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Wolfe I, Williamson ERC, Godwin K, Schon LC, Rose DJ. Allograft Reconstruction of a Ruptured Flexor Hallucis Longus Tendon in a Professional Dancer: A Case Report. Foot Ankle Spec 2025:19386400251330103. [PMID: 40231779 DOI: 10.1177/19386400251330103] [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] [Indexed: 04/16/2025]
Abstract
Stenosing tenosynovitis/tendinitis of the flexor hallucis longus (FHL) tendon is a relatively common occurrence in dancers. When nonoperative management fails, surgical tenolysis/tenosynovectomy has been shown to successfully reduce pain and restore function. In this study, we present the case of a professional contemporary dancer with FHL stenosing tenosynovitis/tendinitis who underwent a z-lengthening of the FHL proximal to the intact tendon sheath which resulted in a rupture of the FHL upon return to dance. He subsequently underwent a FHL reconstruction with tendon allograft. He returned to unrestricted professional dance at 11 months postoperative, which has been maintained at 4-year clinical and MRI follow-up.Level of evidence: V.
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Affiliation(s)
- Isabel Wolfe
- From Department of Orthopedic Surgery, NYU Langone Health, New York, New York
| | - Emilie R C Williamson
- Department of Orthopaedics, University of Rochester Medical Center, Rochester, New York
| | | | - Lew C Schon
- From Department of Orthopedic Surgery, NYU Langone Health, New York, New York
| | - Donald J Rose
- From Department of Orthopedic Surgery, NYU Langone Health, New York, New York
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Cockerill SJ, Arnay-de-la-Rosa M, González-Reimers E. An Atlas of Anatomical Variants of the Human Talus. J Morphol 2025; 286:e70023. [PMID: 39731443 DOI: 10.1002/jmor.70023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2024] [Revised: 12/08/2024] [Accepted: 12/12/2024] [Indexed: 12/29/2024]
Abstract
Anatomical variants can be used effectively to identify relationships between individuals in kinship analysis and they may be useful during surgical procedures. These procedures can be better implemented when the cause, appearance and location are understood. Clear representations and definitions of anatomical traits are necessary. A similar morphology of pathologies and variations of normal morphology can lead to confusion and unnecessary intervention. Therefore, there is a considerable need for an anatomical atlas of the particular skeletal elements, such as the talus bone. We have analyzed a total of 925 tali, 591 belonging to different modern and pre-Hispanic samples. Furthermore, 334 tali were analyzed from a reference collection from Athens. We have identified and defined the anatomical variants of the talus bone, of which only some have been mentioned by other researchers. We propose standardized methods that may potentially improve future research in human skeleton anatomy and its applications. We provide information on anatomical variants with the aim of improving their identification, classification and use in medical professions and bioanthropology.
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Affiliation(s)
- Samuel James Cockerill
- Departamento Geografía e Historia, Facultad de Humanidades, Universidad de La Laguna, Santa Cruz de Tenerife, Spain
| | - Matilde Arnay-de-la-Rosa
- Departamento Geografía e Historia, Facultad de Humanidades, Universidad de La Laguna, Santa Cruz de Tenerife, Spain
| | - Emilio González-Reimers
- Dpto. de Medicina Interna, Hospital Universitario de Canarias, Universidad de La Laguna, La Laguna, Spain
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Katakura M, Clark R, Lee JC, Mitchell AWM, Shaw JW, Tsuchida AI, Jones M, Kelly S, Calder JDF. Foot and Ankle MRI Findings in Asymptomatic Professional Ballet Dancers. Orthop J Sports Med 2024; 12:23259671241263593. [PMID: 39143984 PMCID: PMC11322932 DOI: 10.1177/23259671241263593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2024] [Accepted: 02/13/2024] [Indexed: 08/16/2024] Open
Abstract
Background Previous research in sport populations has demonstrated that abnormal magnetic resonance imaging (MRI) findings may be present in individuals without symptoms or known pathology. Extending this understanding to ballet, particularly in relation to the foot and ankle, is important to guide medical advice given to dancers. Purpose To assess foot and ankle MRI scans in asymptomatic ballet dancers focusing on bone marrow edema and the posterior ankle and to investigate whether these MRI findings would become symptomatic within 1 year. Study Design Case series; Level of evidence, 4. Methods In total, 31 healthy dancers (62 feet/ankles; 15 male and 16 female; age, 26.5 ± 4.3 years) who were dancing in full capacity were recruited from an elite professional ballet company. Orthogonal 3-plane short tau inversion recovery imaging of both feet and ankles was obtained using 3T MRI and the images were reviewed using a standardized evaluation form by 2 musculoskeletal radiologists. Injuries in the company were recorded and positive MRI findings were assessed for correlation with any injuries requiring medical attention during the subsequent 12 months. Results A total of 51 (82%) of the 62 feet and ankles had ≥1 area of bone marrow edema. The most common locations of bone marrow edema were the talus (n = 41; 66%), followed by first metatarsal (n = 14; 23%). Os trigonum and Stieda process were seen in 5 (8%) and 8 (13%) ankles, respectively. Among them, 2 os trigona showed bone marrow edema. Fluid in the anterior and posterior talocrural joints and the subtalar joint was observed in 48%, 63%, and 63% of these joints, respectively. Fluid around foot and ankle tendons was observed, with the most prevalent being the flexor hallucis longus tendon (n = 13; 21%). Two dancers who had positive findings on their MRI subsequently developed symptoms during the next 12 months. Conclusion Positive MRI findings are commonplace in the foot and ankle of asymptomatic professional ballet dancers. The majority do not result in the development of symptoms requiring medical attention within 12 months. Careful interpretation of MRI findings with the dancer's clinical picture is required before recommending activity modification or further intervention.
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Affiliation(s)
- Mai Katakura
- Department of Joint Surgery and Sports Medicine, Tokyo Medical and Dental University, Tokyo, Japan
- Fortius Clinic FIFA Medical Centre of Excellence, London, UK
- Department of Bioengineering, Imperial College London, London, UK
| | - Richard Clark
- Tottenham Hotspur Football Club, London, UK
- Ballet Healthcare, Royal Opera House, London, UK
| | - Justin C Lee
- Fortius Clinic FIFA Medical Centre of Excellence, London, UK
- Division of Surgery & Interventional Science, University College London, London, UK
| | | | | | - Anika I Tsuchida
- Fortius Clinic FIFA Medical Centre of Excellence, London, UK
- Department of Orthopaedic Surgery, Northwest Clinics, Alkmaar, the Netherlands
| | - Mary Jones
- Fortius Clinic FIFA Medical Centre of Excellence, London, UK
| | - Shane Kelly
- Ballet Healthcare, Royal Opera House, London, UK
| | - James D F Calder
- Fortius Clinic FIFA Medical Centre of Excellence, London, UK
- Department of Bioengineering, Imperial College London, London, UK
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Ulrich GL, Meyers AL, Marquart MJ. Os Trigonum Syndrome: A Cause of Posterior Ankle Pain. Orthopedics 2024; 47:e67-e72. [PMID: 38285552 DOI: 10.3928/01477447-20240122-04] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2024]
Abstract
BACKGROUND Os trigonum syndrome represents a cause of posterior ankle pain that is predominantly seen in athletes. The os trigonum ossicle forms from a secondary ossification center of the talus and is located at its posterior aspect in an interval between the posterior lip of the tibial plafond and calcaneus. The os trigonum ossicle is often an incidental finding and asymptomatic. However, repetitive plantarflexion and push-off maneuvers can cause symptoms and lead a patient to pursue orthopedic care. MATERIALS AND METHODS A review of the literature was conducted using the PubMed search engine with the following keywords: "os trigonum", "os trigonum ossicle", "os trigonum syndrome", "posterior ankle impingement", and "Stieda process". RESULTS The pertinent anatomy, clinical presentation, diagnostic evaluation, and treatment of os trigonum syndrome were reviewed in the literature and are extensively discussed in this article. CONCLUSION Os trigonum syndrome represents a potential cause of posterior ankle pain that needs thorough evaluation regarding history, physical examination, and imaging. Once diagnosed, treatment ranges from conservative to surgical interventions depending on surgeon preference and specific case presentation. [Orthopedics. 2024;47(2):e67-e72.].
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Mansur NSB, Femino JE, Chinnakkannu K, Fayed A, Glass N, Phisitkul P, Amendola A. Posterior Ankle Impingement: It's Not Only About the Os Trigonum. FOOT & ANKLE ORTHOPAEDICS 2024; 9:24730114241241326. [PMID: 38559392 PMCID: PMC10981862 DOI: 10.1177/24730114241241326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2024] Open
Abstract
Background Os trigonum and Stieda process are common etiologies for posterior ankle impingement syndrome (PAIS), and diagnosis is typically made by radiographs, computed tomographic, or magnetic resonance imaging. However, these static tests may not detect associated soft tissue and bony pathologies. Posterior ankle and hindfoot arthroscopy (PAHA) is dynamic, providing at least ×8 magnification with full anatomical visualization. The primary aim of this study was to report the prevalence of associated conditions seen with trigonal impingement treated with PAHA. Methods In this retrospective comparative study, patients who underwent PAHA for PAIS due to trigonal impingement, from January 2011 to September 2016, were reviewed. Concomitant open posterior procedures and other indications for PAHA were excluded. Demographic data were collected with pre- and postoperative diagnosis, arthroscopic findings, type of impingement, location, associated procedures, and anatomical etiologies. Trigonal impingements were divided in os trigonal or Stieda and subgrouped as isolated, with flexor hallucis longus (FHL) disorders, with FHL plus other impingement, and with other impingement lesions. Results A total of 111 ankles were studied-74 os trigonum and 37 Stieda. Isolated trigonal disorders accounted for 15.3% of PAIS (n = 17). Cases having associated conditions had a mode of 3 additional pathologies. FHL disorders were found in 69.4%, subtalar impingement in 32.4%, posteromedial ankle synovitis in 25.2%, posterolateral ankle synovitis in 22.5%, and posterior inferior tibiofibular ligament impingement in 19.8% of cases. Associated pathologies were observed in 58.6% of cases when FHL was not considered. Significant differences were noted comparing os and Stieda (isolated: 20.3% to 5.4%, P = .040; FHL plus others: 35.1% to 59.5%, P = .015). Conclusion Trigonal bone (os trigonum or Stieda) was found to cause impingement in isolation in a small proportion of cases even when the FHL was considered part of the same disease spectrum. This should alert surgeons when considering removing trigonal impingement. Open approaches may limit the visualization and assessment of associated posterior ankle and subtalar pathoanatomy, thus possibly overlooking concomitant causes of PAIS. Level of Evidence Level III, retrospective comparative study.
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Affiliation(s)
- Nacime Salomao Barbachan Mansur
- Department of Orthopedics and Rehabilitation, Carver College of Medicine, University of Iowa, Iowa City, IA, USA
- Department of Orthopedics and Rehabilitation, Paulista School of Medicine, Federal University of Sao Paulo, Brazil
| | - John E. Femino
- Department of Orthopedics and Rehabilitation, Carver College of Medicine, University of Iowa, Iowa City, IA, USA
| | - Karthikeyan Chinnakkannu
- Department of Orthopedics and Rehabilitation, Carver College of Medicine, University of Iowa, Iowa City, IA, USA
- BronxCare Health System, Bronx, NY, USA
| | - Aly Fayed
- Department of Orthopedics and Rehabilitation, Carver College of Medicine, University of Iowa, Iowa City, IA, USA
| | - Natalie Glass
- Department of Orthopedics and Rehabilitation, Carver College of Medicine, University of Iowa, Iowa City, IA, USA
| | - Phinit Phisitkul
- Department of Orthopaedics, Tri-State Specialists, Sioux City, IA, USA
| | - Annunziato Amendola
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
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Drysdale L, Gomes Z, Toohey L, Pumpa K, Newman P. Musculoskeletal Injury in an Australian Professional Ballet Company, 2018-2021: 953 Medical-Attention and 706 Time-Loss Injuries Over 4 Years. J Orthop Sports Phys Ther 2023; 53:712-722. [PMID: 37707788 DOI: 10.2519/jospt.2023.11858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/15/2023]
Abstract
OBJECTIVES: To describe the incidence rate, frequency, severity, recurrence, and burden of musculoskeletal injury in professional ballet. STUDY DESIGN: Descriptive epidemiological (retrospective). METHODS: Professional dancers (n = 73, 40 females, 33 males) provided consent for retrospective review of musculoskeletal injury data. Medical-attention injuries were reported to and recorded by onsite physiotherapists between January 2018 and December 2021. Time-loss injuries were any injury that prevented a dancer from taking a full part in all dance-related activities for >1 day. Injuries were classified using the OSICS-10.1 system. Injury incidence rates (IIRs; injuries/1000 h), severity, recurrence, and burden were calculated. RESULTS: Nine hundred and fifty-three medical-attention injuries were recorded in 72 (98%) dancers at an IIR of 2.79/1000 h (95% confidence interval [CI], 2.62-2.98). 706 were time-loss injuries, which were reported in 70 dancers at an IIR of 2.07/1000 h (95% CI: 1.92, 2.23). Overuse injuries represented 53% of medical-attention injuries. The most frequently injured body area and tissue/pathology were thoracic facet joint (n = 63/953, 7%) and ankle synovitis/impingement (n = 62/953, 6%). Bone stress injuries (BSIs) were the most severe with the highest median time loss (135 days, interquartile range [IQR] 181) followed by fractures (72.5 days, IQR 132). The injuries with the highest burden were tibial BSIs (13 days lost/1000 h; 95% CI: 13, 14). Jumping and lifting were the most frequently reported injury mechanisms. CONCLUSION: Almost all dancers required medical attention for at least one injury during the surveillance period. Approximately 74% of injuries resulted in time loss. BSIs and ankle synovitis/impingement were of high burden, and a high proportion of BSIs were recurrent. J Orthop Sports Phys Ther 2023;53(11):712-722. Epub 14 September 2023. doi:10.2519/jospt.2023.11858.
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Volmer E, Mittlmeier T, Weber MA. [Ligamentous injuries of the ankle joint : Importance of radiological imaging procedures]. ORTHOPADIE (HEIDELBERG, GERMANY) 2023; 52:773-783. [PMID: 37642697 DOI: 10.1007/s00132-023-04436-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 06/21/2023] [Indexed: 08/31/2023]
Abstract
Injuries of the ankle joint show lesions of the lateral ligamentous apparatus with an incidence of 1 in 1000 cases. With a range of 0.3-0.7 in 1000 cases, injuries of the medial ligamentous apparatus occur more frequently than previously thought and are often overlooked. Correct imaging diagnostics of the ankle ligaments are mandatory for the prognosis and treatment planning. In cases of clinically strong suspicion of ligamentous injury or osteochondral lesions of the ankle joint, after primary radiographic evaluation magnetic resonance imaging (MRI) is primarily recommended for a more precise assessment. Additionally, the sensitivity for assessment of the ligaments with ultrasonography is good (91% vs. 97% with MRI) but its specificity is inferior compared to MRI (63% vs. 93% with MRI). Supination trauma is the most common ankle injury and attention should be paid to the anterior tibiofibular ligament and calcaneofibular ligament. In approximately 50%, injuries to the superficial layer of the medial collateral ligament complex are associated with lesions of the posterior tibiotalar ligament.
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Affiliation(s)
- Erik Volmer
- Institut für Diagnostische und Interventionelle Radiologie, Kinder- und Neuroradiologie, Universitätsmedizin Rostock, Ernst-Heydemann-Str. 6, 18057, Rostock, Deutschland.
| | - Thomas Mittlmeier
- Klinik für Unfall‑, Hand- und Wiederherstellungschirurgie, Universitätsmedizin Rostock, Rostock, Deutschland
| | - Marc-André Weber
- Institut für Diagnostische und Interventionelle Radiologie, Kinder- und Neuroradiologie, Universitätsmedizin Rostock, Ernst-Heydemann-Str. 6, 18057, Rostock, Deutschland
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Volmer E, Mittlmeier T, Weber MA. [Ligamentous injuries of the ankle joint : Importance of radiological imaging procedures]. RADIOLOGIE (HEIDELBERG, GERMANY) 2023:10.1007/s00117-023-01181-0. [PMID: 37490065 DOI: 10.1007/s00117-023-01181-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Accepted: 06/21/2023] [Indexed: 07/26/2023]
Abstract
Injuries of the ankle joint show lesions of the lateral ligamentous apparatus with an incidence of 1 in 1000 cases. With a range of 0.3-0.7 in 1000 cases, injuries of the medial ligamentous apparatus occur more frequently than previously thought and are often overlooked. Correct imaging diagnostics of the ankle ligaments are mandatory for the prognosis and treatment planning. In cases of clinically strong suspicion of ligamentous injury or osteochondral lesions of the ankle joint, after primary radiographic evaluation magnetic resonance imaging (MRI) is primarily recommended for a more precise assessment. Additionally, the sensitivity for assessment of the ligaments with ultrasonography is good (91% vs. 97% with MRI) but its specificity is inferior compared to MRI (63% vs. 93% with MRI). Supination trauma is the most common ankle injury and attention should be paid to the anterior tibiofibular ligament and calcaneofibular ligament. In approximately 50%, injuries to the superficial layer of the medial collateral ligament complex are associated with lesions of the posterior tibiotalar ligament.
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Affiliation(s)
- Erik Volmer
- Institut für Diagnostische und Interventionelle Radiologie, Kinder- und Neuroradiologie, Universitätsmedizin Rostock, Ernst-Heydemann-Str. 6, 18057, Rostock, Deutschland.
| | - Thomas Mittlmeier
- Klinik für Unfall‑, Hand- und Wiederherstellungschirurgie, Universitätsmedizin Rostock, Rostock, Deutschland
| | - Marc-André Weber
- Institut für Diagnostische und Interventionelle Radiologie, Kinder- und Neuroradiologie, Universitätsmedizin Rostock, Ernst-Heydemann-Str. 6, 18057, Rostock, Deutschland
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Ivanova V, Todd NW, Yurgelon J. Dance-Related Foot and Ankle Injuries and Pathologies. Clin Podiatr Med Surg 2023; 40:193-207. [PMID: 36368843 DOI: 10.1016/j.cpm.2022.07.013] [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: 11/16/2022]
Abstract
Dancers are highly vulnerable to injuries due to high dynamic overload, extreme positions and motions, and excessive use. Increased load at the forefoot with jumping and high-impact lands can cause sesamoiditis and stress fractures of the metatarsals. Significant plantarflexion can lead to posterior joint impingement and flexor hallucis longus tendonitis, whereas forced dorsiflexion can cause anterior joint impingement. Most pathologies can be diagnosed on physical examination and various imaging modalities. Treatment should be tailored to the dancers' needs and should begin with a course of conservative therapy with immobilization, physical therapy, and activity cessation.
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Affiliation(s)
- Varsha Ivanova
- Kaiser Permanente, 710 Lawrence Expressway, Santa Clara, CA 95051, USA
| | - Nicholas W Todd
- Palo Alto Medical Foundation Mountain View Center, 701 East EL Camino Real, Mountain View, CA 94040, USA
| | - Jesse Yurgelon
- Palo Alto Medical Foundation Mountain View Center, 701 East EL Camino Real, Mountain View, CA 94040, USA.
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Rui Xiang T, Zhen Ning Y, Oon Thien Kevin K. Two-Year Outcomes of Posterior Ankle Arthroscopy: A Case Series. Foot Ankle Spec 2022; 15:556-562. [PMID: 33435736 DOI: 10.1177/1938640020985822] [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] [Indexed: 11/17/2022]
Abstract
The aim of this study was to investigate the outcomes and complications after posterior ankle arthroscopy for the treatment of posterior ankle impingement syndrome, in a local population with a single surgeon series. Two-portal posterior ankle or hindfoot arthroscopy is an alternative option to open surgery in cases of posterior ankle impingement, that showed similar results but with less morbidity and faster recovery. There has been increasing interest in minimally invasive surgical techniques. Indications include extra- and intra-articular conditions and range from bony, cartilaginous to soft tissue pathology. Posterior ankle arthroscopy has been shown to be a good option in cases that are refractory to a period of conservative therapy. Posterior ankle arthroscopy also has known complications of sural nerve damage laterally and neurovascular bundle injury medially and also a steep learning curve that has been studied in the context of os trigonum excision. There have been few or no studies on the local Singaporean population and this article seeks to describe the various indications, results, and complications in the local Singaporean population by a single surgeon.Levels of Evidence: Level IV: Case series.
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Affiliation(s)
| | - Yeo Zhen Ning
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
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Posterior Ankle Impingement Syndrome Clinical Features Are Not Associated With Imaging Findings in Elite Ballet Dancers and Athletes. Clin J Sport Med 2022; 32:600-607. [PMID: 36315819 DOI: 10.1097/jsm.0000000000001021] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 01/11/2022] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To assess the association between clinical features and magnetic resonance imaging (MRI) findings in posterior ankle impingement syndrome (PAIS) and to compare the prevalence of imaging findings between participants with and without a clinical diagnosis of PAIS. DESIGN Case-control study. SETTING Elite ballet and sport. PARTICIPANTS Eighty-two male (54%) and female participants comprising ballet dancers (n = 43), cricket fast bowlers (n = 24), and football (soccer) players (n = 15). INDEPENDENT VARIABLES Clinical: posterior ankle pain on body chart, passive plantarflexion pain provocation test. Patient-reported outcome measures: Oslo Sports Trauma Research Center Overuse Injury Questionnaire, Foot and Ankle Ability Measure Sports subscale. MAIN OUTCOME MEASURES Imaging findings including posterior ankle bone marrow edema, os trigonum (± bone marrow edema, and increased signal at synchondrosis), Stieda process (± bone marrow edema), talocrural and subtalar joint effusion-synovitis size, flexor hallucis longus tendinopathy, and tenosynovitis identified as present or absent on 3.0-Tesla MRI. RESULTS Imaging findings were not associated with posterior ankle pain or a positive ankle plantarflexion pain provocation test. Imaging findings were not associated with patient-reported outcome measures. Imaging findings did not differ between PAIS-positive and PAIS-negative groups. Os trigonum and Stieda process were prevalent despite clinical status. CONCLUSIONS The lack of association between imaging findings and clinical features questions the role of imaging in PAIS. Clinicians should rely primarily on clinical assessment in the diagnosis and management of patients with PAIS.
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Kinugasa K, Shimomura K, Tachibana Y, Hiramatsu K, Horibe S, Shino K, Tanaka Y. Posterior Ankle Impingement Caused by Hyaline-Like Cartilage Generation in Ballet Dancers-A Report of 2 Cases. J Foot Ankle Surg 2022; 61:e9-e14. [PMID: 34801380 DOI: 10.1053/j.jfas.2021.10.015] [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: 09/09/2019] [Revised: 04/03/2020] [Accepted: 10/11/2021] [Indexed: 02/03/2023]
Abstract
Posterior ankle impingement syndrome is mainly seen in ballet dancers and frequently associated with specific movements in ballet such as pointe and demi pointe in which the whole-body weight is applied to the maximally plantar flexed ankle. We performed arthroscopic debridement for 2 dedicated ballet dancers on the intervening soft tissue causing posterior ankle impingement syndrome (PAIS). In both cases, T2-weighted magnetic resonance imaging (MRI) revealed low-signal intensity of meniscus-like soft tissue without abnormal osseous findings, connecting from the posterior side of the talus to Kager's fat pad. To examine the intervening soft tissue in detail, we performed histological evaluation by hematoxylin and eosin staining, Safranin O fast green staining, and immunohistochemistry for type I collagen and type II collagen. Hematoxylin and eosin staining showed that there was cartilage-like tissue including chondrocyte-like cells in contact with fibrous tissue. The extracellular matrix in the cartilage zone was consistently stained by Safranin O staining and type II collagen without any staining with type I collagen. These findings suggested that the meniscus-like soft tissue appearing as low-signal intensity on MRI at the posterior side of talus included hyaline-like cartilage. To the extent of our knowledge, these were rare cases of hyaline-like cartilage generation causing PAIS in ballet dancers, which might be associated with ballet specific movements resulting in chondrogenesis.
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Affiliation(s)
- Kazutaka Kinugasa
- Department of Orthopaedic Sports Medicine, Osaka Rosai Hospital, Sakai, Osaka, Japan.
| | - Kazunori Shimomura
- Department of Orthopaedic Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Yuta Tachibana
- Department of Orthopaedic Sports Medicine, Osaka Rosai Hospital, Sakai, Osaka, Japan
| | - Kunihiko Hiramatsu
- Department of Orthopaedic Surgery, Tamai Orthopaedic Hospital, Hannan, Osaka, Japan
| | - Shuji Horibe
- Faculty of Comprehensive Rehabilitation, Osaka Prefecture University, Habikino, Osaka, Japan
| | - Konsei Shino
- Department of Sports Orthopaedics, Yukioka Hospital, Kita-ku, Osaka, Osaka, Japan
| | - Yoshinari Tanaka
- Department of Orthopaedic Sports Medicine, Osaka Rosai Hospital, Sakai, Osaka, Japan
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Gorelik N, Casagranda BU, Colucci PG, Green JL, Roedl JB, Morrison WB, Zoga AC. Spotty Bone Marrow: A Frequent MRI Finding in the Feet of Ballet Dancers. J Dance Med Sci 2022; 26:125-133. [PMID: 35287786 DOI: 10.12678/1089-313x.061522e] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Bone marrow signal abnormalities on magnetic resonance imaging (MRI) are common in athletes. However, few studies evaluate the MRI appearance of bone marrow in the feet of ballet dancers. Our study aims to describe the "spotty bone marrow" (SBM) pattern in the tarsal bones of a cohort of ballet dancers, establishing its prevalence, distribution, potential associations, and evolution.<br/> Methods: Eighty-six MRIs of 68 ankles in 56 ballet dancers were retrospectively reviewed for mar- row signal alterations, which were classified as focal or SBM (defined as patchy fluid-sensitive signal hyperintensity spanning more than one location or tarsal bone). When SBM involved the talus, its anatomic distribution in the bone and morphologic pattern were recorded. Additional osseous and soft tissue findings were documented. For subjects with more than one MRI of the same ankle, the SBM's evolution was monitored.<br/> Results: Spotty bone marrow was identified in 44 ankles (65%). Spotty bone marrow was isolated to the talus (44%), present in all tarsal bones (25%), or distributed between the talus and one to three other tarsal bones (31%). In the talus, The SBM involved the entire bone (65%), the neck and body (31%), or the head and neck (4%). The SBM most commonly showed a random morphologic pattern (87%) but occasionally showed a peripheral predominance (13%). There was no statistically significant difference in the prevalence of other pathologies in ankles with and without SBM. In eight ankles with a follow-up MRI, the SBM worsened in one, remained stable in two, and improved in five ankles. None progressed to a stress fracture.<br/> Conclusion: Spotty bone marrow is an MRI finding frequently encountered in ballet dancers. It is usually self-limiting and should not be misinterpreted as a more aggressive pathology.
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Affiliation(s)
| | | | | | | | - Johannes B Roedl
- Thomas Jefferson University Hospital, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - William B Morrison
- Thomas Jefferson University Hospital, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Adam C Zoga
- Thomas Jefferson University Hospital, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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Baillie P, Mayes S, Lam J, Ferrar K, Cook J. Associations between clinical and imaging findings in posterior ankle impingement syndrome: a systematic review. Acta Radiol 2022; 63:652-657. [PMID: 33874783 DOI: 10.1177/02841851211008389] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
BACKGROUND Posterior ankle impingement syndrome (PAIS) is a common and debilitating condition, commonly affecting people who participate in activities that involve repetitive ankle plantarflexion. The relationship between clinical and imaging findings in PAIS has not been established. PURPOSE To investigate the relationship between clinical and imaging features in PAIS by reviewing the literature comparing symptomatic patients to asymptomatic controls. MATERIAL AND METHODS A systematic literature search was performed to identify all English-language articles that compared imaging features in patients diagnosed with PAIS to imaging in an asymptomatic control group. RESULTS A total of 8394 articles were evaluated by title and abstract, and 156 articles were read in full text. No articles compared imaging findings to an asymptomatic control group, thus no articles met the inclusion criteria. CONCLUSION This systematic review found no published research that compared the imaging findings of people diagnosed with PAIS to asymptomatic people. Until this information is available, imaging features in people with posterior ankle impingement should be interpreted with caution.
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Affiliation(s)
- Peta Baillie
- School of Allied Health, Human Services and Sport, La Trobe University, Bundoora, VIC, Australia
| | - Susan Mayes
- The Australian Ballet, South Melbourne, VIC, Australia
- La Trobe University Sport and Exercise Medicine Research Centre, La Trobe University, Bundoora, VIC, Australia
| | - Jason Lam
- The Australian Ballet, South Melbourne, VIC, Australia
| | - Katia Ferrar
- The Australian Ballet, South Melbourne, VIC, Australia
- La Trobe University Sport and Exercise Medicine Research Centre, La Trobe University, Bundoora, VIC, Australia
| | - Jill Cook
- La Trobe University Sport and Exercise Medicine Research Centre, La Trobe University, Bundoora, VIC, Australia
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Barchi EI, Swensen S, Dimant OE, McKay TE, Rose DJ. Flexor Hallucis Longus Tenolysis and Tenosynovectomy in Dancers. J Foot Ankle Surg 2022; 61:84-87. [PMID: 34301473 DOI: 10.1053/j.jfas.2020.04.028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2019] [Revised: 04/03/2020] [Accepted: 04/08/2020] [Indexed: 02/03/2023]
Abstract
The purpose of this study was to report on a series of dancers who had undergone flexor hallucis longus (FHL) tenolysis/tenosynovectomy after having failed conservative management. Institutional human subjects committee approval was obtained prior to initiating this study. This study is a retrospective case series of 58 dancers and 63 ankles who underwent FHL tenolysis/tenosynovectomy via an open posteromedial approach by a single surgeon between 1993 and 2017. All patients were interviewed and charts reviewed. Collected variables included: preoperative and postoperative pain levels, time to return to dance, and subjective satisfaction with the procedure. Age, primary dance form, and level of dance were determined. Mean preoperative pain level decreased significantly postoperatively. Mean time to return to dance was 7.1 weeks. There was a 98% (62/63) return to dance at some level while 97% (61/63) of patients returned to dance symptom-free. There were no neurovascular or other major complications. Minor complications included stiffness at follow-up (6.3%, 4/63), superficial wound infection (3.1%, 2/63), and hypertrophic scar (4.8%, 3/63). Over 97% (61/63) of dancers considered the procedure a success and 98% (62/63) of dancers would repeat the procedure. This is one of the largest series reported of isolated FHL tenolysis/tenosynovectomy in dancers who have failed nonoperative management. Satisfactory pain relief and return to dance with a low complication rate may be expected from this surgical procedure. The results of this study can be used to help dancers and their providers make informed decisions about treatment in isolated FHL tendinitis.
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Affiliation(s)
- Elizabeth I Barchi
- Clinical Assistant Professor, Department of Orthopedics, NYU Langone Health, New York, NY.
| | - Stephanie Swensen
- Fellow, Department of Orthopedics, Hospital for Special Surgery, New York, NY
| | - Oscar E Dimant
- Resident, Department of Physical Medicine and Rehabilitation, Rutgers New Jersey Medical School, Newark, NJ
| | - Tracy Espiritu McKay
- Clinical Assistant Professor, Department of Physical Medicine and Rehabilitation, NYU Langone Health, New York, NY
| | - Donald J Rose
- Clinical Associate Professor, Department of Orthopedics, NYU Langone Health, New York, NY
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16
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Baillie P, Cook J, Ferrar K, Smith P, Lam J, Mayes S. Magnetic resonance imaging findings associated with posterior ankle impingement syndrome are prevalent in elite ballet dancers and athletes. Skeletal Radiol 2021; 50:2423-2431. [PMID: 34013446 DOI: 10.1007/s00256-021-03811-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Revised: 05/01/2021] [Accepted: 05/06/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To report the prevalence of MRI features commonly associated with posterior ankle impingement syndrome in elite ballet dancers and athletes and to compare findings between groups. MATERIALS AND METHODS Thirty-eight professional ballet dancers (47.4% women) were age- and sex-matched to 38 elite soccer or cricket fast bowler athletes. All participants were training, playing, and performing at full workload and underwent 3.0-T standardised magnetic resonance imaging of one ankle. De-identified images were assessed by one senior musculoskeletal radiologist for findings associated with posterior ankle impingement syndrome (os trigonum, Stieda process, posterior talocrural and subtalar joint effusion-synovitis, flexor hallucis longus tendon pathology and tenosynovitis, and posterior ankle bone marrow oedema). Imaging scoring reliability testing was performed. RESULTS Posterior talocrural effusion-synovitis (90.8%) and subtalar joint effusion-synovitis (93.4%) were common in both groups, as well as the presence of either an os trigonum or Stieda process (61.8%). Athletes had a higher prevalence of either os trigonum or Stieda process than dancers (74%, 50% respectively, P = 0.03). Male athletes had a higher prevalence of either os trigonum or Stieda process than male dancers (90%, 50% respectively, P = 0.01), or female athletes (56%, P = 0.02). Posterior subtalar joint effusion-synovitis size was larger in dancers than athletes (P = 0.02). Male and female dancers had similar imaging findings. There was at least moderate interobserver and intraobserver agreement for most MRI findings. CONCLUSION Imaging features associated with posterior impingement were prevalent in all groups. The high prevalence of os trigonum or Stieda process in male athletes suggests that this is a typical finding in this population.
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Affiliation(s)
- Peta Baillie
- School of Allied Health, Human Services and Sport, La Trobe University, Bundoora, VIC, 3086, Australia.
| | - Jill Cook
- La Trobe University Sport and Exercise Medicine Research Centre, La Trobe University, Bundoora, VIC, 3086, Australia
| | - Katia Ferrar
- La Trobe University Sport and Exercise Medicine Research Centre, La Trobe University, Bundoora, VIC, 3086, Australia.,The Australian Ballet, VIC, PO Box 838, South Melbourne, 3205, Australia
| | - Peter Smith
- I-MED Radiology East Melbourne, VIC, Level 1/141 Grey Street, East Melbourne, 3002, Australia
| | - Jason Lam
- The Australian Ballet, VIC, PO Box 838, South Melbourne, 3205, Australia
| | - Susan Mayes
- La Trobe University Sport and Exercise Medicine Research Centre, La Trobe University, Bundoora, VIC, 3086, Australia.,The Australian Ballet, VIC, PO Box 838, South Melbourne, 3205, Australia
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Causes of delayed diagnosis of posterior ankle impingement in the pediatric and adolescent population. Foot (Edinb) 2021; 47:101799. [PMID: 33957524 DOI: 10.1016/j.foot.2021.101799] [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: 05/09/2020] [Revised: 03/24/2021] [Accepted: 04/03/2021] [Indexed: 02/04/2023]
Abstract
PURPOSE The purpose of this study was to identify and characterize various causes of delay in the diagnosis of posterior ankle impingement syndrome (PAIS) in pediatric patients. METHODS IRB approved prospective study of patients under 18 years who underwent arthroscopic surgery for the diagnosis of posterior ankle impingement after failed conservative treatment at a tertiary children's hospital. Radiographic findings were compared with an age-matched control group. Descriptive and inferential statistics were employed. RESULTS 47 patients (61 ankles), mean age 13 years, had an average 14 months delay in diagnosis of PAIS from the initial presentation. 33 (70%) patients had seen multiple medical providers and given other diagnoses. 9 (19%) patients participated in ballet or soccer, and 16 (34%) patients had unrelated associated foot and ankle diagnoses. 25 (41%) of 61 ankles did not have pain on forced plantar flexion; all 61(100%) ankles had tenderness to palpation over the posterior ankle joint line. Radiographs were reported to be normal in 37/52 (71%) ankles, while MRI report did not mention the diagnosis in 20/41 (49%) studies. There was a significant difference in the MRI findings in the patient population when compared to the control group. Indication for surgery was failed conservative treatment. All 61 ankles had posterior ankle impingement pathology confirmed visually during arthroscopy. At average 15 months follow-up, there was significant improvement pre- to post-operatively (p<0.001) for both pain VAS (6.9-0.9) and AOFAS ankle-hindfoot scores (65-94). CONCLUSION Multiple clinical and imaging factors can lead to delayed diagnosis of posterior ankle impingement. An increased awareness about the features of PAIS is needed amongst medical providers involved in treating young patients.
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Walsh KP, Durante EC, Moser BR, Coetzee JC, Stone McGaver R. Surgical Outcomes of Os Trigonum Syndrome in Dancers: A Case Series. Orthop J Sports Med 2020; 8:2325967120938767. [PMID: 32743013 PMCID: PMC7376299 DOI: 10.1177/2325967120938767] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Accepted: 03/09/2020] [Indexed: 11/17/2022] Open
Abstract
Background Management of ankle pain in dancers can be challenging because of the repetitive stress and complex demands placed on this region. Despite the prevalence of ankle injuries in this population, literature on surgical outcomes and return to dance is limited. Purpose To retrospectively evaluate the efficacy and functional outcomes after surgical excision of a symptomatic os trigonum in dancers. Study Design Case series; Level of evidence, 4. Methods Between June 2006 and June 2016, a total of 44 dancers underwent surgical excision of a symptomatic os trigonum at a single institution and by a single surgeon. All patients presented with symptoms of posterior ankle impingement syndrome and subsequently failed nonsurgical treatment. Clinical analysis was conducted using various pre- and postoperative patient-reported outcome questionnaires, including the Veterans RAND 12-Item Health Survey (VR-12), Foot Function Index-Revised (FFI-R), and visual analog scale (VAS) for pain, as well as subjective patient satisfaction. Results A total of 44 patients (54 ankles; mean age, 18.2 years) were retrospectively evaluated at a mean follow-up of 33.4 months. The VR-12 Physical Health score improved from a mean score of 37.8 ± 11.9 to 51.2 ± 10.5 (P < .001). The cumulative FFI-R score improved from 46.45 ± 13.8 to 31.2 ± 9.7 (P = .044), with the subcategory of "activity limitation" representing the highest-scoring FFI-R subcategory at 65.28 ± 13.4 preoperatively and improving to 34.47 ± 12.4 at follow-up (P < .001). The mean VAS score for subjective pain improved significantly from 5.39 ± 2.84 to 1.73 ± 2.10 (P < .00044). Conclusion Overall, the findings of the present study demonstrate that dancers of varying style and level improved significantly according to various clinical measures. Patients included in this study reported that they returned to their previous level of dance upon completion of physical therapy and maintained thriving postoperative careers, which for several meant dancing at the professional level.
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Affiliation(s)
- Keifer P Walsh
- Alabama College of Osteopathic Medicine, Dothan, Alabama, USA
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Nikolopoulos D, Safos G, Moustakas K, Sergides N, Safos P, Siderakis A, Kalpaxis D, Moutsios-Rentzos A. Endoscopic Treatment of Posterior Ankle Impingement Secondary to Os Trigonum in Recreational Athletes. FOOT & ANKLE ORTHOPAEDICS 2020; 5:2473011420945330. [PMID: 35097403 PMCID: PMC8697201 DOI: 10.1177/2473011420945330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Background: The os trigonum (OT)—the most common accessory bone of the foot—although usually asymptomatic, may cause posterior ankle impingement syndrome (PAIS), which may be a severely debilitating problem for recreational or competitive athletes. The aim of the present study was to evaluate effectiveness of posterior ankle arthroscopy and to assess the outcome in the treatment of PAIS secondary to OT impingement or OT fractures within a group of young athletes and their return to previous sports level. Methods: From 2011 to 2018, a retrospective review of 81 recreational athletes of mean age 27.8 years was performed. All patients were diagnosed with PAIS due to OT pathology and were operated on endoscopically with resection of the OT. Pre- and postoperative clinical evaluation were performed at 3 months, 1 year, and 2 years based on visual analog scale (VAS), ankle range of motion (ROM), American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot score, and the Foot & Ankle Disability Index (FADI) scores, in a follow-up of at least 2 years. Results: VAS score was significantly improved from an average of 7.5 (5-9) preoperatively to 1.9 (1-3) at 3 months postoperatively and to 0.6 (0-2) and 0.3 (0 -1) at 1 and 2 years postoperatively. Ankle ROM was significantly improved from an average of 24.8 (10-35) preoperatively to 58.0 (50-65) at 3 months postoperatively and to 64.0 (50-65) at 1 year and 64.7 (60-65) at 2 years postoperatively. AOFAS and FADI scores were significantly improved from 39.4 (18-55) and 49.7 (42.3-62.5) preoperatively to 85.2 (74-89) and 87.3 (81.7-88.5) postoperatively at 3 months to 97.7 (85-100) and 97.9 (93.3-100) postoperatively at 1 year, respectively (P < .001). Only 5 patients dropped to a lower activity level. There were 5 complications (4 transient). Conclusion: Endoscopic treatment of PAIS due to OT pathology demonstrated excellent results. Posterior ankle arthroscopy was an effective treatment and allowed for a prompt return to a high activity level of their athletic performance. Level of Evidence: Level IV, therapeutic study / retrospective case series.
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Affiliation(s)
- Dimitrios Nikolopoulos
- Central Clinic of Athens, Orthopaedic, Athens, Greece
- Orthopaedic Research Institute for Education and Training, Athens, Greece
| | - George Safos
- Central Clinic of Athens, Orthopaedic, Athens, Greece
- Orthopaedic Research Institute for Education and Training, Athens, Greece
| | - Konstantinos Moustakas
- Central Clinic of Athens, Orthopaedic, Athens, Greece
- Orthopaedic Research Institute for Education and Training, Athens, Greece
| | - Neoptolemos Sergides
- Central Clinic of Athens, Orthopaedic, Athens, Greece
- Orthopaedic Research Institute for Education and Training, Athens, Greece
| | - Petros Safos
- Orthopaedic Research Institute for Education and Training, Athens, Greece
- Ikaria General Hospital, Orthopaedic, Ikaria, Greece
| | | | - Dimitrios Kalpaxis
- Orthopaedic Research Institute for Education and Training, Athens, Greece
- Physiotherapist; Rehabilitation Center of Central Clinic of Athens, Greece
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20
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Batista JP, Duarte Pereira HM, van Dijk CN, Del Vecchio JJ. Posterior arthroscopic treatment of ankle osteochondral lesions: technical note. J ISAKOS 2020. [DOI: 10.1136/jisakos-2019-000375] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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21
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Chronic Lower Leg Pain in Athletes: Overview of Presentation and Management. HSS J 2020; 16:86-100. [PMID: 32015745 PMCID: PMC6973789 DOI: 10.1007/s11420-019-09669-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2018] [Accepted: 01/07/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Athletes with chronic lower leg pain present a diagnostic challenge for clinicians due to the differential diagnoses that must be considered. PURPOSE/QUESTIONS We aimed to review the literature for studies on the diagnosis and management of chronic lower leg pain in athletes. METHODS A literature review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA). The PubMed, Scopus, and Cochrane library databases were searched, and articles that examined chronic lower leg pain in athletes were considered for review. Two independent reviewers conducted the search utilizing pertinent Boolean operations. RESULTS Following two independent database searches, 275 articles were considered for initial review. After the inclusion and exclusion criteria were applied, 88 were included in the final review. These studies show that the most common causes of lower leg pain in athletes include medial tibial stress syndrome, chronic exertional compartment syndrome, tibial stress fractures, nerve entrapments, lower leg tendinopathies, and popliteal artery entrapment syndrome. Less frequently encountered causes include saphenous nerve entrapment and tendinopathy of the popliteus. Conservative management is the mainstay of care for the majority of cases of chronic lower leg pain; however, surgical intervention may be necessary. CONCLUSIONS Multiple conditions may result in lower leg pain in athletes. A focused clinical history and physical examination supplemented with appropriate imaging studies can guide clinicians in diagnosis and management. We provide a table to aid in the differential diagnosis of chronic leg pain in the athlete.
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22
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Kushare I, Ditzler MG, Jadhav SP. Delayed diagnosis of posterior ankle impingement in pediatric and adolescent patients: does radiology play a role? Pediatr Radiol 2020; 50:216-223. [PMID: 31707447 DOI: 10.1007/s00247-019-04547-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Revised: 08/29/2019] [Accepted: 09/24/2019] [Indexed: 12/19/2022]
Abstract
BACKGROUND Posterior ankle impingement syndrome (PAIS) results from the pinching of anatomical structures in the posterior part of the ankle. OBJECTIVE To identify the possible role of imaging in the delayed diagnosis of PAIS and identify key findings on imaging to suggest PAIS in pediatric and adolescent patients. MATERIALS AND METHODS Data were collected prospectively in patients younger than 18 years of age who underwent arthroscopy after being diagnosed with PAIS. Imaging was reviewed retrospectively by two radiologists, compared with findings in literature and an age-matched control group, and correlated with arthroscopic findings. Pre- and postsurgical Visual Analogue Scale (VAS) pain and American Orthopedic Foot Ankle Society (AOFAS) ankle-hindfoot scores were noted. RESULTS Thirty-eight patients (20 females, 18 males), 51 ankles, with an average age of 12.9 years had an average 18-month delay in diagnosis. Twenty-seven of the 38 (73%) patients had previously seen multiple medical providers and were given multiple misdiagnoses. Radiographs were reported normal in 34/47 (72%) ankles. Thirty patients had magnetic resonance imaging (MRI) and findings included the presence of an os trigonum/Stieda process (94%) with associated osseous edema (69%), flexor hallucis longus (FHL) tenosynovitis (16%), and edema in Kager's fat pad (63%). Although individual findings were noted, the impression in the MRI reports in 16/32 (50%) did not mention PAIS as the likely diagnosis. There was a significant difference in the MRI findings of ankle impingement in the patient population when compared to the control group. Surgery was indicated after conservative treatment failed. All 51 ankles had a PAIS diagnosis confirmed during arthroscopy. At an average follow-up of 10.2 months, there was improvement of VAS pain (7.0 to 1.1) and AOFAS ankle-hindfoot scores (65.1 to 93.5). CONCLUSION PAIS as a diagnosis is commonly delayed clinically in young patients with radiologic misinterpretation being a contributing factor. Increased awareness about this condition is needed among radiologists and physicians treating young athletes.
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Affiliation(s)
- Indranil Kushare
- Department of Orthopedics, Texas Children's Hospital, Houston, TX, USA
| | - Matthew G Ditzler
- E. B. Singleton Department of Pediatric Radiology, Texas Children's Hospital, 6701 Fannin St., Suite 470, Houston, TX, 77030, USA
| | - Siddharth P Jadhav
- E. B. Singleton Department of Pediatric Radiology, Texas Children's Hospital, 6701 Fannin St., Suite 470, Houston, TX, 77030, USA.
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Abstract
Members of the International Skeletal Society compiled a glossary of terms for musculoskeletal radiology. The authors also represent national radiology or pathology societies in Asia, Australia, Europe, and the USA. We provide brief descriptions of musculoskeletal structures, disease processes, and syndromes and address their imaging features. Given the abundance of musculoskeletal disorders and derangements, we chose to omit most terms relating to neoplasm, spine, intervention, and pediatrics. Consensus agreement was obtained from 19 musculoskeletal radiology societies worldwide.
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Kushare I, Kastan K, Allahabadi S. Posterior ankle impingement–an underdiagnosed cause of ankle pain in pediatric patients. World J Orthop 2019; 10:364-370. [PMID: 31750084 PMCID: PMC6854055 DOI: 10.5312/wjo.v10.i10.364] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2019] [Revised: 08/08/2019] [Accepted: 09/16/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Posterior ankle impingement syndrome (PAIS) is a cause of ankle pain due to pinching of bony or soft tissue structures in the hindfoot. The diagnosis is primarily made based on detailed history and accurate clinical examination. The delay in its diagnosis has not yet been described in the pediatric and adolescent population.
AIM To identify and characterize misdiagnosed cases of PAIS in pediatric and adolescent patients.
METHODS This descriptive prospective study at a tertiary children’s hospital included patients ≤ 18 years who underwent posterior ankle arthroscopy after presenting with chronic posterior ankle pain after being diagnosed with PAIS. Collected data included: Demographics, prior diagnoses and treatments, providers seen, time to diagnosis from presentation, and prior imaging obtained. Visual Analogue Scale (VAS) for pain and American Orthopedic Foot Ankle Society (AOFAS) ankle-hindfoot scores were noted at initial presentation and follow-up.
RESULTS 35 patients (46 ankles) with average age of 13 years had an average 19 mo (range 0-60 mo) delay in diagnosis from initial presentation. 25 (71%) patients had previously seen multiple medical providers and were given multiple other diagnoses. All 46 (100%) ankles had tenderness to palpation over the posterior ankle joint. Radiographs were reported normal in 31/42 (72%) exams. In 32 ankles who underwent MRI, the most common findings included os trigonum (47%)/Stieda process (47%). Conservative treatment had already been attempted in all patients. Ankle impingement pathology was confirmed during arthroscopy in 46 (100%) ankles. At an average follow-up of 13.1 mo, there was an improvement of VAS (pre-op 7.0 to post-op 1.2) and AOFAS scores (pre-op 65.1 to post-op 94).
CONCLUSION This is the first study which shows that PAIS is a clinically misdiagnosed cause of posterior ankle pain in pediatric and adolescent population; an increased awareness about this diagnosis is needed amongst providers treating young patients.
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Affiliation(s)
- Indranil Kushare
- Department of Orthopaedics, Texas Children’s hospital, The Woodlands, TX 77384, United States
| | - Kristen Kastan
- Department of Orthopaedics, Texas Children’s hospital, The Woodlands, TX 77384, United States
| | - Sachin Allahabadi
- Department of Orthopaedics, University of California, San Francisco, CA 94143, United States
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Os Conundrum: Identifying Symptomatic Sesamoids and Accessory Ossicles of the Foot. AJR Am J Roentgenol 2019; 213:417-426. [DOI: 10.2214/ajr.18.20761] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Edama M, Takabayashi T, Inai T, Hirabayashi R, Ikezu M, Kaneko F, Kanta M, Kageyama I. Morphological features of the posterior intermalleolar ligament. Surg Radiol Anat 2019; 41:1441-1443. [PMID: 31338536 DOI: 10.1007/s00276-019-02295-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Accepted: 07/19/2019] [Indexed: 10/26/2022]
Abstract
PURPOSE In the present study, the posterior intermalleolar ligament (PIML) was classified by type using large-scale cadavers to provide basic information to help elucidate the mechanism of ankle joint posterior impingement syndrome. METHODS This investigation examined 100 legs from 49 Japanese cadavers (mean age at death, 79 ± 11 years; 58 sides from men, 42 from women). In the classification method, an absent PIML was classified as Type I, a PIML with one fiber bundle (attachment to one place) was Type II, a PIML with two fiber bundles (attachment to two places) was Type III, and a PIML with three fiber bundles (attachment to three or more places) was Type IV. Furthermore, according to other adhering tissues, they were further subdivided and classified by type. RESULTS There were various types of PIML: 19 (19%) Type I; 24 (24%) Type II; 23 (23%) Type III; and 34 (34%) Type IV. A PIML was present in 81 legs (81%). There were no significant differences between men and women and between left and right sides. CONCLUSIONS The complex relationships of the PIML with the surrounding ligaments and tissues are considered to be among the factors that make interpretation of imaging findings difficult.
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Affiliation(s)
- Mutsuaki Edama
- Institute for Human Movement and Medical Sciences, Niigata University of Health and Welfare, Shimami-cho 1398, Kita-ku, Niigata, 950-3198, Japan. .,Department of Anatomy, School of Life Dentistry at Niigata, Nippon Dental University, Niigata, Japan.
| | - T Takabayashi
- Institute for Human Movement and Medical Sciences, Niigata University of Health and Welfare, Shimami-cho 1398, Kita-ku, Niigata, 950-3198, Japan
| | - T Inai
- Institute for Human Movement and Medical Sciences, Niigata University of Health and Welfare, Shimami-cho 1398, Kita-ku, Niigata, 950-3198, Japan
| | - R Hirabayashi
- Institute for Human Movement and Medical Sciences, Niigata University of Health and Welfare, Shimami-cho 1398, Kita-ku, Niigata, 950-3198, Japan
| | - M Ikezu
- Institute for Human Movement and Medical Sciences, Niigata University of Health and Welfare, Shimami-cho 1398, Kita-ku, Niigata, 950-3198, Japan
| | - F Kaneko
- Institute for Human Movement and Medical Sciences, Niigata University of Health and Welfare, Shimami-cho 1398, Kita-ku, Niigata, 950-3198, Japan
| | - M Kanta
- Institute for Human Movement and Medical Sciences, Niigata University of Health and Welfare, Shimami-cho 1398, Kita-ku, Niigata, 950-3198, Japan
| | - I Kageyama
- Department of Anatomy, School of Life Dentistry at Niigata, Nippon Dental University, Niigata, Japan
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Özer M, Yıldırım A. Evaluation of the Prevalence of Os Trigonum and Talus Osteochondral Lesions in Ankle Magnetic Resonance Imaging of Patients With Ankle Impingement Syndrome. J Foot Ankle Surg 2019; 58:273-277. [PMID: 30612863 DOI: 10.1053/j.jfas.2018.08.043] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2018] [Indexed: 02/03/2023]
Abstract
The prevalence of os trigonum and osteochondral lesions of talus (OCLT) have been presented in different prevalences among different groups in the literature for the patients with ankle impingement syndrome. Our main objective in the study was to determine the possible relationship between the impingement syndrome and the prevalence of os trigonum and OCLT in specific groups. The presence of anterior ankle impingement syndrome (AAIS), posterior ankle impingement syndrome (PAIS), os trigonum, OCLT, and the location of OCLT were evaluated in a blinded manner on magnetic resonance imaging from patients clinically considered to be diagnosed with ankle impingement syndrome from January 2014 to July 2017. The patients were separated into specific groups according to the confirmation of their clinical diagnosis of ankle impingement syndrome on magnetic resonance imaging . A total of 333 patients were included. The prevalence of os trigonum was found to be 1.3% in patients with PAIS(-) AAIS(+), 7.7% in patients with PAIS(-) AAIS(-), 63.3% in patients with PAIS(+) AAIS(-), and 81.1% in patients with PAIS(+) AAIS(+) (p < .001). The prevalence of OCLT was found to be 41.3% in patients with PAIS(-) AAIS(+), 23.1% in patients with PAIS(-) AAIS(-), 18.3% in patients with PAIS(+) AAIS(-), and 27% in patients with PAIS(+) AAIS(+) (p= .005). Our study showed that, for patients with isolated PAIS and AAIS combined with PAIS, the prevalence of os trigonum was 63.3% and 81.1%, respectively, which is more common than previously reported. For patients with isolated AAIS and PAIS, the prevalence of OCLT was 41.3% and 18.3%, respectively. Of the OCLTs combined with ankle impingement syndromes, 87.1% were medially located.
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Affiliation(s)
- Mustafa Özer
- Assistant Professor, Department of Orthopaedics & Traumatology, Necmettin Erbakan University Meram Faculty of Medicine, Konya, Turkey.
| | - Ahmet Yıldırım
- Assistant Professor, Department of Orthopaedics & Traumatology, Selçuk University School of Medicine, Konya, Turkey
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Sharabianlou Korth M, Fritz LB. [Postoperative MRI of the ankle]. Radiologe 2019; 57:891-906. [PMID: 29046932 DOI: 10.1007/s00117-017-0306-z] [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: 11/30/2022]
Abstract
CLINICAL/METHODICAL ISSUE Postoperative imaging of the ankle can be challenging, even for the experienced radiologist. Pathological and postoperative changes to the primarily complex anatomy of the ankle with its great variety of bone structures, tendons, ligaments, and soft tissue in a very limited space may cause great difficulty in differentiating underlying pathology from expected postoperative changes and artifacts, especially in magnetic resonance imaging (MRI). STANDARD RADIOLOGICAL METHODS Selecting the appropriate radiological modality is key to making the correct diagnosis. Therefore, knowledge of the initial and current symptoms is just as important as familiarity with the most frequently performed operations in the ankle. PRACTICAL RECOMMENDATIONS This article aims to give its reader a summary of the most important and frequently performed operation techniques of the ankle and discusses the expected appearance and possible complications in postoperative imaging.
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Affiliation(s)
| | - L B Fritz
- Rheinlandärzte, Bahnstraße 31, 47877, Willich, Deutschland.
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Heyer JH, Dai AZ, Rose DJ. Excision of Os Trigonum in Dancers via an Open Posteromedial Approach. JBJS Essent Surg Tech 2018; 8:e31. [PMID: 30775136 DOI: 10.2106/jbjs.st.18.00015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
An os trigonum is a potential source of posterior ankle pain in dancers, often associated with flexor hallucis longus (FHL) pathology. Surgical excision is indicated on failure of nonoperative management. Options for surgical excision include open excision (via a posterolateral or posteromedial approach), subtalar arthroscopy, and posterior endoscopy. Os trigonum excision via an open posteromedial approach with concomitant FHL tenolysis/tenosynovectomy is a safe and effective method for the operative treatment of a symptomatic os trigonum that allows for identification and treatment of associated FHL pathology. The major steps in the procedure, which are demonstrated in this video article, are: (1) preoperative planning with appropriate imaging; (2) patient is positioned in a supine position with the operative extremity in figure-of-4 position; (3) a 3-cm, slightly curvilinear longitudinal incision is made midway between the posterior aspect of the medial malleolus and the anterior aspect of the Achilles tendon, over the palpated FHL tendon, and the flexor retinaculum is exposed and incised; the neurovascular bundle is retracted anteriorly, exposing the FHL tendon and sheath; (4) FHL tenolysis/tenosynovectomy is performed; (5) the FHL is retracted anteriorly and a capsulotomy is performed over the os trigonum and the os trigonum is excised; (6) the capsule is repaired and closure is performed; and (7) dressings and a CAM (controlled ankle motion) walking boot are applied. The patient begins physical therapy at 2 weeks postoperatively and may return to dance at 4 to 6 weeks postoperatively as tolerated. In our series of 40 cases, 95% of patients who desired to return to dance were able to return to their pre-injury level of dance. There were no major neurovascular complications.
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Affiliation(s)
- Jessica H Heyer
- Department of Orthopaedic Surgery, George Washington University Hospital, Washington, DC
| | - Amos Z Dai
- Department of Orthopaedic Surgery, Stony Brook University Hospital, Stony Brook, New York
| | - Donald J Rose
- Department of Orthopaedic Surgery, NYU Langone Orthopedic Hospital, New York, NY
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LiMarzi GM, Khan O, Shah Y, Yablon CM. Imaging Manifestations of Ankle Impingement Syndromes. Radiol Clin North Am 2018; 56:893-916. [DOI: 10.1016/j.rcl.2018.06.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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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: 1.1] [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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Abstract
Impingement syndrome of the ankle is a clinical diagnosis caused posttraumatically by overuse due to repetitive mechanical loading or the presence of predisposing anatomical variants. Ankle impingement syndrome is characterized by chronic pain and limited range of movement caused by mechanical compression of bony or soft tissues within the joint compartments. Ankle impingement syndrome is classified according to the various anatomical locations around the tibiotalar joint as anterior, anterolateral, anteromedial, posterior or posteromedial. Various imaging modalities are helpful in confirming the clinical diagnosis of ankle impingement. Radiography and computed tomography are used to identify bony abnormalities and intra-articular loose bodies. Magnetic resonance imaging is the modality of choice to demonstrate pathological soft tissue changes, bone marrow edema and osteochondral lesions. Dynamic sonography can identify the anatomical structures leading to impingement during movement.
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Affiliation(s)
- R-I Milos
- Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Wien, Österreich.,Abteilung für Neuroradiologie und Muskuloskelettale Radiologie, Universitätsklinik für Radiologie und Nuklearmedizin, Wien, Österreich
| | - L B Fritz
- Rheinlandärzte, Willich & Meerbusch, Willich, Deutschland
| | - C Schueller-Weidekamm
- Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Wien, Österreich. .,Abteilung für Neuroradiologie und Muskuloskelettale Radiologie, Universitätsklinik für Radiologie und Nuklearmedizin, Wien, Österreich.
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Physical Therapy Rehabilitation of an Adolescent Preprofessional Dancer Following Os Trigonum Excision: A Case Report. J Orthop Sports Phys Ther 2018; 48:194-203. [PMID: 29113569 DOI: 10.2519/jospt.2018.7508] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Study Design Case report. Background An os trigonum can be a source of pain for dancers due to impingement during repetitive ankle plantar flexion movements. Following excision of an os trigonum, it is important to have a gradual, progressive return-to-dance program for optimal recovery. The purpose of this case report is to describe the postoperative management and return-to-dance progression of an adolescent dancer post os trigonum excision. Case Description An adolescent preprofessional female dancer had an extensive history of left posterior heel pain, beginning at age 8, that led to surgical removal of an os trigonum at age 15. Post surgery, the patient was seen for a total of 22 visits over the course of 20 weeks. Treatment included therapeutic exercises, neuromuscular re-education, and manual therapy. Return-to-dance tests and guidelines were used to safely progress to full, unrestricted dance participation. Outcomes The dancer had a full return of ankle range of motion, strength, and balance, improved patient-reported outcome scores, and was able to fully return to dance participation. Discussion Treating a dancer following os trigonum excision should involve a screen for hypermobility, clear communication with the dance instructor, awareness of dance-specific biomechanics, and proper reintegration into dance participation. Level of Evidence Therapy, level 5. J Orthop Sports Phys Ther 2018;48(3):194-203. Epub 7 Nov 2017. doi:10.2519/jospt.2018.7508.
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Abstract
BACKGROUND The os trigonum is known as one of the main causes of posterior ankle impingement. In the literature, a wide variation of occurrence has been reported. METHODS All foot and/or ankle computed tomography (CT) scans made between January 2012 and December 2013 were reviewed. CT images were assessed, blinded for patient characteristics, for the presence of an os trigonum, size of the os trigonum, and type of os trigonum. In addition, the shape of the lateral tubercle of the posterior talar process was assessed. RESULTS A total of 628 patients (1256 ankles) were included. In 32.5% of the patients of the cohort, an os trigonum was present. In 14.3% of these patients, it was present bilaterally. In a subgroup of patients without posterior ankle impingement the prevalence was 30.3%. Of the nonaffected ankles, an os trigonum was present in 23.7%. Patients with posterior ankle impingement were more likely to have an os trigonum (adjusted odds ratio [OR], 1.86). Afro-Caribbean/Surinamese/Central African origin was associated with a lower rate of occurrence of os trigonum (adjusted OR 0.43). In the ankles without an os trigonum, an enlarged lateral tubercle of the posterior talar process was found in 34.9% and 36.5% of the ankles. CONCLUSION This study showed that os trigonum is a common accessory bone. With a prevalence of 30.3% in a population of patients with CT imaging of both ankles and 23.7% of the nonaffected ankles, the os trigonum is more common than previously reported. Patients with posterior ankle impingement complaints had a higher prevalence of an os trigonum. In one-third of the patients without an os trigonum, there was an enlarged lateral tubercle of the posterior talar process. LEVEL OF EVIDENCE Level III, retrospective comparative study.
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Affiliation(s)
- Ruben Zwiers
- 1 Academic Medical Center, Department of Orthopaedic Surgery, University of Amsterdam, Amsterdam, the Netherlands.,2 Academic Center for Evidence based Sports medicine (ACES), Amsterdam, the Netherlands.,3 Amsterdam Collaboration for Health and Safety in Sports (ACHSS) Amsterdam, the Netherlands
| | - Thomas P A Baltes
- 1 Academic Medical Center, Department of Orthopaedic Surgery, University of Amsterdam, Amsterdam, the Netherlands.,2 Academic Center for Evidence based Sports medicine (ACES), Amsterdam, the Netherlands.,3 Amsterdam Collaboration for Health and Safety in Sports (ACHSS) Amsterdam, the Netherlands
| | - Kim T M Opdam
- 1 Academic Medical Center, Department of Orthopaedic Surgery, University of Amsterdam, Amsterdam, the Netherlands.,2 Academic Center for Evidence based Sports medicine (ACES), Amsterdam, the Netherlands.,3 Amsterdam Collaboration for Health and Safety in Sports (ACHSS) Amsterdam, the Netherlands
| | - Johannes I Wiegerinck
- 1 Academic Medical Center, Department of Orthopaedic Surgery, University of Amsterdam, Amsterdam, the Netherlands.,2 Academic Center for Evidence based Sports medicine (ACES), Amsterdam, the Netherlands.,3 Amsterdam Collaboration for Health and Safety in Sports (ACHSS) Amsterdam, the Netherlands
| | - C Niek van Dijk
- 1 Academic Medical Center, Department of Orthopaedic Surgery, University of Amsterdam, Amsterdam, the Netherlands.,2 Academic Center for Evidence based Sports medicine (ACES), Amsterdam, the Netherlands.,3 Amsterdam Collaboration for Health and Safety in Sports (ACHSS) Amsterdam, the Netherlands
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Ankle MRI and Arthroscopy Correlation With Cartilaginous Defects and Symptomatic Os Trigonum. Sports Med Arthrosc Rev 2017; 25:237-245. [DOI: 10.1097/jsa.0000000000000169] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Al-Riyami AM, Tan HK, Peh WCG. Imaging of Ankle Impingement Syndromes. Can Assoc Radiol J 2017; 68:431-437. [PMID: 28865671 DOI: 10.1016/j.carj.2017.04.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2016] [Revised: 03/14/2017] [Accepted: 04/08/2017] [Indexed: 01/17/2023] Open
Abstract
Ankle impingement syndromes are a commonly encountered clinical entity seen in athletes, secondary to repetitive forceful microtrauma. Symptoms are related to impingement of osseous or soft tissue abnormalities in the ankle joint, in particular the tibiotalar joint, which may result in painful limitation of ankle movements. Imaging modalities, such as radiographs and magnetic resonance imaging, are very useful in diagnosing osseous and soft tissue abnormalities seen in different types of ankle impingement syndromes. This article reviews the classification of ankle impingement syndromes, their etiology, and clinical and radiological findings.
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Affiliation(s)
| | - Hsien Khai Tan
- Department of Diagnostic Radiology, Khoo Teck Puat Hospital, Republic of Singapore
| | - Wilfred C G Peh
- Department of Diagnostic Radiology, Khoo Teck Puat Hospital, Republic of Singapore.
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Martins N, Seixas MI, Couto M, Monteiro P. Posterior Ankle Impingement Syndrome. REUMATOLOGIA CLINICA 2017; 14:244-245. [PMID: 28830674 DOI: 10.1016/j.reuma.2017.07.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Revised: 06/30/2017] [Accepted: 07/12/2017] [Indexed: 10/19/2022]
Affiliation(s)
- Nádia Martins
- Rheumatology Department, Hospital de São Teotónio, Viseu, Portugal.
| | | | - Maura Couto
- Rheumatology Department, Hospital de São Teotónio, Viseu, Portugal
| | - Paulo Monteiro
- Rheumatology Department, Hospital de São Teotónio, Viseu, Portugal
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Abstract
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.
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Abstract
BACKGROUND An os trigonum is a potential source of posterior ankle pain in dancers, often associated with flexor hallucis longus (FHL) pathology. Options for operative excision include open excision, subtalar arthroscopy, and posterior endoscopy. The purpose of this paper was to present a series of dancers who underwent excision of a symptomatic os trigonum via an open posteromedial approach. METHODS This study is a retrospective case series of 40 ankles in 38 dancers who underwent os trigonum excision via an open posteromedial approach with FHL tenolysis between 2000 and 2013. All patients were interviewed and charts retrospectively analyzed. Collected variables included pre- and postoperative pain level, time to return to dance, and subjective satisfaction. The average age was 19.2 years; ballet was the primary dance form in 36 (95%) of patient-cases. Eight (20%) of the patient-cases were professional dancers, and 30 (75%) were students or preprofessional dancers. RESULTS Average preoperative pain level was 7.7/10, which decreased to 0.6/10 postoperatively. Seventeen (42.5%) experienced concurrent preoperation-associated FHL symptomatology, all of whom experienced relief postoperatively. The average time to return to dance was 7.9 weeks, and time to pain-free dance was 17.7 weeks. Of the 37 patient-cases desiring to return to dance, 35 (94.6%) returned to their preoperative level of dance. There were no neurovascular or other major complications. Four (10%) had minor wound complications that resolved, and 38 cases (95%) considered the procedure a success. CONCLUSION Open posteromedial excision of an os trigonum in dancers provided satisfactory pain relief, return to dance, and complication rates compared to other approaches, and allowed for identifying and treating any associated FHL pathology. LEVEL OF EVIDENCE Level IV, retrospective case series.
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Affiliation(s)
- Jessica H Heyer
- 1 Orthopaedic Surgery Department, George Washington University Hospital, Washington, DC, USA
| | - Donald J Rose
- 2 Department of Orthopaedic Surgery, Harkness Center for Dance Injuries, New York University Hospital for Joint Diseases, New York, NY, USA
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Kudaş S, Dönmez G, Işık Ç, Çelebi M, Çay N, Bozkurt M. Posterior ankle impingement syndrome in football players: Case series of 26 elite athletes. ACTA ORTHOPAEDICA ET TRAUMATOLOGICA TURCICA 2016; 50:649-654. [PMID: 27919560 PMCID: PMC6197591 DOI: 10.1016/j.aott.2016.03.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/05/2015] [Revised: 01/27/2016] [Accepted: 03/12/2016] [Indexed: 12/12/2022]
Abstract
Objective To describe a clinical treatment algorithm for posterior ankle impingement (PAI) syndrome in professional football players. Material and methods A case series of 26 elite professional football players diagnosed and treated for posterior ankle impingement syndrome were included for the study. All of the athletes received conservative treatment with physical therapy modalities initially. If the first line medical treatment and rehabilitation was ineffective to alleviate the symptoms, ultrasound-guided corticosteroid injection was proposed and thereafter the patients underwent posterior ankle arthroscopy if the complaints are still unresolved. The pain scores (AOFAS, VAS), and time to return to play were the main outcome measures. Results The complaints of 18 (69.2%) players were subsided with non-surgical treatment whereas three of acute cases and five of the chronic cases did not respond to medical treatment and arthroscopic surgery was performed for eight athletes. Eighteen players returned to training for a mean time of 36.3 days (24–42 days) after conservative treatment. The patients who underwent arthroscopic surgery returned to training for a mean time of 49.8 days (42–56 days) after the surgery. All athletes returned to their previous level of competition after treatment without any complications or recurrence in a mean follow-up 36.5 months (19–77 months). Conclusion Non-surgical treatment modalities were effective in 2/3 of posterior ankle impingement syndrome in elite football players. On the other hand, posterior ankle arthroscopy is safe and effective treatment option for posterior ankle impingement syndrome if the conservative treatment fails. Level of evidence Level IV, Therapeutic study
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Sánchez Prida N, Sánchez Domínguez P, Martín Fernández A, Martín Gordo O, Martín Moreno V. Valoración del dolor de tobillo: síndrome del impacto posterior del tobillo secundario a proceso de Stieda. Semergen 2016; 42:e146-e148. [DOI: 10.1016/j.semerg.2016.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2016] [Revised: 02/25/2016] [Accepted: 03/13/2016] [Indexed: 10/21/2022]
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Wong GNL, Tan TJ. MR imaging as a problem solving tool in posterior ankle pain: A review. Eur J Radiol 2016; 85:2238-2256. [PMID: 27842673 DOI: 10.1016/j.ejrad.2016.10.016] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Revised: 10/10/2016] [Accepted: 10/14/2016] [Indexed: 12/12/2022]
Abstract
Posterior ankle pain is a cause of chronic pain and disability, afflicting a wide range of individuals. While proper identification of the cause is essential for timely and adequate treatment, identifying the cause and excluding mimickers is often challenging for the physician due to the complex nature of the joint. In addition, pathology that can cause posterior ankle pain may occur on their own or in co-existence. Clinical conditions that can present as posterior ankle pain include: posterior ankle impingement, Achilles tendon pathology, medial flexor tendon pathology, peroneal pathology, retrocalcaneal bursitis, posterior subtalar tarsal coalition, sinus tarsi, and tarsal tunnel syndrome. In this review we introduce current concepts of pathophysiology in the main conditions involved in posterior ankle pain, and review the role of MR in the diagnosis and management of each condition. When pathology can be detected earlier and with more specificity, appropriate and time-sensitive treatment can be commenced, thus improving clinical outcomes.
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Affiliation(s)
- Gloria N L Wong
- Department of Radiology, Changi General Hospital, 2 Simei Street 3, 529889, Singapore.
| | - Tien Jin Tan
- Department of Radiology, Changi General Hospital, 2 Simei Street 3, 529889, Singapore.
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Shane AM, Reeves CL, Vazales R, Farley Z. Soft Tissue Impingement of the Ankle: Pathophysiology, Evaluation, and Arthroscopic Treatment. Clin Podiatr Med Surg 2016; 33:503-20. [PMID: 27599436 DOI: 10.1016/j.cpm.2016.06.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Soft tissue impingement (STI) syndrome is one of 3 causes of a larger all-encompassing joint impingement pathologic condition, which also includes bone and neuropathic entrapment. Altered joint biomechanics and friction of joint tissues combine to cause chronic pain and often functional instability. Although the most common form of STI to the ankle is anterolateral in location, posterior and anteromedial impingement is also discussed in this article. Furthermore, a discussion of biomechanical deficiencies and how they may effect location and cause of STI of the ankle is explored along with pathophysiology, clinical and diagnostic evaluation, current treatments, and long-term outcomes.
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Affiliation(s)
- Amber M Shane
- Reconstructive Foot and Ankle Surgery, Orlando Foot and Ankle Clinic, 250 North Alafaya Trail, Suite 115, Orlando, FL 32825, USA.
| | - Christopher L Reeves
- Reconstructive Foot and Ankle Surgery, Orlando Foot and Ankle Clinic, 250 North Alafaya Trail, Suite 115, Orlando, FL 32825, USA
| | - Ryan Vazales
- Reconstructive Foot and Ankle Surgery, Orlando Foot and Ankle Clinic, 250 North Alafaya Trail, Suite 115, Orlando, FL 32825, USA
| | - Zachary Farley
- Reconstructive Foot and Ankle Surgery, Orlando Foot and Ankle Clinic, 250 North Alafaya Trail, Suite 115, Orlando, FL 32825, USA
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Abstract
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.
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Affiliation(s)
- Kyle P Lavery
- Division of Sports Medicine, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, 175 Cambridge Street, Suite 400, Boston, MA, 02114, USA.
| | - Kevin J McHale
- Division of Sports Medicine, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, 175 Cambridge Street, Suite 400, Boston, MA, 02114, USA
| | - William H Rossy
- Division of Sports Medicine, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, 175 Cambridge Street, Suite 400, Boston, MA, 02114, USA
| | - George Theodore
- Division of Sports Medicine, Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, 175 Cambridge Street, Suite 400, Boston, MA, 02114, USA
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Russell JA, Yoshioka H. Assessment of female ballet dancers' ankles in the en pointe position using high field strength magnetic resonance imaging. Acta Radiol 2016; 57:978-84. [PMID: 26567962 DOI: 10.1177/0284185115616295] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2015] [Accepted: 10/11/2015] [Indexed: 01/07/2023]
Abstract
BACKGROUND The en pointe position of the ankle in ballet is extreme. Previously, magnetic resonance imaging (MRI) of ballet dancers' ankles en pointe was confined to a low field, open MR device. PURPOSE To develop a reproducible ankle MRI protocol for ballet dancers en pointe and to assess the positions of the key structures in the dancers ankles. MATERIAL AND METHODS Six female ballet dancers participated; each was randomly assigned to stand en pointe while one of her feet and ankles was splinted with wooden rods affixed with straps or to begin with the ankle in neutral position. She lay in an MR scanner with the ankle inside a knee coil for en pointe imaging and inside an ankle/foot coil for neutral position imaging. Proton density weighted images with and without fat suppression and 3D water excitation gradient recalled echo images were obtained en pointe and in neutral position in sagittal, axial, and coronal planes. We compared the bones, cartilage, and soft tissues within and between positions. RESULTS No difficulties using the protocol were encountered. En pointe the posterior articular surface of the tibial plafond was incongruent with the talar dome and rested on the posterior talus. The posterior edge of the plafond impinged Kager's fat pad. All participants exhibited one or more small ganglion cysts about the ankle and proximal foot, as well as fluid accumulation in the flexor and fibularis tendon sheaths. CONCLUSION Our MRI protocol allows assessment of female ballet dancers' ankles in the extreme plantar flexion position in which the dancers perform. We consistently noted incongruence of the talocrural joint and convergence of the tibia, talus, and calcaneus posteriorly. This protocol may be useful for clinicians who evaluate dancers.
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Affiliation(s)
- Jeffrey A Russell
- School of Applied Health Sciences, Ohio University, Athens, Ohio, USA
| | - Hiroshi Yoshioka
- Department of Radiological Sciences, School of Medicine, University of California, Irvine, California, USA
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Anatomy of the ankle ligaments: a pictorial essay. Knee Surg Sports Traumatol Arthrosc 2016; 24:944-56. [PMID: 27052302 DOI: 10.1007/s00167-016-4059-4] [Citation(s) in RCA: 85] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2010] [Accepted: 02/16/2010] [Indexed: 12/26/2022]
Abstract
Understanding the anatomy of the ankle ligaments is important for correct diagnosis and treatment. Ankle ligament injury is the most frequent cause of acute ankle pain. Chronic ankle pain often finds its cause in laxity of one of the ankle ligaments. In this pictorial essay, the ligaments around the ankle are grouped, depending on their anatomic orientation, and each of the ankle ligaments is discussed in detail.
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Funasaki H, Hayashi H, Sakamoto K, Tsuruga R, Marumo K. Arthroscopic Release of Flexor Hallucis Longus Tendon Sheath in Female Ballet Dancers: Dynamic Pathology, Surgical Technique, and Return to Dancing Performance. Arthrosc Tech 2015; 4:e769-74. [PMID: 27284509 PMCID: PMC4886817 DOI: 10.1016/j.eats.2015.07.025] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2015] [Accepted: 07/29/2015] [Indexed: 02/03/2023] Open
Abstract
Stenosing tenosynovitis of the flexor hallucis longus (FHL) tendon is known as a major overuse lesion in female dancers. We describe arthroscopic surgical techniques in relation to the dynamic pathology of the disease. Crepitus and pain on moving the great toe with the ankle in plantar flexion on preoperative examination confirm the diagnosis of FHL stenosing tenosynovitis even if the os trigonum is not evident. The ankle is approached through standard posterolateral and posteromedial portals. A 4.0-mm-diameter 30° arthroscope is used. Soft tissues around the talus are cleared with a motorized shaver and a radiofrequency device. The posterior aspects of the talus, os trigonum, and FHL tendon surrounded by the tendon sheath are visualized. The dynamic pathology of the FHL tendon is well observed on passive motion of the great toe. The prominent bone fragment of the talus is removed and the tendon sheath is cut with a retrograde knife and a motorized shaver from the superior border down to the entrance of the fibro-osseous tunnel. Arthroscopic release of the FHL tendon sheath is a useful and easy method to directly approach the dynamic pathology of FHL tenosynovitis in female ballet dancers.
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Affiliation(s)
- Hiroki Funasaki
- Address correspondence to Hiroki Funasaki, M.D., Department of Sports and Wellness Clinic, Jikei University School of Medicine, 3-25-8 Nishishinbashi Minato-ku, Tokyo 105-8461, Japan.
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Cha JG, Yi JS, Han JK, Lee YK. Comparison of Quantitative Cartilage T2 Measurements and Qualitative MR Imaging between Professional Ballet Dancers and Healthy Volunteers. Radiology 2015; 276:199-206. [PMID: 25759971 DOI: 10.1148/radiol.15142021] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Jang Gyu Cha
- From the Departments of Radiology (J.G.C., J.S.Y.) and Orthopedics (Y.K.L.), Soonchunhyang University Bucheon Hospital, 170 Jomaru-ro, Wonmi-gu, Bucheon, South Korea, 420-767; and Department of Radiology, Soonchunhyang University Cheonan Hospital, Cheonan, South Korea (J.K.H.)
| | - Ji Sook Yi
- From the Departments of Radiology (J.G.C., J.S.Y.) and Orthopedics (Y.K.L.), Soonchunhyang University Bucheon Hospital, 170 Jomaru-ro, Wonmi-gu, Bucheon, South Korea, 420-767; and Department of Radiology, Soonchunhyang University Cheonan Hospital, Cheonan, South Korea (J.K.H.)
| | - Jong Kyu Han
- From the Departments of Radiology (J.G.C., J.S.Y.) and Orthopedics (Y.K.L.), Soonchunhyang University Bucheon Hospital, 170 Jomaru-ro, Wonmi-gu, Bucheon, South Korea, 420-767; and Department of Radiology, Soonchunhyang University Cheonan Hospital, Cheonan, South Korea (J.K.H.)
| | - Young Koo Lee
- From the Departments of Radiology (J.G.C., J.S.Y.) and Orthopedics (Y.K.L.), Soonchunhyang University Bucheon Hospital, 170 Jomaru-ro, Wonmi-gu, Bucheon, South Korea, 420-767; and Department of Radiology, Soonchunhyang University Cheonan Hospital, Cheonan, South Korea (J.K.H.)
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The anatomic variations of the posterior talofibular ligament associated with os trigonum and pathologies of related structures. Surg Radiol Anat 2015; 37:955-62. [DOI: 10.1007/s00276-015-1428-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2014] [Accepted: 01/13/2015] [Indexed: 10/24/2022]
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