Foot and Ankle Assessment-Investigations and Tests: Difference between revisions

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MRI adequately demonstrates the sesamoid anatomy, plantar glenosesamoid apparatus, and the adjoining flexor, abductor, and adductor tendons and is the investigation of choice for metatarsalgia<ref>Batta NS, Gupta A, Batra V. [https://mss-ijmsr.com/imaging-findings-of-bilateral-medial-hallucal-sesamoid-insufficiency-in-a-marathon-runner/ Imaging Findings of Bilateral Medial Hallucal Sesamoid Insufficiency in a Marathon Runner]. Indian J Musculoskelet Radiol 2019;1(1):57-60.</ref>
MRI adequately demonstrates the sesamoid anatomy, plantar glenosesamoid apparatus, and the adjoining flexor, abductor, and adductor tendons and is the investigation of choice for metatarsalgia<ref>Batta NS, Gupta A, Batra V. [https://mss-ijmsr.com/imaging-findings-of-bilateral-medial-hallucal-sesamoid-insufficiency-in-a-marathon-runner/ Imaging Findings of Bilateral Medial Hallucal Sesamoid Insufficiency in a Marathon Runner]. Indian J Musculoskelet Radiol 2019;1(1):57-60.</ref>
In the MRI scan of the ankle joint with weight-bearing MRI, because the transverse position and the coronal position can show more full length of the ligament, it should be used as a routine inspection method of the ankle ligament<ref name=":3" />
The diagnostic accuracy of oblique axial-coronal plane MRI was higher than the routine axial plane concerning ATFL injury, and the interobserver agreement was excellent. The oblique axial-coronal plane could be added to the MRI scanning protocol during clinical practices to improve the diagnostic accuracy of ATFL injury.<ref>Cao S, Wang C, Ma X, Wang X, Huang J, Zhang C, Wang K. [https://josr-online.biomedcentral.com/track/pdf/10.1186/s13018-019-1102-4.pdf Reliability and validity of different ankle MRI scanning planes for the anterior talofibular ligament injury diagnosis: a cadaveric study]. Journal of orthopaedic surgery and research. 2019 Dec;14(1):1-8.</ref>


==== ''CT Scan'' ====
==== ''CT Scan'' ====

Revision as of 12:53, 11 January 2022

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Introduction[edit | edit source]

Taking a patient's history and completing an objective assessment is a gold standard for the foot and ankle assessment. The purpose of using special investigations and tests is to confirm the clinical diagnosis.

"We can't treat the patient just on x-rays or just on MRI findings. These things have to come together (with the objective assessment)". Helene Simpson

Techniques[edit | edit source]

Investigations[edit | edit source]

X-Rays[edit | edit source]

X-ray can help to investigate bone, air and soft tissue injury:

  • Assists with the diagnosis of the Achilles tendon rupture based on the presence of five radiological X-ray signs[1]. Lateral ankle X-ray is reliable to support diagnosis of the Achilles tendon rupture[1]
  • May not be sufficient to identify malleolar fractures[2]
  • Syndesmosis injury is often overlooked on X-ray[2]
  • Assists with diagnosis of the ankle fracture. AP, lateral and mortise views are recommended. Mortise view refers to AP view with 15° internal rotation. If possible, the X-ray should be done with patient in standing position. When ankle fracture was ruled out, but there is no progress in patient's rehabilitation and patient continues to complaint of pain: X-ray should be repeated within 6 weeks to rule out osteochondrial lesion or hairline fracture
  • Malalignment of the second tarsometatarsal joint is a common feature in Lisfranc fracture-dislocations. The X-ray's AP view shows lateral displacement of the second metatarsal base and diastasis over 2 mm between the first and second metatarsal bases. It is recommended that the x-ray of both feet is taken in weight bearing position on one foot and compared with the contralateral side. [3]
  • Hindfoot malalignment causes foot and ankle disability and the assessment of X-ray results of hindfoot alignment is important. The recommendation for a clinical and research purpose is to use the long axial hindfoot view in bilateral stance. [4]
  • The fracture of the sesamoid bone is shown on the the X-ray image as a rough space between the bone pieces. A smooth separation of two bones visible on the X-ray is a normal sign in about 10 % of population.
  • The ligament injuries were confirmed on the first X-ray diagnosis in only 50% of patients. This number increased to 66% of patients during the second X-ray when the diagnosis was confirmed. [5]

Diagnostic Ultrasound[edit | edit source]

Diagnostic ultrasound allows for dynamic examination of the foot and ankle pathology. It is a noninvasive, economical and readily available tool that is recommended as a first-line diagnostic modality to rule out torn ligaments, tendonitis, tenosynovitis, plantar fascia, sof tissue masses or Morton's neuroma . [6] [7]

Diagnostic ultrasound was found to be an effective diagnostic tool for the following foot and ankle injuries:

  • Fifth metatarsal, lateral and medial malleolus fractures in patients with foot and/or ankle sprains. Note: sensitivity for navicular fractures is low.[8]
  • To rule out torn vs sprained anterior talofibular ligament and calcaneofibular ligament.[9][10][11]
  • Ankle pain related to lateral ligament pathologies, tendinous pathologies, and joint effusion. Note: limited use in a suspected posterior talofibular ligament injury.[12]
  • Achilles tendon injuries.[13]
  • Statistically significant for diagnosing a syndesmosis injury at ≥6.0 mm of tibiofibular clear space widening. [14]
  • For foot and ankle fractures should be considered as a primary modality.[15]

MRI[edit | edit source]

MRI is the imaging modality of choice in many types of diseases causing chronic foot pain, due to high resolution and excellent soft tissue contrast.

the gold standard for the diagnosis of Achilles tendon rupture[1]

In this study, clinical examination was insufficient to detect syndesmotic injuries in acute ankle sprains. MRI scanning revealed a syndesmotic lesion in 15 % of patients. MRI scanning should be recommended in patients with ongoing pain at rest following ankle sprains.[16]

Preoperative MRI of the ATFL is a reliable and valid decisional tool to choose the surgical technique for stabilization of chronic lateral ankle instability.[17]

In the Ankle ligament injury MRI examinations are usually required. In the MRI scan of the ankle joint with weight-bearing MRI, because the transverse position and the coronal position can show more full length of the ligament, it should be used as a routine inspection method of the ankle ligament.[5]

value of MR in evaluation of patients with ankle pain caused by traumatic injury. He concluded MR gives additional insight into ligamentous, tendon and cartilage injuries. However MR is expensive and not easily accessible on many ERs around the world

While applying their classification, Rosenberg et al found MRI for diagnosing ruptures of the tendons to be sensitive in (95%) of cases and specific in (100%). MRI has (96%) accuracy in detecting tendon rupture [18]

MRI is particularly advantageous for assessing soft tissue structures around the ankle such as tendons, ligaments, nerves, and fascia and for detecting occult bone injuries[18]

MRI adequately demonstrates the sesamoid anatomy, plantar glenosesamoid apparatus, and the adjoining flexor, abductor, and adductor tendons and is the investigation of choice for metatarsalgia[19]

In the MRI scan of the ankle joint with weight-bearing MRI, because the transverse position and the coronal position can show more full length of the ligament, it should be used as a routine inspection method of the ankle ligament[5]

The diagnostic accuracy of oblique axial-coronal plane MRI was higher than the routine axial plane concerning ATFL injury, and the interobserver agreement was excellent. The oblique axial-coronal plane could be added to the MRI scanning protocol during clinical practices to improve the diagnostic accuracy of ATFL injury.[20]

CT Scan[edit | edit source]

The use of CT in cases of foot and ankle trauma has been proposed in several previous studies

CT is a very useful tool for assessing fractures in the ankle joint area [2]

Special Tests[edit | edit source]

Ottawa Foot and Ankle Rules[edit | edit source]

Knee To Wall Test[edit | edit source]

Anterior Drawer Test[edit | edit source]

Squeeze Test[edit | edit source]

External Rotation Test[edit | edit source]

Cotton Test[edit | edit source]

Coleman Block Test[edit | edit source]

Other special tests include:

Questionnaires[edit | edit source]

FAAM

FADI

Visa-A

CRPS

Additional details can be found on the Foot and Ankle Assessment page.

The following video demonstrates the application and interpretation of special tests for foot and ankle assessment:

[21]


References[edit | edit source]

  1. ↑ 1.0 1.1 1.2 Bowen L, Evans R, Bodger O, Howard J, Anne-Marie H. Investigating the Validity of Soft Tissue Signs on Lateral Ankle X-Ray to Aid Diagnosis of Achilles Tendon Rupture in the Emergency Department. Int J Foot Ankle. 2019;3:033.
  2. ↑ 2.0 2.1 2.2 Szymański T, Zdanowicz U. Comparison of routine computed tomography and plain X-ray imaging for malleolar fractures—How much do we miss?. Foot and Ankle Surgery. 2021 Apr 1.
  3. ↑ Stavlas P, Roberts CS, Xypnitos FN, Giannoudis PV. The role of reduction and internal fixation of Lisfranc fracture-dislocations: a systematic review of the literature. Int Orthop. 2010 Dec;34(8):1083-91.
  4. ↑ ML Reilingh, L Beimers, GJM Tuijthof, SAS Stufkens, M Maas, et al. Measuring hindfoot alignment radiographically: the long axial view is more reliable than the hindfoot alignment view. Skeletal radiology 2010;39 (11): 1103-1108.
  5. ↑ 5.0 5.1 5.2 Qi H, Feng Y. Analysis of clinical value of weight-bearing magnetic resonance diagnosis of ankle ligament sports injury. IEEE Access. 2020 Mar 30;8:62725-37.
  6. ↑ Khoury V, Guillin R, Dhanju J, Cardinal É. Ultrasound of ankle and foot: overuse and sports injuries. InSeminars in musculoskeletal radiology 2007 Jun; 11(02): 149-161.
  7. ↑ Rawool NM, Nazarian LN. Ultrasound of the ankle and foot. InSeminars in Ultrasound, CT and MRI 2000 Jun; 21(3): 275-284.
  8. ↑ Atilla OD, Yesilaras M, Kilic TY, Tur FC, Reisoglu A, Sever M, Aksay E. The accuracy of bedside ultrasonography as a diagnostic tool for fractures in the ankle and foot. Academic Emergency Medicine. 2014 Sep;21(9):1058-61.
  9. ↑ Hosseinian SH, Aminzadeh B, Rezaeian A, Jarahi L, Naeini AK, Jangjui P. Diagnostic Value of Ultrasound in Ankle Sprain. The Journal of Foot and Ankle Surgery. 2021 Aug 20.
  10. ↑ Esmailian M, Ataie M, Ahmadi O, Rastegar S, Adibi A. Sensitivity and specificity of ultrasound in the diagnosis of traumatic ankle injury. Journal of Research in Medical Sciences: The Official Journal of Isfahan University of Medical Sciences. 2021;26.
  11. ↑ Gribble PA. Evaluating and differentiating ankle instability. Journal of athletic training. 2019 Jun;54(6):617-27.
  12. ↑ Singh K, Thukral CL, Gupta K, Singh A. Comparison of high resolution ultrasonography with clinical findings in patients with ankle pain. J Ultrason. 2018;18:316–24.
  13. ↑ Lee SH, Yun SJ. The feasibility of point-of-care ankle ultrasound examination in patients with recurrent ankle sprain and chronic ankle instability: Comparison with magnetic resonance imaging. Injury. 2017;48:2323–8.
  14. ↑ Fisher CL, Rabbani T, Johnson K, Reeves R, Wood A. Diagnostic capability of dynamic ultrasound evaluation of supination-external rotation ankle injuries: a cadaveric study. BMC musculoskeletal disorders. 2019 Dec;20(1):1-7.
  15. ↑ Wu J, Wang Y, Wang Z. The diagnostic accuracy of ultrasound in the detection of foot and ankle fractures: a systematic review and meta-analysis. Medical Ultrasonography. 2021 May 20;23(2):203-12.
  16. ↑ Grossterlinden LG, Hartel M, Yamamura J, Schoennagel B, Burger N, Krause M, et al. Isolated syndesmotic injuries in acute ankle sprains: diagnostic significance of clinical examination and MRI. Knee Surg Sports Traumatol Arthrosc. 2016;24(4):1180–6.
  17. ↑ Morvan A, Klouche S, Thes A, Hardy P, Bauer T. Reliability and validity of preoperative MRI for surgical decision making in chronic lateral ankle instability. European Journal of Orthopaedic Surgery & Traumatology. 2018 May;28(4):713-9.
  18. ↑ 18.0 18.1 Elgohary MM, Abdul Rahim SA, Ibrahim TA. Role of MRI in Evaluation of Traumatic Ankle Injuries. The Egyptian Journal of Hospital Medicine. 2017 Oct 1;69(3):2016-24.
  19. ↑ Batta NS, Gupta A, Batra V. Imaging Findings of Bilateral Medial Hallucal Sesamoid Insufficiency in a Marathon Runner. Indian J Musculoskelet Radiol 2019;1(1):57-60.
  20. ↑ Cao S, Wang C, Ma X, Wang X, Huang J, Zhang C, Wang K. Reliability and validity of different ankle MRI scanning planes for the anterior talofibular ligament injury diagnosis: a cadaveric study. Journal of orthopaedic surgery and research. 2019 Dec;14(1):1-8.
  21. ↑ Kris Porter DPT. Movement Screen of the Lower Quarter. Available from: https://www.youtube.com/watch?v=l6gkHR02rIM [last accessed 30/6/2021]


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