Assessment of Bony Subfibular Impingement in Flatfoot Patients Using Weight-Bearing CT Scans - Clifford L. Jeng, Tyler Rutherford, Michael G. Hull, Rebecca A. Cerrato, John T. Campbell, 2019 MENU Browse Resources Authors Librarians Editors Societies Reviewers Advanced Search IN THIS JOURNAL Journal Home Browse Journal Current Issue OnlineFirst MRI; Subfibular impingement is one cause of extraarticular ankle . However, there is no associated ligamentous ankle instability. MRI may be useful in examining patients in whom coexistent abnormalities are suspected clinically [29]. By continuing to use this website you are giving consent to cookies being used. On examination, there may be soft-tissue swelling or a palpable spur over the anterior ankle joint [31]. It is of paramount importance, however, to remember that MRI features supportive of impingement may be present in asymptomatic individuals and that accurate diagnosis requires careful correlation of imaging features with the clinical picture. These include talonavicular arthrodesis, double arthrodesis at Chopart joints, a subtalar arthrodesis, and a triple arthrodesis. Role of imaging and imaging features Conventional radiographs with the addition of the anteromedial impingement view are helpful in the detection and characterization of spurs and in the visualization of the ankle joint space [43]. Furthermore, mild posteromedial synovitis was present in two control subjects [20]. 4 Statistical analyses were performed using Cochran-Armitage, Fisher's exact, and Mann-Whitney tests. 1A, 1B). Conventional weight-bearing ankle radiographs are useful to assess the plantar arch and hindfoot valgus. On physical examination, flatfoot and hindfoot valgus deformity are evaluated with the patient sitting and standing. Peroneal tendon subluxation (Fig. Anterolateral Impingement (Ankle) 6 min. Conventional MRI can accurately detect abnormalities at the synchondrosis including opposing marrow edema or fluid signal at the synchondrosis related to motion [49, 50, 59] (Fig. Administration of IV gadolinium may improve detection of small focal areas of synovitis surrounding the posterior ligaments [60]. This is the American ICD-10-CM version of M75.42 - other international versions of ICD-10 M75.42 may differ. to maintaining your privacy and will not share your personal information without Ligamentous and capsular tearing and the resultant microinstability and hemorrhage after an ankle sprain may lead to reactive synovial hyperplasia and scarring in the anterolateral gutter [2] (Fig. An additional imaging feature, seen more commonly in patients with clinical anterolateral impingement, includes the absence of the recess between the anterolateral soft tissues and the anterior surface of the fibula despite adequate joint distention with contrast material [25]. In patients with advanced synovitis, the synovial tissue may become molded to the triangular shape of the anterolateral gutter. A trial of nonoperative management should be exhausted prior to open or arthroscopic procedures being considered. Anterolateral impingement has also been described in a subset of patients with an accessory fascicle of the anteroinferior tibiofibular ligament [ 12 ]. 2). CONCLUSION. 3). Ankle impingement, typically secondary to an ankle sprain, is classified according to its anatomic relationship to the tibiotalar joint as anterolateral [2], anterior [3], anteromedial [4], posteromedial [5], or posterior [6] impingement. Additionally, MRI is valuable in the detection of extraarticular, lateral hindfoot impingements in patients with hindfoot valgus deformity. Ankle impingement syndromes are important causes of persistent ankle pain after an ankle sprain. MRI often is necessary to rule out other causes of ankle pain. However, in the setting of a prior ankle sprain, posterolateral ankle laxity leads to anterior extrusion of the talar dome with dorsiflexion, increased pressure at the site of contact, and subsequent synovial hypertrophy and impingement between the anterolateral talus and the accessory anteroinferior tibiofibular ligament [12]. CT is more sensitive than radiography for identifying cystic and sclerotic changes [9]. Wolters Kluwer Health Indirect MR arthrography is a noninvasive alternative to direct MR arthrography, which requires IV administration of contrast material followed by 20 minutes of joint exercise. The objective of this article is to review the pathophysiology and clinical presentation of impingement syndromes at the ankle joint (anterolateral, anterior, anteromedial, posteromedial, and posterior) and the role of MRI in evaluating impingement at the ankle joint and at extraarticular locations, lateral to the ankle joint (talocalcaneal and calcaneofibular). Advanced imaging findings are related to abutment between the fibula and calcaneus and include subcortical marrow edema, cystic changes, sclerosis, and the presence of soft-tissue entrapment or extensive soft-tissue thickening between the fibula and the calcaneus. Subfibular impingement is one cause of extraarticular ankle impingement characterized by pain in the lateral aspect of the hindfoot. Keywords Methods:: Patients with posterior tibial tendonitis were retrospectively searched and reviewed. Wolters Kluwer Health, Inc. and/or its subsidiaries. Delaminated Tears of the Rotator Cuff: Prevalence, Characteristics, and Diagnostic Accuracy Using Indirect MR Arthrography, Original Report. Mott Children's Hospital, the von Voigtlander Women's Hospital, Frankel Cardiovascular Center, and Rogel Cancer Center on the main campus. This can include talocalcaneal, calcaneofibular (subfibular)or combined talocalcaneal-subfibular impingements. 4 The awareness of hindfoot malalignment on non-weight-bearing ankle MRI. Icahn School of Medicine at Mount Sinai Home, Subfibular impingement: Current concepts, imaging findings and management strategies, https://doi.org/10.1097/BCO.0000000000000702. 5A, 5B). Clinical presentation varies on the basis of the cause of flatfoot and hindfoot valgus. However, the severity of symptoms is not associated with the presence or size of either of these two structures [6]. A provocative physical examination test in which a physician attempts to pinch hypertrophied synovium between the tibia and the talus has been described. Extraarticular lateral hindfoot impingement with posterior tibial tendon tear: MRI correlation. Current Orthopaedic Practice30(1):69-76, January/February 2019. Advanced imaging findings are related to abutment between the fibula and calcaneus and include subcortical marrow edema, cystic changes, sclerosis, and the presence of soft-tissue entrapment or extensive soft-tissue thickening between the fibula and the calcaneus. Acute synovitis is treated with rest and NSAIDs to reduce inflammation. Osseous outgrowths at the anterior ankle joint, which are at times asymptomatic, represent a major pathologic component of this impingement syndrome, but soft-tissue impingement due to hypertrophied synovium also occurs [33] (Fig. Data is temporarily unavailable. Current concepts, imaging findings and management strategies. Some error has occurred while processing your request. (2009) AJR. Production or aggravation of pain during this maneuver, or so-called positive impingement sign, has been shown to be highly sensitive and specific (94.8% and 88%, respectively) for identifying anterolateral impingement [17]. MRI often is necessary to rule out other causes of ankle pain, and advanced imaging findings are related to abutment between the fibula and calcaneus and include subcortical marrow edema, cystic changes, sclerosis, and the presence of soft-tissue entrapment or extensive soft-Tissue thickening between the Fibula and the calcaneu. ;Nguyen, Duc M. Clinical presentation All rights reserved. presence of subfibular impingement, and hindfoot valgus angle measurements. Advanced imaging findings are related to abutment between the fibula and calcaneus and include subcortical marrow edema, cystic changes, sclerosis, and the presence of soft-tissue entrapment MRI is valuable in assessing both osseous and soft-tissue abnormalities associated with impingement syndromes. MRI often is necessary to rule out other causes of ankle pain. Glenohumeral Joint, Wrist and Ankle Plica. described for the management of these deforming forces. This accessory, or distal, fascicle is separated from the anteroinferior tibiofibular ligament by a fibrofatty septum (Fig. Subcortical cyst formation is also prominent within the mid talus and lesser so at the distal fibula with subfibular soft tissue edema. This condition is most commonly seen in ballet dancers [51] and soccer players [39]. It is thought to represent a normal variant and may be identified in 2197% of ankles [12, 1416]. On this page: Article: Clinical presentation Pathology Radiographic features Treatment and prognosis References Images: Cases and figures A clinical sign that is helpful in differentiating posteromedial impingement and PTT abnormalities is posteromedial tenderness on inversion with the ankle in plantar flexion, which is seen in patients with posteromedial impingement and not in those with PTT abnormalities [5]. Physical therapy and orthotics relieve stress and pain in the ankle. (2021) Skeletal Radiology. Interobserver agreement and accuracy, sensitivity, and specificity in the detection of fibular periostitis, peroneal . T2 - Current concepts, imaging findings and management strategies. MRI often is necessary to rule out other causes of ankle pain. MRI Appearance of Wrisberg Variant of Discoid Lateral Meniscus, MRI Findings Associated with Distal Tibiofibular Syndesmosis Injury, Original Research. 3: 3 MRI has been used to evaluate both the subacute stage (i.e., within 4 weeks of the participating injury) and the chronic stage (i.e., 1452 weeks after injury) of posteromedial impingement [20, 48] (Fig. Arthroscopic dbridement of the impinging soft tissue has been shown to be effective in many patients [11, 18]. MRI often is necessary to rule out other causes of ankle pain. It usually occurs following a sprain injury or repetitive microtrauma causing haemorrhage, synovial hyperplasia, and abnormal soft tissue interposition within the joint. Ultrasound-guided therapeutic injections can provide symptom relief in appropriately selected patients. In patients with anterolateral impingement, indirect MR arthrography did not offer additional information compared with conventional MRI [29]. Calcaneocuboid joint effusion. 3 topics. Although the initial injury is usually minor and does not result in clinical ankle instability [2], repetitive microtrauma and subclinical microinstability may lead to soft-tissue abnormalities in the anterolateral gutter. This form of synovitis has been described as a meniscoid lesion [13]. Repetitive kicking in plantar flexion has been postulated to lead to traction on the anterior capsule and enthesophyte formation [37]. Bilateral posterior ankle impingement syndrome has been described but is rare 5 . In patients with PTT dysfunction, medial ankle pain is the presenting symptom during the early stages of PTT dysfunction, whereas lateral ankle pain related to hindfoot valgus and lateral impingement predominates in long-standing PTT dysfunction [7]. Ankle impingement refers to a chronic painful mechanical limitation of ankle motion caused by soft-tissue or osseous abnormality affecting the tibiotalar joint or extraarticular soft tissues. Pain can be caused by disruption of the cartilaginous synchondrosis between the os trigonum and the lateral talar tubercle due to repetitive microtrauma and chronic inflammation. Talocalcaneal and subfibular impingement in symptomatic flatfoot in adults. 13A, 13B, 13C). ;Vulcano, Ettore Thus, it is thought that impingement occurs laterally first through the sinus tarsi and then progresses to the calcaneofibular interval 3. Several mechanisms have been proposed for spur formation along the anterior margin of the joint. These patients include those with isolated posteromedial synovitis and no associated chondral injury or ligament instability. Several normal osseous and soft-tissue anatomic variants predispose individuals to posterior impingement including a prominent os trigonum, a prominent lateral talar process (Stieda process), a shelflike superior prominence of the calcaneal tuberosity, and a posterior intermalleolar ligament [49, 52]. Patients usually present after the development of significant soft-tissue abnormality such as synovial thickening along the posterior capsule or thickening of the posterior intermalleolar or talofibular ligaments [52, 54]. Ligaments of the Transverse Tarsal Joint Complex: MRIAnatomic Correlation in Cadavers. This can include talocalcaneal, calcaneofibular (subfibular) or combined talocalcaneal-subfibular impingements. Associated with severe hindfoot deformity, subfibular impingement can be secondary to posterior tibial tendon dysfunction, calcaneal fracture malunion, or neuropathic or inflammatory arthritidies. Kaplan, MD, Other articles in this journal by Jonathan R.M. Conventional axial T1 and fluid-sensitive images are optimal for detecting the intermediate- to low-signal synovial hypertrophy and scarring in the anterolateral gutter [2125] (Fig. The Achilles tendon may show contracture and tightness [72]. or neuropathic or inflammatory arthritidies. Conservative management is usually successful in most patients with anterior ankle impingement syndrome. 8). Similar to conventional MRI, this technique is limited by a lack of joint fluid [29]. author = "Kaplan, {Jonathan R.M.} Department of Orthopedics, Icahn School of Medicine at Mount Sinai, New York, NY Level of Evidence: Level V.". The diagnosis of anterior impingement is usually clinical, based on anterior ankle pain with limited and painful dorsiflexion [31]. The treatment for anterior impingement in the ankle can include physical therapy to . @article{573babf591204f73998be74cfa79bf3d. Department of Radiology, University of Miami Miller School of Medicine, Miami, FL. The MRI features of posteromedial impingement are not specific. A trial of nonoperative management should be exhausted prior to open or arthroscopic procedures being considered. Anterolateral impingement has also been described in a subset of patients with an accessory fascicle of the anteroinferior tibiofibular ligament [12]. Femoroacetabular impingement is an intra-articular or internal form of impingement, where structural changes combined with dynamic factors as repetitive abnormal contact of the acetabulum and the femoral head-neck junction lead to mechanical stress and shear forces on the labrum and chondral surfaces and subsequent damage 1-4. 1A, 1B). Extra-articular lateral hindfoot impingement syndrome is a non-traumatic cause of ankle impingement. Advanced imaging findings are related to abutment between the fibula and calcaneus and . Get new journal Tables of Contents sent right to your email inbox, January/February 2019 - Volume 30 - Issue 1, January/February 2019 - Volume 30 - Issue 1 - p 69-76, Subfibular impingement: current concepts, imaging findings and management strategies, Articles in PubMed by Jonathan R.M. 3 min. Early detection of impingement using MRI may be beneficial for successful surgical results [9, 10]. 14A, 14B). your express consent. Pathophysiology and clinical features Posteromedial impingement is the least recognized ankle impingement syndrome and is thought to be a sequela of severe inversion injury [47, 48]. Extra-articular lateral hindfoot impingement syndrome is a non-traumatic cause of ankle impingement. {"url":"/signup-modal-props.json?lang=us\u0026email="}, Weerakkody Y, Knipe H, Knipe H, et al. The hindfoot valgus angle was statistically larger in the group with periostitis than in the control group ( p = .01-.002) and among patients with versus those without peroneal tendon subluxation . With progressive deformity, secondary osteoarthrosis of the subtalar, talonavicular, and calcaneocuboid articulations contribute to pain symptoms [62]. For more information, please refer to our Privacy Policy. Pathophysiology and clinical features Anterior ankle impingement syndrome is a common cause of chronic ankle pain, especially in ballet dancers and soccer players [31, 32]. Extra-articular lateral hindfoot impingement syndrome. lateral hindfoot impingement; Level of Evidence: Level V. AB - Subfibular impingement is one cause of extraarticular ankle impingement characterized by pain in the lateral aspect of the hindfoot. MRI often is necessary to rule out other causes of ankle pain. Conventional MRI may play a role in excluding other abnormalities contributing to a patient's symptoms, such as talar osteochondral injuries, but may not be sensitive in detecting subtle capsular changes. Severe flatfoot and hindfoot valgus deformity may present with lateral ankle pain in the region bounded by the anterior fibula and the sinus tarsi [7]. Impingement results from abnormal contact laterally as the valgus deformity results in sinus tarsi narrowing, which it does normally during eversion (although to a lesser degree in normal individuals)3. / Kaplan, Jonathan R.M. This can include talocalcaneal, calcaneofibular (subfibular) or combined talocalcaneal-subfibular impingements. Associated with severe hindfoot deformity, subfibular impingement can be secondary to posterior tibial tendon dysfunction, calcaneal fracture malunion, or neuropathic or inflammatory arthritidies. MRI, in particular, is also valuable for identifying other causes of persistent ankle pain that may mimic or coexist with ankle impingement, such as occult fractures, cartilage damage, intraarticular bodies, osteochondral talar lesions, tendon abnormalities, and ankle instability [1]. N2 - Subfibular impingement is one cause of extraarticular ankle impingement characterized by pain in the lateral aspect of the hindfoot. Impingement can be associated with a prior single traumatic event or repetitive microtrauma, often in an adolescent with anatomical predisposition. Copyright 2019 Wolters Kluwer Health, Inc. All rights reserved. The accessory anteroinferior tibiofibular ligament may normally contact the anterolateral corner of the talus. ;Aiyer, Amiethab Results: Twenty-eight cases (37%) of lateral hindfoot impingement were identified, including six talocalcaneal, eight subfibular, and 14 talocalcaneal-subfibular impingements. No Citation information available - sign in for access. For patients unable to undergo an MRI examination, CT arthrography may be useful. View Record in Scopus Google Scholar. Pressing the buy now button more than once may result in multiple purchases. Coronal CT images have been shown to best depict nodular thickening related to synovial impingement [30]. These impingements are sequelae of flatfoot deformity and hindfoot valgus from a variety of causes such as posterior tibial tendon (PTT) deficiency, rheumatologic disorders, diabetes, calcaneal fractures, and congenital flatfoot [7, 8]. There may be decreased range of motion of the ankle, hindfoot, midfoot, and forefoot and lateral ankle pain on palpation. Role of imaging and imaging featuresIn most cases, conventional, preferably weight-bearing, radiography is the imaging study of choice because anterior impingement is typically related to osseous abnormalities [3, 42]. Associated with severe hindfoot deformity, subfibular impingement can be secondary to posterior tibial tendon dysfunction, calcaneal fracture malunion, or neuropathic or inflammatory arthritidies. 3. However, in recalcitrant cases unresponsive to conservative treatment, there are several surgical procedures described for the management of these deforming forces. In patients with chronic posteromedial impingement (1452 weeks after injury), there was a higher incidence of posterior tibiotalar ligament disruption and abnormal signal encasing or abutting the PTT and flexor digitorum longus tendons [48]. 50 (7): 1317. CT may be helpful for further characterizing the location and size of the spurs but is rarely indicated [36] (Fig. MRI of Ankle and Lateral Hindfoot Impingement Syndromes. Sagittal T1-weighted images may show secondary displacement of normal fat anterior to the fibula by the presence of syno vitis or scar tissue [26]. Search for Similar Articles A scoring system based on the size and location of radiographically detected spurs is used as a prognostic factor for postoperative success [34, 35]. Imaging features of subfibular impingement often include extensive lateral soft-tissue thickening between the fibula and the calcaneus (Fig. MDa; Aiyer, Amiethab MDb; Nguyen, Duc M. MDb; Vulcano, Ettore MDc; Buller, Leonard T. MDb; Sheth, Pooja MDd; Jose, Jean DOd, aOrthopaedic Specialty Institute, Orange, CA, bDepartment of Orthopedics, University of Miami Miller School of Medicine, Miami, FL, cDepartment of Orthopedics, Icahn School of Medicine at Mount Sinai, New York, NY, dDepartment of Radiology, University of Miami Miller School of Medicine, Miami, FL. Ultrasound is helpful in guiding therapeutic injection of the posteromedial synovial mass in select patients with no associated osteochondral abnormality or joint instability [20]. subfibular impingement, Affiliations: Jonathan R.M. Level of Evidence: Level V. Subfibular impingement : Current concepts, imaging findings and management strategies. Kaplan JRM, Aiyer A, Nguyen DM, Vulcano E, Buller LT, Sheth P et al. ;Sheth, Pooja Surgical strategies for the treatment of posteromedial impingement include dbride ment of abnormal soft tissue from the postero medial corner. The radiographic finding of fibular tip periostitis in patients with hindfoot valgus can be a predictor of peroneal tendon subluxation-dislocation and may also suggest advanced hindfoot valgus and subfibular impingement. In addition to ankle impingement sy ndromes, extraarticular soft-tissue and osseous impingements occur lateral to the ankle joint, such as talocalcaneal and calcaneofibular impingements [7]. Arthroscopy and open surgery to remove spurs or soft-tissue abnormalities are effective in patients with no underlying tibiotalar articular disease [3, 34, 36, 40, 41]. Together they form a unique fingerprint. Cross-sectional imaging, ultrasound or MRI, is useful for assessing ankle impingement. Hindfoot valgus (often defined as a tibiocalcaneal angle >11) with one or both of the following 5: Treatment may be non-operative or operative. The aim of operative treatment is to correct the hindfoot valgus and includes 4: ADVERTISEMENT: Supporters see fewer/no ads, Please Note: You can also scroll through stacks with your mouse wheel or the keyboard arrow keys. Using real-time images from X-ray, CT, ultrasound or MRI, interventional radiologists . Marrow edema was seen infrequently and had no specific distribution [20]. It is classically described in ballet dancers. Keywords: ankle impingement, calcaneofibular impingement, extraarticular impingement, MRI, sports medicine, talocalcaneal impingement. In patients with impingement that is resistant to conservative therapy, imaging-guided therapeutic injection with a mixture of local anesthetic and steroids offers a rapid return to athletic activity and long-lasting symptom relief [56]. The responsibility for the publication content rests with the publishers providing the material. In cases of trauma and calcaneal fractures that have malunited, there may be lateral calcaneal wall blow-out with widening of the heel 4. Less frequent findings include fibular tip marrow edema and contact between the fibula and calcaneus, occasionally with the formation of a neocalcaneal facet (Fig. Check for errors and try again. The addition of Doppler assessment has not been shown to be helpful [19]. Clinical presentation It presen. Please enable scripts and reload this page. Furthermore, ultrasound can facilitate imaging-guided therapeutic injection of the synovial lesion [20]. ;Jose, Jean Healed intra-articular calcaneal fractures, neuropathic arthropathy, and inflammatory arthritides may also play a causative role. 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Triangular shape of the talus adolescent with anatomical predisposition E, Buller LT, Sheth P et al Jose Jean..., there is no associated ligamentous ankle instability tissue edema and forefoot and ankle... Advanced imaging findings are related to abutment between the fibula and the calcaneus (.. Out other subfibular impingement radiology of ankle pain be lateral calcaneal wall blow-out with widening of the heel.! A non-traumatic cause of flatfoot and hindfoot valgus deformity subfibular impingement radiology 9 ] patients. Ligaments [ 60 ] the distal fibula with subfibular soft tissue edema and... Of posteromedial impingement are not specific is treated with rest and NSAIDs to reduce inflammation unable to undergo an examination!, often in an adolescent with anatomical predisposition more information, please refer to our Privacy Policy persistent ankle.... Not been shown to be helpful for further characterizing the location and size of either of these two structures 6... Weight-Bearing ankle radiographs are useful to assess the plantar arch and hindfoot valgus deformity are evaluated the... Https: //doi.org/10.1097/BCO.0000000000000702 malunited, there are several surgical procedures described for the publication content rests with publishers!, extraarticular impingement, extraarticular impingement, Indirect MR arthrography did not offer additional information compared with MRI... Meniscus, MRI findings associated with the patient sitting and standing of Discoid lateral Meniscus, MRI findings associated a. Medicine at Mount Sinai Home, subfibular impingement: Current concepts, imaging findings and management.... And calcaneus and injury or repetitive microtrauma, often in an adolescent with anatomical predisposition joints, a subtalar,! Meniscus, MRI, interventional radiologists is the American ICD-10-CM version of M75.42 - other international versions of M75.42. Described for the publication content rests with the publishers providing the material include dbride ment abnormal. With isolated posteromedial synovitis and no associated chondral injury or repetitive microtrauma, often in an adolescent anatomical! Extraarticular impingement, MRI is valuable in the ankle, hindfoot,,... Lang=Us\U0026Email= '' }, Weerakkody Y, Knipe H, et al version of M75.42 - other international versions ICD-10... Flexion has been shown to best depict nodular thickening related to synovial impingement [ 30 ] with posterior tibial tear... Other causes of ankle pain helpful for further characterizing the location and size of the Transverse Tarsal joint Complex MRIAnatomic.

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