Semin Musculoskelet Radiol 2007; 11(2): 149-161
DOI: 10.1055/s-2007-1001880
© Thieme Medical Publishers

Ultrasound of Ankle and Foot: Overuse and Sports Injuries

Viviane Khoury1 , Raphaël Guillin1 , Jag Dhanju2 , Étienne Cardinal1
  • 1Department of Radiology, Hôpital Notre-Dame, Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada
  • 2The Canadian Centre for Musculoskeletal Ultrasound, North York, Ontario, Canada
Further Information

Publication History

Publication Date:
20 December 2007 (online)

ABSTRACT

Sports and overuse injuries of the ankle and foot are commonly encountered in clinical practice. Ultrasound (US) has been established as an excellent diagnostic modality for foot and ankle injuries, providing a rapid noninvasive, economical, and readily available tool that is well tolerated by the patient with acute or chronic pain. The opportunity for dynamic examination is another advantage of US in evaluating ankle and foot pathology, where maneuvers such as muscle contraction and stressing of the joint may be particularly helpful. In many cases, US can be used as a first-line and only imaging modality for diagnosis. This article focuses on ankle disorders related to sports or overuse that affect tendons, including tendinosis, tenosynovitis, paratendinitis, rupture, dislocation, and ligaments that are commonly torn. The sonographic features of certain common foot disorders related to physical activity and overuse are also discussed, including plantar fasciitis, Morton's neuroma, stress fractures, and plantar plate injury.

REFERENCES

  • 1 Jacobson J A, van Holsbeeck M T. Musculoskeletal ultrasonography.  Orthop Clin North Am. 1998;  29 135-167
  • 2 Bianchi S, Martinoli C, Gaignot C, De Gautard R, Meyer J M. Ultrasound of the ankle: anatomy of the tendons, bursae, and ligaments.  Semin Musculoskelet Radiol. 2005;  9 243-259
  • 3 Morvan G, Busson J, Wybier M, Mathieu P. Ultrasound of the ankle.  Eur J Ultrasound. 2001;  14 73-82
  • 4 Peetrons P, Creteur V, Bacq C. Sonography of ankle ligaments.  J Clin Ultrasound. 2004;  32 491-499
  • 5 Khoury V, Cardinal E, Bureau N J. Musculoskeletal sonography: a dynamic tool for usual and unusual disorders.  AJR Am J Roentgenol. 2007;  188 W63-73
  • 6 Jarvinen T A, Kannus P, Maffulli N, Khan K M. Achilles tendon disorders: etiology and epidemiology.  Foot Ankle Clin. 2005;  10 255-266
  • 7 Kannus P, Natri A. Etiology and pathophysiology of tendon ruptures in sports.  Scand J Med Sci Sports. 1997;  7 107-112
  • 8 Rawool N M, Nazarian L N. Ultrasound of the ankle and foot.  Semin Ultrasound CT MR. 2000;  21 275-284
  • 9 Fessell D P, Vanderschueren G M, Jacobson J A et al.. US of the ankle: technique, anatomy, and diagnosis of pathologic conditions.  Radiographics. 1998;  18 325-340
  • 10 Waitches G M, Rockett M, Brage M, Sudakoff G. Ultrasonographic-surgical correlation of ankle tendon tears.  J Ultrasound Med. 1998;  17 249-256
  • 11 Rockett M S, Waitches G, Sudakoff G, Brage M. Use of ultrasonography versus magnetic resonance imaging for tendon abnormalities around the ankle.  Foot Ankle Int. 1998;  19 604-612
  • 12 Erickson S J. High-resolution imaging of the musculoskeletal system.  Radiology. 1997;  205 593-618
  • 13 Martinoli C, Derchi L E, Pastorino C, Bertolotto M, Silvestri E. Analysis of echotexture of tendons with US.  Radiology. 1993;  186 839-843
  • 14 Fornage B D. The hypoechoic normal tendon. A pitfall.  J Ultrasound Med. 1987;  6 19-22
  • 15 Hsu T C, Wang C L, Wang T G, Chiang I P, Hsieh F J. Ultrasonographic examination of the posterior tibial tendon.  Foot Ankle Int. 1997;  18 34-38
  • 16 Nazarian L N, Rawool N M, Martin C E, Schweitzer M E. Synovial fluid in the hindfoot and ankle: detection of amount and distribution with US.  Radiology. 1995;  197 275-278
  • 17 Neustadter J, Raikin S M, Nazarian L N. Dynamic sonographic evaluation of peroneal tendon subluxation.  AJR Am J Roentgenol. 2004;  183 985-988
  • 18 Diaz G C, van Holsbeeck M, Jacobson J A. Longitudinal split of the peroneus longus and peroneus brevis tendons with disruption of the superior peroneal retinaculum.  J Ultrasound Med. 1998;  17 525-529
  • 19 Smania L, Craig J G, von Holsbeeck M. Ultrasonographic findings in peroneus longus tendon rupture.  J Ultrasound Med. 2007;  26 243-246
  • 20 Bianchi S, Zwass A, Abdelwahab I F, Zoccola C. Evaluation of tibialis anterior tendon rupture by ultrasonography.  J Clin Ultrasound. 1994;  22 564-566
  • 21 Grant T H, Kelikian A S, Jereb S E, McCarthy R J. Ultrasound diagnosis of peroneal tendon tears. A surgical correlation.  J Bone Joint Surg Am. 2005;  87 1788-1794
  • 22 Wang X T, Rosenberg Z S, Mechlin M B, Schweitzer M E. Normal variants and diseases of the peroneal tendons and superior peroneal retinaculum: MR imaging features.  Radiographics. 2005;  25 587-602
  • 23 Hyer C F, Dawson J M, Philbin T M, Berlet G C, Lee T H. The peroneal tubercle: description, classification, and relevance to peroneus longus tendon pathology.  Foot Ankle Int. 2005;  26 947-950
  • 24 Bencardino J T, Rosenberg Z S, Serrano L F. MR imaging features of diseases of the peroneal tendons.  Magn Reson Imaging Clin N Am. 2001;  9 493-505 , x
  • 25 Shetty M, Fessell D P, Femino J E, Jacobson J A, Lin J, Jamadar D. Sonography of ankle tendon impingement with surgical correlation.  AJR Am J Roentgenol. 2002;  179 949-953
  • 26 Sammarco G J. Peroneal tendon injuries.  Orthop Clin North Am. 1994;  25 135-145
  • 27 Gray J M, Alpar E K. Peroneal tenosynovitis following ankle sprains.  Injury. 2001;  32 487-489
  • 28 Di Giovanni B F, Fraga C J, Cohen B E, Shereff M J. Associated injuries found in chronic lateral ankle instability.  Foot Ankle Int. 2000;  21 809-815
  • 29 Patel S, Fessell D P, Jacobson J A, Hayes C W, van Holsbeeck M T. Artifacts, anatomic variants, and pitfalls in sonography of the foot and ankle.  AJR Am J Roentgenol. 2002;  178 1247-1254
  • 30 Saxena A, Cassidy A. Peroneal tendon injuries: an evaluation of 49 tears in 41 patients.  J Foot Ankle Surg. 2003;  42 215-220
  • 31 Bassett III F H, Speer K P. Longitudinal rupture of the peroneal tendons.  Am J Sports Med. 1993;  21 354-357
  • 32 Tavernier T, Bonnin M, Bouysset M. Longitudinal splitting syndrome of the short fibular tendon. Imaging and classification by MRI.  J Radiol. 1997;  78 353-357
  • 33 Sobel M, Geppert M J, Olson E J, Bohne W H, Arnoczky S P. The dynamics of peroneus brevis tendon splits: a proposed mechanism, technique of diagnosis, and classification of injury.  Foot Ankle. 1992;  13 413-422
  • 34 Geppert M J, Sobel M, Bohne W H. Lateral ankle instability as a cause of superior peroneal retinacular laxity: an anatomic and biomechanical study of cadaveric feet.  Foot Ankle. 1993;  14 330-334
  • 35 Link S C, Erickson S J, Timins M E. MR imaging of the ankle and foot: normal structures and anatomic variants that may simulate disease.  AJR Am J Roentgenol. 1993;  161 607-612
  • 36 Rosenberg Z S, Rademaker J, Beltran J, Colon E. Peroneus brevis tendon in normal subjects: MR morphology and its relationship to longitudinal tears.  J Comput Assist Tomogr. 1998;  22 262-264
  • 37 Brigido M K, Fessell D P, Jacobson J A et al.. Radiography and US of os peroneum fractures and associated peroneal tendon injuries: initial experience.  Radiology. 2005;  237 235-241
  • 38 Safran M R, O'Malley Jr D, Fu F H. Peroneal tendon subluxation in athletes: new exam technique, case reports, and review.  Med Sci Sports Exerc. 1999;  31 S487-S492
  • 39 Schweitzer M E, Eid M E, Deely D, Wapner K, Hecht P. Using MR imaging to differentiate peroneal splits from other peroneal disorders.  AJR Am J Roentgenol. 1997;  168 129-133
  • 40 Yao L, Tong D J, Cracchiolo A, Seeger L L. MR findings in peroneal tendinopathy.  J Comput Assist Tomogr. 1995;  19 460-464
  • 41 McConkey J P, Favero K J. Subluxation of the peroneal tendons within the peroneal tendon sheath. A case report.  Am J Sports Med. 1987;  15 511-513
  • 42 Scheller A D, Kasser J R, Quigley T B. Tendon injuries about the ankle.  Clin Sports Med. 1983;  2 631-641
  • 43 Rimoldi R L, Oberlander M A, Waldrop J I, Hunter S C. Acute rupture of the tibialis anterior tendon: a case report.  Foot Ankle. 1991;  12 176-177
  • 44 Mengiardi B, Pfirrmann C W, Vienne P et al.. Anterior tibial tendon abnormalities: MR imaging findings.  Radiology. 2005;  235 977-984
  • 45 Petersen W, Stein V, Tillmann B. Blood supply of the tibialis anterior tendon.  Arch Orthop Trauma Surg. 1999;  119 371-375
  • 46 Lee M H, Chung C B, Cho J H et al.. Tibialis anterior tendon and extensor retinaculum: imaging in cadavers and patients with tendon tear.  AJR Am J Roentgenol. 2006;  187 W161-8
  • 47 Ouzounian T J, Anderson R. Anterior tibial tendon rupture.  Foot Ankle Int. 1995;  16 406-410
  • 48 Kausch T, Rutt J. Subcutaneous rupture of the tibialis anterior tendon: review of the literature and a case report.  Arch Orthop Trauma Surg. 1998;  117 290-293
  • 49 Stuart M J. Traumatic disruption of the anterior tibial tendon while cross-country skiing. A case report.  Clin Orthop Relat Res. 1992;  (281) 193-194
  • 50 Din R, Therkilsden L. Rupture of tibialis anterior associated with a closed midshaft tibial fracture.  J Accid Emerg Med. 1999;  16 459
  • 51 Mechrefe A P, Walsh E F, DiGiovanni C W. Anterior tibial tendon avulsion with distal tibial fracture entrapment: case report.  Foot Ankle Int. 2006;  27 645-647
  • 52 Fessell D P, Jamadar D A, Jacobson J A et al.. Sonography of dorsal ankle and foot abnormalities.  AJR Am J Roentgenol. 2003;  181 1573-1581
  • 53 Peetrons P. Lesions of the anterior tibial tendon using ultrasonography: report of 2 cases.  JBR-BTR. 1999;  82 157-158
  • 54 Tytherleigh-Strong G, Baxandall R, Unwin A. Rupture of the ankle extensor retinaculum in a dancer.  J R Soc Med. 2000;  93 638-639
  • 55 Akhtar M, Levine J. Dislocation of extensor digitorum longus tendons after spontaneous rupture of the inferior retinaculum of the ankle. Case report.  J Bone Joint Surg Am. 1980;  62 1210-1211
  • 56 Conti S F. Posterior tibial tendon problems in athletes.  Orthop Clin North Am. 1994;  25 109-121
  • 57 Porter D A, Baxter D E, Clanton T O, Klootwyk T E. Posterior tibial tendon tears in young competitive athletes: two case reports.  Foot Ankle Int. 1998;  19 627-630
  • 58 Schweitzer M E, Caccese R, Karasick D, Wapner K L, Mitchell D G. Posterior tibial tendon tears: utility of secondary signs for MR imaging diagnosis.  Radiology. 1993;  188 655-659
  • 59 Foster A P, Thompson N W, Crone M D, Charlwood A P. Rupture of the tibialis posterior tendon: an important differential in the assessment of ankle injuries.  Emerg Med J. 2005;  22 915-916
  • 60 Mann R A, Thompson F M. Rupture of the posterior tibial tendon causing flat foot. Surgical treatment.  J Bone Joint Surg Am. 1985;  67 556-561
  • 61 Johnson K A, Strom D E. Tibialis posterior tendon dysfunction.  Clin Orthop Relat Res. 1989;  (239) 196-206
  • 62 Chen Y J, Liang S C. Diagnostic efficacy of ultrasonography in stage I posterior tibial tendon dysfunction: sonographic-surgical correlation.  J Ultrasound Med. 1997;  16 417-423
  • 63 Gerling M C, Pfirrmann C W, Farooki S et al.. Posterior tibialis tendon tears: comparison of the diagnostic efficacy of magnetic resonance imaging and ultrasonography for the detection of surgically created longitudinal tears in cadavers.  Invest Radiol. 2003;  38 51-56
  • 64 Nallamshetty L, Nazarian L N, Schweitzer M E et al.. Evaluation of posterior tibial pathology: comparison of sonography and MR imaging.  Skeletal Radiol. 2005;  34 375-380
  • 65 Ouzounian T J, Myerson M S. Dislocation of the posterior tibial tendon.  Foot Ankle. 1992;  13 215-219
  • 66 Miller S D, Van Holsbeeck M, Boruta P M, Wu K K, Katcherian D A. Ultrasound in the diagnosis of posterior tibial tendon pathology.  Foot Ankle Int. 1996;  17 555-558
  • 67 Bencardino J, Rosenberg Z S, Delfaut E. MR imaging in sports injuries of the foot and ankle.  Magn Reson Imaging Clin N Am. 1999;  7 131-149 , ix
  • 68 Schulhofer S D, Oloff L M. Flexor hallucis longus dysfunction: an overview.  Clin Podiatr Med Surg. 2002;  19 411-418 , v
  • 69 Bureau N J, Cardinal E, Hobden R, Aubin B. Posterior ankle impingement syndrome: MR imaging findings in seven patients.  Radiology. 2000;  215 497-503
  • 70 Schonbauer H R. Diseases of the Achilles tendon.  Wien Klin Wochenschr Suppl. 1986;  168 1-47
  • 71 Kvist M. Achilles tendon injuries in athletes.  Sports Med. 1994;  18 173-201
  • 72 Paavola M, Paakkala T, Kannus P, Jarvinen M. Ultrasonography in the differential diagnosis of Achilles tendon injuries and related disorders. A comparison between pre-operative ultrasonography and surgical findings.  Acta Radiol. 1998;  39 612-619
  • 73 Fornage B D. Achilles tendon: US examination.  Radiology. 1986;  159 759-764
  • 74 Hartgerink P, Fessell D P, Jacobson J A, van Holsbeeck M T. Full- versus partial-thickness Achilles tendon tears: sonographic accuracy and characterization in 26 cases with surgical correlation.  Radiology. 2001;  220 406-412
  • 75 Kainberger F M, Engel A, Barton P, Huebsch P, Neuhold A, Salomonowitz E. Injury of the Achilles tendon: diagnosis with sonography.  AJR Am J Roentgenol. 1990;  155 1031-1036
  • 76 Zanetti M, Metzdorf A, Kundert H P et al.. Achilles tendons: clinical relevance of neovascularization diagnosed with power Doppler US.  Radiology. 2003;  227 556-560
  • 77 Blei C L, Nirschl R P, Grant E G. Achilles tendon: US diagnosis of pathologic conditions. Work in progress.  Radiology. 1986;  159 765-767
  • 78 Astrom M, Gentz C F, Nilsson P, Rausing A, Sjoberg S, Westlin N. Imaging in chronic Achilles tendinopathy: a comparison of ultrasonography, magnetic resonance imaging and surgical findings in 27 histologically verified cases.  Skeletal Radiol. 1996;  25 615-620
  • 79 Peetrons P SS, Saillant G. Imagerie du tendon d'Achille. In: Lagier RMG, Godefroy D Pied et cheville. Imagerie et clinique. Montpellier, France; Sauramps Medical 1991: 143-147
  • 80 Nistor L. Surgical and non-surgical treatment of Achilles tendon rupture. A prospective randomized study.  J Bone Joint Surg Am. 1981;  63 394-399
  • 81 Fong D T, Hong Y, Chan L K, Yung P S, Chan K M. A systematic review on ankle injury and ankle sprain in sports.  Sports Med. 2007;  37 73-94
  • 82 Garrick J G. The frequency of injury, mechanism of injury, and epidemiology of ankle sprains.  Am J Sports Med. 1977;  5 241-242
  • 83 Ferran N A, Maffulli N. Epidemiology of sprains of the lateral ankle ligament complex.  Foot Ankle Clin. 2006;  11 659-662
  • 84 van Dijk C N, Mol B W, Lim L S, Marti R K, Bossuyt P M. Diagnosis of ligament rupture of the ankle joint. Physical examination, arthrography, stress radiography and sonography compared in 160 patients after inversion trauma.  Acta Orthop Scand. 1996;  67 566-570
  • 85 Brasseur J L, Luzzati A, Lazennec J Y, Guerin-Surville H, Roger B, Grenier P. Ultrasono-anatomy of the ankle ligaments.  Surg Radiol Anat. 1994;  16 87-91
  • 86 Milz P, Milz S, Steinborn M, Mittlmeier T, Reiser M. 13-MHc high frequency ultrasound of the lateral ligaments of the ankle joint and the anterior tibia-fibular ligament. Comparison and results of MRI in 64 patients.  Radiologe. 1999;  39 34-40
  • 87 Morvan G, Mathieu P, Busson J, Wybier M. Ultrasonography of tendons and ligaments of foot and ankle.  J Radiol. 2000;  81 361-380
  • 88 Campbell D G, Menz A, Isaacs J. Dynamic ankle ultrasonography. A new imaging technique for acute ankle ligament injuries.  Am J Sports Med. 1994;  22 855-858
  • 89 Bozic R, Weiser J. Epidemiologic data of rupture of the fibular ligament of the upper ankle joint.  Aktuelle Traumatol. 1991;  21 118-120
  • 90 Friedrich J M, Schnarkowski P, Rubenacker S, Wallner B. Ultrasonography of capsular morphology in normal and traumatic ankle joints.  J Clin Ultrasound. 1993;  21 179-187
  • 91 Copercini M, Bonvin F, Martinoli C, Bianchi S. Sonographic diagnosis of talar lateral process fracture.  J Ultrasound Med. 2003;  22 635-640
  • 92 Lagalla R, Iovane A, Midiri M, Lo Casto A, De Maria M. Comparison of echography and magnetic resonance in sprains of the external compartment of the ankle.  Radiol Med (Torino). 1994;  88 742-748
  • 93 Kreitner K F, Ferber A, Grebe P, Runkel M, Berger S, Thelen M. Injuries of the lateral collateral ligaments of the ankle: assessment with MR imaging.  Eur Radiol. 1999;  9 519-524
  • 94 Hedrick M R. The plantar aponeurosis.  Foot Ankle Int. 1996;  17 646-649
  • 95 DeMaio M, Paine R, Mangine R E, Drez Jr D. Plantar fasciitis.  Orthopedics. 1993;  16 1153-1163
  • 96 Schepsis A A, Leach R E, Gorzyca J. Plantar fasciitis. Etiology, treatment, surgical results, and review of the literature.  Clin Orthop Relat Res. 1991;  (266) 185-196
  • 97 Acevedo J I, Beskin J L. Complications of plantar fascia rupture associated with corticosteroid injection.  Foot Ankle Int. 1998;  19 91-97
  • 98 Gibbon W W. Plantar fasciitis: US imaging.  Radiology. 1992;  182 285
  • 99 Kane D, Greaney T, Shanahan M et al.. The role of ultrasonography in the diagnosis and management of idiopathic plantar fasciitis.  Rheumatology (Oxford). 2001;  40 1002-1008
  • 100 Sabir N, Demirlenk S, Yagci B, Karabulut N, Cubukcu S. Clinical utility of sonography in diagnosing plantar fasciitis.  J Ultrasound Med. 2005;  24 1041-1048
  • 101 Wall J R, Harkness M A, Crawford A. Ultrasound diagnosis of plantar fasciitis.  Foot Ankle. 1993;  14 465-470
  • 102 Cardinal E, Chhem R K, Beauregard C G, Aubin B, Pelletier M. Plantar fasciitis: sonographic evaluation.  Radiology. 1996;  201 257-259
  • 103 Walther M, Radke S, Kirschner S, Ettl V, Gohlke F. Power Doppler findings in plantar fasciitis.  Ultrasound Med Biol. 2004;  30 435-440
  • 104 Zanetti M, Strehle J K, Zollinger H, Hodler J. Morton neuroma and fluid in the intermetatarsal bursae on MR images of 70 asymptomatic volunteers.  Radiology. 1997;  203 516-520
  • 105 Sharp R J, Wade C M, Hennessy M S, Saxby T S. The role of MRI and ultrasound imaging in Morton's neuroma and the effect of size of lesion on symptoms.  J Bone Joint Surg Br. 2003;  85 999-1005
  • 106 Quinn T J, Jacobson J A, Craig J G, van Holsbeeck M T. Sonography of Morton's neuromas.  AJR Am J Roentgenol. 2000;  174 1723-1728
  • 107 Lee M J, Kim S, Huh Y M et al.. Morton neuroma: Evaluated with ultrasonography and MR imaging.  Korean J Radiol. 2007;  8 148-155
  • 108 Bossley C J, Cairney P C. The intermetatarsophalangeal bursa-its significance in Morton's metatarsalgia.  J Bone Joint Surg Br. 1980;  62-B 184-187
  • 109 Pollak R A, Bellacosa R A, Dornbluth N C, Strash W W, Devall J M. Sonographic analysis of Morton's neuroma.  J Foot Surg. 1992;  31 534-537
  • 110 Perini L, Del Borrello M, Cipriano R, Cavallo A, Volpe A. Dynamic sonography of the forefoot in Morton's syndrome: correlation with magnetic resonance and surgery.  Radiol Med (Torino). 2006;  111 897-905
  • 111 Torriani M, Kattapuram S V. Technical innovation. Dynamic sonography of the forefoot: The sonographic Mulder sign.  AJR Am J Roentgenol. 2003;  180 1121-1123
  • 112 Chauveaux D, Le Huec J C, Midy D. The supra-transverse intermetatarsocapital bursa: a description and its relation to painful syndromes of the forefoot.  Surg Radiol Anat. 1987;  9 13-18
  • 113 Iagnocco A, Coari G, Palombi G, Valesini G. Sonography in the study of metatarsalgia.  J Rheumatol. 2001;  28 1338-1340
  • 114 Koski J M. Ultrasound detection of plantar bursitis of the forefoot in patients with early rheumatoid arthritis.  J Rheumatol. 1998;  25 229-230
  • 115 Banal F, Etchepare F, Rouhier B et al.. Ultrasound ability in early diagnosis of stress fracture of metatarsal bone.  Ann Rheum Dis. 2006;  65 977-978
  • 116 Bodner G, Stockl B, Fierlinger A, Schocke M, Bernathova M. Sonographic findings in stress fractures of the lower limb: preliminary findings.  Eur Radiol. 2005;  15 356-359
  • 117 Ford L A, Collins K B, Christensen J C. Stabilization of the subluxed second metatarsophalangeal joint: flexor tendon transfer versus primary repair of the plantar plate.  J Foot Ankle Surg. 1998;  37 217-222
  • 118 Gregg J, Silberstein M, Schneider T, Marks P. Sonographic and MRI evaluation of the plantar plate: a prospective study.  Eur Radiol. 2006;  16 2661-2669
  • 119 Gregg J M, Silberstein M, Schneider T, Kerr J B, Marks P. Sonography of plantar plates in cadavers: correlation with MRI and histology.  AJR Am J Roentgenol. 2006;  186 948-955

Viviane KhouryM.D. 

Department of Radiology, Hôpital Notre-Dame

Centre Hospitalier de l'Université de Montréal 1560 Sherbrooke St. E., Montreal, Quebec, Canada H2L 4M1

Email: viviane.khoury@umontreal.ca

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