be examined by ultrasonography. Our study included one case of flexor digitorum longus tenosynovitis which was diagnosed by US and approved by MRI study.

Pathology of flexor hallucis longus tendon has been reported more frequently than the flexor digitorum longus. Because of its deep location and changes in its direction, the FHL tendon can be difficult to evaluate with US [6].

Our study included only one case of FHL tenosynovitis which was missed at US most probably due to the mild form of the disease, the deep position of the tendon in posterior ankle and most importantly overlooking the tendon by the associated ligamentous injury and joint effusion which drew the attention at ultrasonography.

Twenty-two entities of ligamentous injury were diagnosed in our study representing 53.7% of the whole encountered pathological entities. Anterior talofibular ligament was the most frequently injured ligament representing 66.6% of the whole ligamentous injuries followed by calcaneofibular ligament 19%. Deltoid ligament was the least ligament injured 14.2%.This coincides with different literatures evaluating ankle ligaments.

Finally, sonography is not the primary imaging modality in diagnosing fracture as it is limited in evaluating structures that are deep. However, fractures may be strongly suspected by focal cortical irregularities or step-off deformities in combination with clinical history [7].

In our study, US could suspect fractures in tibia and fibula representing 7.5% of the encountered pathological entities. All cases were confirmed on plain radiographs ([Figure 1],[Figure 2],[Figure 3],[Figure 4]).
Figure 1 Longitudinal image of Achilles tendon showing mildly thickened inhomogeneous and hypoechoic tendon.

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Figure 2 Longitudinal ultrasound (US) scanning of the Achilles tendon revealed rupture of Achilles tendon with retraction and gapping.

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Figure 3 Longitudinal ultrasound (US) scanning over the longitudinal axis of the tibialis anterior tendon inhomogeneous hypoechoic texture of the tendon.

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Figure 4 Longitudinal ultrasound (US) scanning of the Achilles tendon revealed rupture of Achilles tendon with retraction and gapping.

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Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Finlay K, Friedman LUltrasonography of the lower extremityOrthop Clin N Am200637245275  Back to cited text no. 1
    
2.
Fessell DP, Vanderschueren GM, Jacobson JA, Ceulemans RY, Prasad A, Craig JG et al.US of the ankle: technique, anatomy, and diagnosis of pathologic conditionsRadiographics199818325340  Back to cited text no. 2
    
3.
Bianchi S, Martinoli C, Gaignot C, De Gautard R, Meyer JMUltrasound of the ankle: anatomy of the tendons, bursae, and ligamentsSemin Musculoskelet Radiol20059243259  Back to cited text no. 3
    
4.
Hartgerink P, Fessell DP, Jacobson JA, van Holsbeeck MTFull- versus partial-thickness Achilles tendon tears: sonographic accuracy and characterization in 26 cases with surgical correlationRadiology2001220406412  Back to cited text no. 4
    
5.
Rawool NM, Levon NUltrasound of the ankle and footSemin Ultrasound CT MRI2000121275284  Back to cited text no. 5
    
6.
Morvan G, Busson J, Wybier M, Mathieu PUltrasound of the ankleEur J Ultrasound2001147382  Back to cited text no. 6
    
7.
Williamson D, Watura R, Cobby MUltrasound imaging of forearm fractures in children: a viable alternative?J Accid Emerg Med2000172224  Back to cited text no. 7
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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