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ISSN: Print -2349-0977, Online - 2349-4387

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Year : 2017  |  Volume : 3  |  Issue : 4  |  Page : 213-220

Spectrum of high-resolution sonographic findings in painful ankle and foot

1 Department of Radiodiagnosis, S. N. Medical College, Agra, India
2 Department of Radiodiagnosis, Dr. R.M.L.I.M.S., Lucknow, Uttar Pradesh, India

Date of Web Publication7-Jul-2017

Correspondence Address:
Anil Rawat
H-2/8 Sector-D, LDA Colony Kanpur Road, Lucknow, Uttar Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/astrocyte.astrocyte_39_17

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The most common clinical presentation of patients with ankle and foot pathology is pain and swelling followed by pain alone who attends the musculoskeletal clinic or orthopedic department. This leads to disability in performing regular normal activities. Although magnetic resonance imaging is gold standard for musculoskeletal pathologies, but the recent improvement of technology, wide availability, and radiation-free modality makes ultrasound the first line of investigation in musculoskeletal pathologies. This pictorial essay based on high-resolution ultrasonography (HRSG) study of 70 patients at our institute describes the role of HRSG in the evaluation of spectrum of various pathologies of ankle and foot with their positive sonographic findings.

Keywords: Ankle and foot, high-resolution ultrasonography, musculoskeletal pathologies

How to cite this article:
Kumar S, Verma V, Singh H, Rawat A. Spectrum of high-resolution sonographic findings in painful ankle and foot. Astrocyte 2017;3:213-20

How to cite this URL:
Kumar S, Verma V, Singh H, Rawat A. Spectrum of high-resolution sonographic findings in painful ankle and foot. Astrocyte [serial online] 2017 [cited 2023 Dec 6];3:213-20. Available from: http://www.astrocyte.in/text.asp?2017/3/4/213/209929

  Introduction Top

The most common clinical presentation of patients with ankle and foot pathology is pain and swelling followed by pain alone. The most common etiologies are trauma, inflammatory, degenerative, and neoplastic conditions.

Within the past decade, high-resolution ultrasonography (HRSG) becomes an established imaging technique for diagnosis and follow-up of cases affected by musculoskeletal pathologies, especially rheumatic disease.[1] HRSG is capable of depicting real-time static and dynamic structural information.[2] Owing to the better axial and lateral resolution of ultrasonogram, even minute bone abnormalities may be picked up; thus hypertrophic/destructive/reparative changes on bone surface may be seen before they appear on X-ray or magnetic resonance imaging (MRI).[1] Although MRI is a better modality in soft tissue pathologies and also in areas which are inaccessible to sonography that include deep small joints like subtalar joint, deep parts of various ligament, and areas obscured by bone, skilled sonologist with high resolution of technique makes HRSG the first line investigation of choice for musculoskeletal pathologies.

In this pictorial essay, we will discuss in brief spectrum of pathologies affecting ankle and foot with their positive sonographic findings that includes arthritis, ligament and tendons injuries, bumps and lumps of ankle and foot, and miscellaneous conditions.

  Disease Spectrum Top


Many studies have confirmed the superiority of HRSG over clinical examination in the detection of synovitis, synovial hypertrophy, effusion, and related pathologies.[3],[4]

Rheumatoid arthritis

Rheumatoid arthritis (RA) is a chronic inflammatory disease of unknown etiology marked by a symmetric, peripheral polyarthritis. It may affect any age group, but peak incidence is between 40 and 60 years group. Major abnormalities of RA on HRSG are synovial hypertrophy, synovial effusion, bursitis, and tenosynovitis. Earliest pathological feature seen in RA is proliferative synovitis and is usually bilateral and symmetric [Figure 1].[5] Cartilage interface sign in tibiotalar joint anterior aspect indicator of synovial effusion [Figure 2].
Figure 1: Longitudinal scan bilateral dorsal aspect of foot in a 17 year old male showing bilaterally symmetrical hypoechoic synovial thickening in right and left 2nd metatarsophalangeal joint.

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Figure 2: Longitudinal scan of the anterior aspect left tibiotalar joint in a 26 year old male showing synovial effusion with cartilage of interface sign.

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Synovial hypertrophy with or without erosions in symmetric distribution involving tibiotalar joint [Figure 1] and [Figure 3], intertarsal joint [Figure 4], metatarsophalangeal joint, and proximal interphalangeal joints [Figure 5] in varying proportion increases the probability of disease being RA.
Figure 3: Longitudinal scan left anterior tibio-talar joint in a 40 year old female showing synovial thickening of the with minimal effusion.

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Figure 4: Longitudinal scan left dorsum of foot in a 26 year old male showing synovial thickening with minimal of the effusion in left tarso-matatarsal joint.

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Figure 5: Longitudinal scan bilateral plantar aspect of foot in a 40 year old female showing synovial thickening of the with erosion of the left 1st metatarsophalangeal joint and synovial thickening of right 1st metatarsophalangeal joint. Tarsal plate involvement is also apparent on the left side.

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Bone erosions with synovial hypertrophy are related to poor functional outcome of cases. Joints of foot eroded earlier than the hands.[6] Intrarticular erosions are more common in 5th metatarsophalangeal joint and proximal interphalangeal joint.[7],[8]

In our study, erosions are also most commonly seen in 5th metatarsophalangeal joint [Figure 6]. Tenosynovitis is a common sonographic finding in patients with early RA, usually seen as synovial hypertrophy, however, synovial effusion can be seen without synovial hypertrophy [Figure 7].[9]
Figure 6: Longitudinal scan of the dorsum of foot at left 5th metatarsophalangeal joint and 5th proximal interphalangeal joint in a 40 year old female showing 5th metatarsal head erosion and synovial thickening in the 5th metatarsophalangeal joint and proximal interphalangeal joint.

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Figure 7: Medial Perimalleous Transverse scan. Effusion along the flexor hallucis tendon in rheumatoid arthritis patient suggestive of tenosynovitis.

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Additional findings in spectrum of RA include retrocalcaneal bursitis [Figure 8] and calcaneal erosions.
Figure 8: Longitudinal scan bilateral posterior aspect of ankle. Bursal wall thickening with fluid on left side and bursal wall thickening on right side suggestive of bilateral retrocalcaneal bursitis.

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Osteoarthritis (OA)/degenerative joint disease is a noninflammatory degeneration of joint cartilage with secondary impact on bones. It usually affects over 50 years of age group. HRSG can detect its manifestations including osteophytes, effusion, erosions, and synovitis. Osteophytes are usually found in metatarsophalangeal joint, 1st metatarsophalangeal joint (most commonly) [Figure 9], intertarsal joint, tibiotalar joint, proximal interphalangeal joint, and distal interphalangeal joints usually accompanied by effusion.[10]
Figure 9: Longitudinal scan right foot dorsum in a 53 year old female showing echogenic osteophyte with of the hypoechoic synovial effusion in the right 1st metatarsophalangeal joint.

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Importance of synovitis detection on HRSG in OA is lying because of its association with the pain.[11]

Psoriatic arthritis

Psoriatic arthritis is an inflammatory arthritis. Both intra-articular and extra-articular manifestations of psoriatic arthritis can be done based on HRSG. The findings on HRSG include enthesopathy and bony proliferation, involvement of anterior talo-fibular ligament (ATFL) tenosynovitis bilaterally, bilateral synovial thickening with effusion in tibiotalar joint, bilateral retrocalcaneal effusion with Achilles enthesitis near insertion.[12]

Gouty arthritis

Gout is a metabolic disorder. Men over 40–50 years are commonly affected; however, it can also occur in postmenopausal women.

The HRSG findings in gout include joint effusion, synovitis, and erosions.

Monosodium urate crystals (tophi) [Figure 10] are known to deposit in the joints, over hyaline cartilage and within capsular soft tissue.[13],[14]
Figure 10: Longitudinal scan of left foot dorsum. Multiple echogenic foci (tophi) in left 1st metatarsophalangeal joint with synovial thickening.

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Double contour sign [Figure 11] and snowstorm appearance (aggregates of microtophi) [Figure 12] can be very well evaluated on sonography.[13],[14]
Figure 11: Longitudinal scan of right foot dorsum. Double contour sign in 1st metatarsophalangeal joint with the normal left 1st metatarsophalangeal joint.

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Figure 12: Longitudinal scan right foot dorsum. Mildly echogenic synovial thickening with multiple tiny of the echogenic foci /microtophi (<) without posterior acoustic shadowing (snowstorm appearence) seen in right 1st metatarsophalangeal joint.

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Infective arthritis

On HRSG evaluation, unilateral monoarticular foot involvement is observed, showing erosion, synovial thickening, and reduced joint space.

Ligament and tendons injury

Tendon injuries can be classified as: tendinosis, peritendinosis, tenosynovitis, entrapment, rupture, and dislocation.

Anterior talo-fibular ligament injury

The most common ligament injury in lateral ligament complex. Normal thickness of ATFL is equal to or <2 mm. Typically, it occurs with inversion of ankle with or without plantar flexion. ATFL tear and its grading can be done well on HRSG.[15],[16]

  • Grade 1: Thickened ligament which largely maintained its echopattern
  • Grade 2: Partial thickness tear indicates hypoechoic gap and hypoattenuated ligament [Figure 13]a and [Figure 13]b
  • Grade 3: Full-thickness tear.
Figure 13: Longitudinal scan right lateral aspect parallel to surface with foot in plantar flexed and inverted position. Grade 2 AFTL tear with a thickened hypoattenuated ligament (1.02 cm x 0.52 cm).

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Deltoid ligament injury

It is the medial collateral ligament of ankle that results from eversion or pronation of ankle.

Grading of ligament injury on HRSG:

  • Grade 1: Proximal tear or avulsion of ligament
  • Grade 2: Intermediate tear of ligament
  • Grade 3: Distal tear or avulsion of ligament.

Achilles tendon injury

Achilles tendon injury can be classified as: noninsertional and insertional.[17] Former includes acute or chronic peritendinosis, tendinosis, or rupture 2–6 cm above insertion to calcaneum, while latter group may be associated with Haglund's deformity or insertional calcific tendinopathy.

Studies have demonstrated that HRSG can be used to differentiate a full-thickness tear from a partial-thickness tear of the Achilles tendon with accuracy.

Tendon retraction for a 1 cm, shadowing from a calcification, Kager's fat herniation into the defect and visualization of plantaris tendon favors full-thickness tear or near-total thickness tear [Figure 14]a and [Figure 14]b rather than a partial-thickness tear.[18]
Figure 14: Longitudinal scan of the posterior aspect of right side ankle, (a and b) in a 44 year old female on showing proximal retracted tendon with calcification, fluid and kagers fat herniation into the defect with few intact fibres at periphery suggestive of right near total achilles tendon tear.

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Peroneal tendon tear

Injuries to the peroneal tendons are frequently encountered. Peroneal tendons injury occurs due to overuse or wear and tear. Calcaneal fractures also predispose peroneal tendons to injury. Usually it occurs in young athletes.

Injury may lead to partial-thickness tear, full-thickness tear, or intrasubstance tear [Figure 15].
Figure 15: Longitudinal right lateral perimalleous scan. PERONEUS LONGUS intrasubstance tear. Muscle fibre showing ill defined hypoechoic area with fluid in muscle belly.

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Flexor hallucis longus tendon injuries

Fibro-osseous tunnel between the lateral and medial talar tubercles is the frequent site of flexor hallucis longus tendon tear. Repetitive injury at that site may lead to stenosing tenosynovitis, partial tear, or complete tendon rupture.

Lumps and bumps of ankle and foot

Subcutaneous tissue, tendons, synovium, and ligaments can be depicted on real-time HRSG. Comparative study with contralateral ankle and foot help in the detection of normal variants and evaluation of a lump.


On HRSG, these lesions have a variable appearance, but often are compressible, echogenic, or hypoechoic masses with cystic serpiginous areas [Figure 16]a.[19],[20] Echogenic phleboliths may be seen. Vascularity is usually demonstrated on color Doppler ultrasound [Figure 16]b. In addition, a feeding artery and draining vein was easily demonstrable.[19],[20]
Figure 16: 26 year old male showing ill defined soft tissue with cystic lesions. (a) calcification dorso-medial aspect of right side of foot showing vascularity on color doppler (b) suggestive of hemangioma.

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Isolated tubercular tenosynovitis

Musculoskeletal system is a rare manifestation of extrapulmonary cases of tuberculosis. Foot tendon involvement is very rare, with only a few cases being reported so far. The most characteristic feature of the disease is the long latency period between disease onset and diagnosis. Tuberculin test is positive in most of the cases; however, 50% of cases show normal chest X-ray. On HRSG, disease appears as minimal fluid accumulation in the synovial sheath together with synovial thickening.

Foreign body granuloma

Radio-opaque foreign bodies are usually detected by conventional radiography. Radiolucent foreign body like wooden could be easily missed by conventional radiography. These foreign bodies can be evaluated on HRSG. Detection depends on echogenicity, posterior acoustic shadowing, reverberations, and development of hypoechoic rim or granuloma around foreign body [Figure 17]a,[Figure 17]b,[Figure 17]c.
Figure 17: Longitudinal scan of the right tibiotalar joint of anterior aspect (a-c) in a 26 year old male, showing echogenic foreign body with hypoechoic synovial thickening with fluid in tibiotalar joint of anterior aspect and multiple echogenic foreign bodies with hypoechoic synovial thickening adjacent to tibialis anterior tendon.

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In this study, surgical intervention proved the wooden nature (radiolucent) of foreign body.

Morton's neuroma

It is a nonneoplastic condition. Middle-age groups are usually affected, and more common in females. Swelling and perineural fibrosis of digital nerves leads to mass-like enlargement. They are most commonly seen in the 3rd intermetatarsal space followed by 2nd intermetatarsal joint space.

On HRSG, it can be seen as well-defined hypoechoic lesions in web spaces [Figure 18] showing minimal or no vascularity on color Doppler.
Figure 18: Transverse scan of the right forefoot dorsum. Mortonas neuroma-well defined hypoechoic lesion in right 2nd web space.

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On HRSG, they appear as well-defined, anechoic cystic lesion containing debris and lying close to the tendon sheath or joint capsule. Septations with echoes may be noted in a complex ganglion. Peripheral vascularity may be seen on color Doppler.

Insertional achilles tendon calcific tendinopathy

Tenderness localized to Achilles tendon insertion. The HRSG findings are thickened, hypoechoic, and granular echotexture of Achilles tendon with localized calcification at tendon insertion or Haglund's deformity [Figure 19]a and [Figure 19]b. Normal thickness for Achilles tendon should not be more than 8 mm in antero-posterior diameter. Site of measurement of tendon is at the level of distal portion of the medial malleolus in transverse scan.
Figure 19: Longitudinal scan of the posterior aspect of left ankle (a and b) in a 35 year old male showing thickened hypoechoic achilles tendon with calcification and fluid near insertion site suggestive of left calcified insertional tendinopathy. (b) 40 year old male showing thickened hypoechoic achilles tendon with calcification near insertion site suggestive of left calcified insertional tendinopathy.

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On HRSG bursitis appears as anechoic fluid within a normal bursa, with or without increase in bursal wall thickness [Figure 20]. Increased vascularity may be seen on color Doppler.
Figure 20: Longitudinal scan of the left posterior aspect of ankle. Left bursal wall thickening with fluid suggestive of Retrocalcaneal bursitis.

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On HRSG, osteophytes are seen as hyperechoic and in continuity with the bone surface with posterior acoustic shadowing adjacent to the joints.

  Miscellaneous Top

Morel-Lavallee lesion

This lesion is as a result of posttraumatic soft tissue degloving injury. Tangential or direct force separates the skin and subcutaneous tissue from underlying fascia, leading to development of potential space filled with blood, fat, lymph, or debris.

On HRSG, these lesions are well-defined and may be anechoic/hyperechoic/hypoechoic depending on the content below the subcutaneous tissue and above the fascia with fibrous pseudocapsule [Figure 21]a and [Figure 21]b.
Figure 21: (a) Perimalleous lateral aspect and (b) transverse scan of the right side ankle in a 28 year old female with history of trauma showing well defined encapsulated anechoic subcutaneous fluid collection in right ankle lateral aspect.

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Plantar fasciitis

Plantar fasciitis/heel spur syndrome is the most common cause of heel pain. Heel spur syndrome is a misnomer. There is no correlation between spur and pain. Its incidence and severity correlate strongly with the obesity. Site of measurement fascia crosses the anterior-most aspect of the inferior border of the calcaneus. Diagnosis by high-resolution ultrasound is easy and consists of showing thickened fascia of more than 4 mm with or without spur [Figure 22].
Figure 22: Longitudinal scan of the plantar aspect of left side of hind foot in a 50 year old female showing calcaneal spur with thickened plantar fascia (4.6 mm).

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Sonography shows variable appearance. From anechoic to irregularly hyperechoic with internal echoes may find hyperechoic sediments, septa, or gas with or without bone erosive changes [Figure 23]a and [Figure 23]b.
Figure 23: (a) Transverse scan dorsum of right side foot in a 11 year old male showing hetergenoushypoechoic collection with echos and tarsal bones erosion with tract to skin. Perimalleolus transverse scan of the lateral aspect of right side in a (b) 11 year old male showing hetergenous hypoechoic collection with echos and lateral malleolus bone erosion.

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Isolated tuberculosis of navicular bone

Isolated tuberculosis of navicular bone is a rare disease. Route of infection is either hematogenous or direct inoculation. Up to 50% skeletal tuberculosis patients show normal chest X-ray. Radiological features of musculoskeletal tuberculosis on HRSG are usually nonspecific, but may include lytic lesions of navicular bone with surrounding tissue that may show synovial thickening, synovial effusions, tenosynovitis, or soft tissue collections [Figure 24]. A bone biopsy should always be taken for culture and histological examination.
Figure 24: Longitudinal scan of the foot dorsum in a 26 year old male showing synovial thickening with erosion of left navicular bone.

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  Summary Top

Radiation-free, noninvasive, fast scanning, easily availability, low cost, high resolution, capability of depicting real-time static and dynamic structural information about the small and large joints with their surrounding tissues makes HRSG the first line investigation of choice, for both screening and diagnosis of diseases affecting musculoskeletal system.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Backhaus M, Burmester GR, Gerber T, Grassi W, Machold P, Swen WA, et al. Guidelines for musculoskeletal ultrasound in rheumatology. Ann Rheum Dis 2001;60:641-9.  Back to cited text no. 1
Fessell DP, Jamadar DA, Jacobson JA, Caoili EM, Dong Q, Pai SS, et al. Sonography of dorsal ankle and foot abnormalities. AJR Am J Roentgenol 2003;181:1673-81.  Back to cited text no. 2
Grassi W. Clinical evaluation versus ultrasonography: Who is the winner? J Rheumatol 2003;30:908-9.  Back to cited text no. 3
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Rowbotham EL, Grainger AJ. Rheumatoid arthritis: Ultrasound versus MRI. AJR Am J Roentgenol 2011 197:3:541-6.  Back to cited text no. 5
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Gladman DD. Current concepts in psoriatic arthritis. Curr Opin Rheumatol 2001;14:361-6.  Back to cited text no. 12
Rettenbacher T, Ennemoser S, Weirich H, Ulmer H, Hartig F, Koltz W, et al. Diagnostic imaging of gout: Comparison of high resolution US versus conventional X-ray. Eur Radiol 2008;18:621-30.  Back to cited text no. 13
Filippucci E, Meenagh G, Delle Sedie A, Sakellariou G, Iagnocco A, Riente L, et al. Ultrasound imaging for the rheumatologist. Part XXXVI. Sonographic assessment of the foot in gout patients. Clin Exp Rheumatol 2011;29:901-5.  Back to cited text no. 14
Leach RE, Schepsis AA. Acute injury to the ligaments of the ankle. In: Evarts C, editor. Surgery of the Musculoskeletal System. Vol. 4. New York: Churchill Livingstone; 1990. p. 3887-913.  Back to cited text no. 15
Kannus P, Renstrom P. Treatment for acute tears of the lateral ligaments of the ankle. Operation, cast, or early controlled mobilization. J Bone Joint Surg Am 1991;73:305-12.  Back to cited text no. 16
Mohamed N, Maboud A, Hytham I, Elsaeed H. Lesion of Achilles tendon: Evaluation with ultrasonography and magnetic resonance imaging. Egyptian J Radiol Nucl Med 2013;44:581-7.  Back to cited text no. 17
Hartgerink P, Fessell DP, Jacobson JA, van Holsbeck MT. Full- versus partial-thickness Achilles tendon tear: Sonographic accuracy and characterization in 26 cases with surgical correlation. Radiology 2001;220:406-12.  Back to cited text no. 18
Seale KS, Lange TA, Manson D, Hackbarth DA. Soft tissue tumor of the foot and ankle. Foot Ankle 1988;9:19-27.  Back to cited text no. 19
Cohen EK, Kressel HY, Preosio T. MR imaging of soft tissue hemangioma: Correlation with pathologic finding. AJR Am J Roentgenol 1988;150:1079-81.  Back to cited text no. 20


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14], [Figure 15], [Figure 16], [Figure 17], [Figure 18], [Figure 19], [Figure 20], [Figure 21], [Figure 22], [Figure 23], [Figure 24]


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