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SON5024 MSK > Topic 7 - the foot and ankle > Flashcards

Topic 7 - the foot and ankle Flashcards

1
Q

What are the two movements of the ankle joint?

A

plantarflexion and dorsiflexion

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2
Q

What are the three ligament groups of the ankle?

A

o The medial ligament complex, known as the Deltoid ligament which binds the medial malleolus to the talus, calacaneus and navicular bone.
o The lateral ligament complex which binds the lateral malleolus to the talus and calcaneus.
o The inferior tibio-fibular syndesmosis

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3
Q

What is unique to the Achilles tendon at the anke?

A

• Apart from the Achilles tendon all the tendons crossing the ankle joint have a synovial sheath.

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4
Q

What is the appearance of the normal synovial sheath?

A

• Sonographically the normal synovial sheath is seen as a hypoechoic halo surrounding the tendon

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5
Q

What is the normal appearance of the peritendon?

A

• the peritendon is seen as a hyperechoic line surrounding the tendon.

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6
Q

What are the names of the different retinacula of the ankle?

A

o Superior and Inferior Peroneal Retinaculum
o Superior and Inferior Extensor Retinaculum
o Flexor Retinaculum

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7
Q

What does the tibialis anterior do?

A

Main dorsiflexor of the foot

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8
Q

What can happen to the tibialis anterior when a patient has RA?

A

• Spontaneous tears of this tendon are common in cases of rheumatoid arthritis

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9
Q

What is a common cause of irritation for the extensor digitorum longus?

A

• The extensor tendons may be subject to inflammation as a result of inappropriate footwear or excessively tight shoe laces

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10
Q

What is a common irritation of flexor hallicus longus?

A

• Tendinitis of the FHl is a common finding in ballet dancers due to extreme plantar flexion of the foot.

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11
Q

What is the main function of Peroneus longus and Peroneus Brevis ?

A

everters

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12
Q

What are the insertions of PB and PL?

A
  • Peroneus Brevis inserts onto the base of the 5th metatarsal
  • Peroneus longus runs in a groove on the undersurface of the cuboid and continues across the sole of the foot to insert onto the first metatarsal and medial cuneiform.
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13
Q

What can happen to PB and PL after direct trauma?

A

• Trauma to the lateral ankle can result in rupture of this retinaculum leading to subluxation or dislocation of the peroneal tendons.

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14
Q

What can subluxation do to PB and PL?

A

• Constant subluxation causes tendonitis I tenosynovitis of the tendons and can ultimately result in longitudinal tears, usually in Peroneus Brevis but occasionally both.

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15
Q

How can subluxation of PB and PL be assessed?

A

• To diagnose this condition sonographically the tendon/s must be observed to move over the lateral malleolus during eversion and dorsiflexion of the foot.

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16
Q

How can refraction artefact be helpful when scanning tendons?

A

Refraction may be seen at the site of a tendon tear while the longitudinal course of a tendon is being scanned, and therefore, its presence can help to establish diagnosis of a tear.

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17
Q

What is a negative effect of refraction artefact when scanning tendons?

A

During transverse scanning of a tendon, refraction can produce shadowing from the curved outer surface of a normal tendon. Such shadowing could simulate a tear in a deeper adjacent tendon

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18
Q

What is the function of the tibialis posterior?

A

Inverter of the foot

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19
Q

Where does the tibialis posterior attach?

A

As a fan at the navicular

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20
Q

What is important to be careful of when scanning the tibialis posterior attachment?

A

• At the attachment of the tendon to the navicular there is a fanning of the fibres and hence it is normal to get a hypoechoic appearance not to be confused with tendonitis

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21
Q

Where do most tears of the tibialis posterior occur?

A

• Most tears of this tendon occur below the level of the malleolus

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22
Q

What associations do longitudinal and transverse tears of the tibialis posterior have?

A
  • Transverse tears are most often associated with trauma and rheumatoid arthritis
  • longitudinal tears are seen most often with degenerative changes.
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23
Q

Where can you find the accessory muscle peroneus quartus?

A

• medial and posterior to the peroneus brevis tendon

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24
Q

What is the significance of the peronus quartus muscle?

A
  • presence of a peroneus quartus can stretch the retinaculum and compress the peroneus brevis tendon against the fibula, leading to a split or tear of the peroneus brevis tendon.
  • can also be confused with a longitudinal tear of the peroneus brevis tendon.
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25
Q

If present what is the insertion of the peroneus quartus muscle?

A

Lateral calcaneus

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26
Q

What else can cause confusion when assessing the peroneus brevis tendon?

A

Low lying peroneus brevis muscle

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27
Q

What are the accessory ossicles found in the foot?

A

Common ossicles found around the foot and ankle include the os tibiale externum at the distal posterior tibial tendon and the os peroneum in the peroneus longus tendon

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28
Q

Why is it important to have knowledge of the accessory ossicles of the foot?

A

Knowledge of their location and appearance prevents confusing these structures with true abnormalities, such as tendon calcification.

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29
Q

How can synovitis be differentiated from joint effusion?

A
  • A complex effusion can mimic synovitis because both may appear hypoechoic.
  • Power Doppler sonography can be useful in revealing the internal flow that can be present in synovitis but not in an effusion.
  • Dynamic imaging allows observation of the fluid as it moves during joint motion;
  • no movement is observed in synovitis.
  • Applying pressure with the transducer can also induce swirling of debris that helps to distinguish a complex effusion from a simple effusion
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30
Q

What artefact must you always be aware of when scanning tendons?

A

anisotropy

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31
Q

What dynamic manoeuvre can you use to separate the plantar fascia from the FHL?

A

Use sonographer assisted flexion and extension of the big toe to separate the plantar fascia from the flexor hallucis longus tendon

32
Q

Where is it normal to see up to 3mm of fluid?

A

o peroneal tendons
o anterior tibiotalar joint
o retrocalcaneal bursa in a healthy person

33
Q

Where should you never see fluid in the foot?

A

o flexor digitorum longus
o anterior tibial tendon
o posterior ankle joint
o Achilles tendon.

34
Q

What are the sonographic signs of ligament tears?

A
  • Presence of a hypo or anechoic defect in the ligament
  • Discontinuity of the ligament with fluid intervening
  • Echogenicity will depend on time since tearing
  • Fluid around or across the ligament (may be from a capsular tear)
  • Thickened hypoechoic ligament in partial thickness tears
  • Abnormal relaxation of the ligament in chronic tears ie loss of taut appearance
  • Bone avulsions
35
Q

Why shouldn’t the foot be placed in maximum dorsiflexion while examining the achilles?

A

this will make the tendon too taut and will reduce contact. It may even compress or obliterate tears.

36
Q

What must tears and ruptures be assessed for?

A

Tears and ruptures need to be evaluated for the site and size, and the distance between torn and retracted tendon ends.
The size of the tendon gap measured with the foot in plantar flexion may determine surgical versus conservative treatment

37
Q

What can make assessing an achilles tear difficult?

A

• Herniation of the Kager’s fat into the defect can sometimes be seen with complete rupture, or the gap formed by the retracted tendon can be filled with echogenic granulation tissue, making assessment of the tear quite difficult.

38
Q

What tendon can make assessing achilles rupture difficult and why?

A

full rupture of the Achilles tendon, it becomes a complex heterogenous mass.
The plantaris is a thin tendinous band sitting medial to the Achilles, is often spared in this rupturing process.
It is important not to mistake a spared plantaris as an area of remnant Achilles tendon. This will be placed medially if present.

39
Q

What is the function of the achilles tendon?

A
  • It is the common tendon of the Gastrocnemius and Soleus muscles.
  • It is the main plantar flexor of the foot at the ankle
40
Q

What are the two bursa at the achilles insertion?

A

• Its insertion is protected by two synovial bursae:
o - the subcutaneous bursa
o - located between the skin and the tendon
o - the retrocalcaneal bursa
o - lying between the tendon and the calcaneus

41
Q

What is the normal sonographic appearance of the achilles tendon?

A
  • Normal sonographic appearance is a homogenously echogenic fibrillar band with thin echogenic margins lying between a thin layer of subcutaneous tissues and the pre-Achilles fat pad.
  • The retrocalcaneal bursa can be identified on most subjects whilst the subcutaneous bursa is only seen in pathologic cases.
42
Q

What is haglunds disease?

A
  • occurs at the tendon-bone interface where the Achilles inserts onto the calcaneus.
  • Bony protrusions and spurs develop at the posterosuperior surface of the calcaneus with an associated thickening of the overlying dermis and soft tissues.
  • The Achilles fibres may not be directly involved, but the continual dorsi and plantar flexion of the foot during walking will cause a retrocalcaneal bursitis to develop.
43
Q

What is retrocalcaneal bursitis?

A

• overuse and inflammatory condition involving the bursa that lies between the posterior fibres of the Achilles tendon and the superior border of the calcaneus.

44
Q

How does retrocalcaneal bursitis appear on ultrasound?

A

• Increased fluid will gather inside the bursa, with thickening of the bursal walls and extension of the bursa into the Kager’s fat pad.

45
Q

What is paratenonopathy of the achilles tendon?

A
  • or paratenonitis
  • paratenon can undergo acute injury during repetitive stress resulting in acute oedema and hyperaemia.
  • It usually involves a focal region rather than the whole paratenon, and can occur in the absence of any tendon injury.
46
Q

How does paratenonopathy appear on ultrasound?

A
  • a focal hypoechoic swelling around the Achilles
  • usually involving the lateral surface.
  • In the transverse plane a cresenteric thickening will appear at the margin of the Achilles, extending into the deeper fat pad. It is painful with compression.
47
Q

What is achilles xanthoma?

A

• results from gout and hypercholesterolemia which can cause swelling of the Achilles tendon through the deposition of uric acid and cholesterol.

48
Q

How does achilles xanthoma appear on ultrasound?

A
  • This deposition is often symmetric in both Achilles, and calcifications can occur in the deposits.
  • the appearances range from a single hypoechoic nodule within the tendon fibres
  • to a diffusely enlarged, heterogeneously hypoechoic tendon.
49
Q

What does kagers fat pad look like on ultrasound?

A
  • anterior to the Achilles tendon
  • often hypoechoic
  • should not be mistaken for a fluid collection in the retrocalcaneal bursa
  • Correlation with the patient’s symptoms and examination of the opposite, nonsymptomatic side can help in determining the diagnosis.
50
Q

What is the most common presentation for achilles tendon pathology

A

acute on chronic

51
Q

How do you detect low grade fusiform swelling of the achilles?

A

Compare to the other side

52
Q

What is plantar fasciitis?

A

• Plantar fasciitis is an overuse injury manifested by pain at the medial tubercle of the calcaneus and/or along the medial longitudinal arch

53
Q

What causes plantar faciitis?

A

• It develops when repetitive and prolonged stress is placed on the plantar fascia leading to microtears and inflammation in the fascia or near its insertion.

54
Q

What does the plantar fascia look like on ultrasound?

A

appears as a mildly hypoechoic linear band of tissue originating from the undersurface of the calcaneus
• It should generally not exceed 3mm in thickness
• Often associated with a spur that develops on the under surface of the medial calcaneal tubercle

55
Q

How can plantar fasciitis appear on ultrasound?

A
  • the fascia can become swollen
  • its normally flat superficial surface will become convex.
  • Some fasciitis can be focal and just involve a short segment of the plantar fascia more distal than the calcaneal origin.
  • These nodules of fasciitis are usually oval shaped hypoechoic swellings within the fibres of the fascia, known as plantar fibromatosis.
56
Q

What is an abnormal plantar fascia thickness?

A

An AP diameter greater than four millimetres is considered abnormal.

57
Q

What are three way to improve imaging of the plantar fascia?

A
  1. Pressure: This examination requires considerable pressure with the transducer.
  2. Decrease the frequency: On occasions, the L7-4 will significantly improve you visualisation.
  3. Dynamic Range: It will improve the delineation of the fascia ensuring accurate measurement.
58
Q

What are the tear types that occur in the tibialis posterior tendon and where?

A
  • Above the medial mallolous these will appear as degenerative splits while below the malleolus, as a transverse rupture.
  • The former is by far the more common presentation and usually occurs after a history of chronic tendinosis in this area.
59
Q

What nerve should you look for while examining the medial ankle and why?

A
  • Pay attention to the tibialis posterior nerve particularly where it passes over the flexor hallucis longus tendon at the tarsal tunnel.
  • This is a site of possible nerve entrapment and subsequent neuropathy
60
Q

Why are medial ligament injuries rare?

A
  • Rare as eversion injuries are not common and the ligament itself is very strong.
  • The force required to produce an injury is thus excessive and a fracture is more likely to occur.
61
Q

How can you differentiate injury at the posterior tibial insertion from normal hypoechoic fan?

A

• Applying pressure with the transducer to elicit symptoms at the site of a suspected abnormality can aid in distinguishing normal asymptomatic heterogeneity from true symptomatic disease or injury, such as a tendon tear.

62
Q

What common injury should you look for when scanning the peroneus brevis?

A

• particular attention should be paid to the peroneus brevis insertion for avulsion fracture of the 5th metatarsal

63
Q

Which ligaments make up the lateral ligament complex?

A

o Anterior talo fibular (ATFL)
o Calcaneo fibular
o Posterior talo fibular

64
Q

Where do the majority of ankle injuries occur?

A
  • vast majority of ankle injuries occur on inversion

* principally involve the lateral ligament complex.

65
Q

What ligament should you carefully inspect in the setting of a torn ATFL and why?

A

• If the inversion force continues following rupture of the Anterior Talo-Fibular Ligament the Calcaneo-Fibular Ligament will be injured

66
Q

What are the different grades of lateral ligament injuries?

A

Grade 1: Mild stretching of the ligament/s with no instability
Grade 2: Partial or complete tear with no instability
Grade 3: Complete tear with gross laxity and instability.

67
Q

How can you assess for diastasis of the anterior tibiofibular ligament?

A

squeeze test

68
Q

Why tis the ATFL so commonly damaged?

A
  • Weakest and most vulnerable of all ligaments

* Connects the anterior margin if the lateral malleolus with the lateral neck of the talus

69
Q

What is the normal appearance of the ATFL?

A
  • Taut
  • Flat
  • Relatively hyperechoic
  • Fibrillar
  • Runs between lateral malleolus and the talus
70
Q

How does a torn ATFL appear?

A
  • Full thickness tear will show a defect, may bow inward,
  • Partial thickness may appear thick, hypoechoic
  • Chronic full thickness may appear intact, hypoechoic, lacking normal fibrillar pattern and relaxed (no taut appearance)
  • May avulse a bone fragment
71
Q

What pathology can a normal calc fib lig appear as?

A
  • appearance of the calcaneofibular ligament on transverse scanning can mimic an intraarticular body deep in relation to the peroneal tendons
  • Longitudinal scanning shows the normal fibrillar echotexture of the ligament.
  • Familiarity with the appearance of the normal calcaneofibular ligament prevents misdiagnosis.
72
Q

Where does pathology usually occur in the tibialis anterior tendon?

A

• Tendinopathies usually involve its insertion at the medial cuneiform and first metatarsal, and just distal to the superior extensor retinaculum.

73
Q

What is a mortons neuroma?

A
  • Not a true neuroma, due to fibrous thickening in and around the nerve
  • Morton’s neuroma is a mass of fibrous tissue that forms in and around the common digital nerve between the metatarsal heads.
  • It occurs due to a type of nerve compression syndrome where the overlying interdigital ligament becomes swollen and entraps the nerve.
74
Q

Where are you most likely to find a mortons neuroma?

A

• Most common in the 3rd webspace, then the second, and rarely in the first or fourth

75
Q

How does a mortons neuroma appear on ultrasound?

A
  • oval hypoechoic mass lying approximately one centimetre distal to the interosseous muscle
  • With power Doppler you can usually show the neuroma lying in the fork between the superficial and deep branches of the digital artery.
  • Often there is an associated thickening of the overlying bursa, which can be difficult to separate from the neuroma.
76
Q

Why must you check a mass in the interspace doesnt communicate with the joint?

A

It would be suggestive of a complex ganglion rather than a mortons neuroma

SON5024 MSK (15 decks)

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