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Diagnostic Imaging of the Foot and Ankle Ulrike Szeimies, MD Head of Department München-Harlaching Imaging Center Munich, Germany Axel Staebler, MD Professor of Radiology München-Harlaching Imaging Center Munich, Germany Markus Walther, MD Professor of Orthopedic Surgery Medical Director Head of the Department of Foot and Ankle Surgery Schön Klinik München-Harlaching FIFA Medical Center Munich Munich, Germany 532 illustrations Thieme Stuttgart • New York • Delhi • Rio Library of Congress Cataloging-in-Publication Data Szeimies, Ulrike, author. [Bildgebende Diagnostik des Fusses. English] Diagnostic imaging of the foot and ankle / Ulrike Szeimies, Axel Staebler, Markus Walther. Translation of: Bildgebende Diagnostik des Fusses / Ulrike Szeimies, Axel Staebler, Markus Walther. Stuttgart: Thieme, 2012. Includes bibliographical references and index. ISBN 978-3-13-176461-4 (alk. paper) – ISBN 978-3-13-176471-3 (e-ISBN) I. Staebler, Axel, author. II. Walther, Markus, 1967-, author. III. Title. [DNLM: 1. Foot Diseases–diagnosis. 2. Magnetic Resonance Imaging– methods. 3. Tomography, Spiral Computed–methods. WE 880] RD563 617.5'8507543–dc23 2014023829 This book is an authorized translation of the German edition published and copyrighted 2012 by Georg Thieme Verlag, Stuttgart. Title of the German edition: Bildgebende Diagnostik des Fußes Translator: Terry C. Telger, Fort Worth, TX, USA Illustrator: Roland Geyer, Weilerswist, Germany Important note: Medicine is an ever-changing science undergoing continual development. Research and clinical experience are continually expanding our knowledge, in particular our knowledge of proper treatment and drug therapy. Insofar as this book mentions any dosage or application, readers may rest assured that the authors, editors, and publishers have made every effort to ensure that such references are in accordance with the state of knowledge at the time of production of the book. 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Argentina Building 16th floor, Ala A, 228 Praia do Botafogo Rio de Janeiro 22250-040 Brazil +55 21 3736-3631 Cover design: Ulrike Szeimies, MD & Thieme Publishing Group Typesetting by DiTech Process Solutions Pvt. Ltd., India Printed in India by Replika Press Ltd. ISBN 9783131764614 Also available as e-book: eISBN 9783131764713 This book, including all parts thereof, is legally protected by copyright. Any use, exploitation, or commercialization outside the narrow limits set by copyright legislation without the publisher’s consent is illegal and liable to prosecution. This applies in particular to photostat reproduction, copying, mimeographing or duplication of any kind, translating, preparation of microfilms, and electronic data processing and storage. To my beloved daughter Emilia Ulrike Szeimies To my beloved wife Susann Axel Staebler To all those dedicated to treating patients with foot and ankle disorders Markus Walther Contents 1 Imaging Techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 1.1 Magnetic Resonance Imaging (MRI) . . . . . . . . . . 2 U. Szeimies 1.1.1 1.1.2 Imaging Strategy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Post-Exercise MRI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 1.2 Multidetector-Row Spiral Computed Tomography (CT) . . . . . . . . . . . . . . . . . . . . . . . . . 3 U. Szeimies 1.2.4 Special Techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 1.3 Radiography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 M. Walther 1.3.1 1.3.2 Forefoot . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Hindfoot . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 1.4 Ultrasound . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 H. Gaulrapp 1.5 Bibliography . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 1.2.1 1.2.2 1.2.3 Positioning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Protocol . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Indications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 2 Clinical Evaluation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13 R. Degwert and M. Walther 2.1 Diagnostic Algorithm. . . . . . . . . . . . . . . . . . . . . 13 2.7 2.1.1 2.1.2 2.1.3 Clinical Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . .13 Imaging and Other Tests . . . . . . . . . . . . . . . . . . . . . . . . .13 Referral for Further Evaluation . . . . . . . . . . . . . . . . . . .13 2.8 Special Tests on the Foot . . . . . . . . . . . . . . . . . . 16 2.8.1 2.8.2 2.8.3 2.8.4 Hindfoot . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16 Joint Stability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17 Nerve Irritation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18 Forefoot . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18 2.9 Stress Tests and Provocative Testing . . . . . . . . 19 2.10 Other Diagnostic Options . . . . . . . . . . . . . . . . . 19 2.11 Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Assessment of Blood Flow . . . . . . . . . . . . . . . . . 16 2.2 History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 2.2.1 2.2.2 Relevant Questions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13 Pain History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .14 2.3 Inspection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 2.4 Palpation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 2.5 Motion Tests . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 2.5.1 2.5.2 Translation Tests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15 Muscle Function Tests . . . . . . . . . . . . . . . . . . . . . . . . . . .15 2.12 Special Case: Chronic Pain Syndrome without Objective Findings . . . . . . . . . . . . . . . . . . . . . . . 19 2.6 Sensory Testing . . . . . . . . . . . . . . . . . . . . . . . . . 15 2.13 Bibliography . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 3 Ankle and Hindfoot. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .21 3.1 Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 3.1.1 3.1.2 Capsule and Ligaments . . . . . . . . . . . . . . . . . . . . . . . . . .21 Fractures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .34 3.2 Chronic, Posttraumatic, and Degenerative Changes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64 3.2.1 3.2.2 3.2.3 3.2.4 3.2.5 Axial Malalignment of the Hindfoot . . . . . . . . . . . . . .64 Impingement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .69 Instability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .74 Chronic Disorders of Cartilage and Bone . . . . . . . . . .79 Achilles Tendon Pathology . . . . . . . . . . . . . . . . . . . . . . .92 3.2.6 3.2.7 3.2.8 3.2.9 3.2.10 3.2.11 Disorders of the Flexor Hallucis Longus Tendon (Posterior Impingement, Os Trigonum Syndrome, Partial Tear) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 103 Peroneal Tendon Pathology . . . . . . . . . . . . . . . . . . . . 105 Posterior Tibial Tendon Dysfunction . . . . . . . . . . . . 112 Anterior Tibial Tendon Pathology . . . . . . . . . . . . . . 117 Subtalar Joint: Sinus Tarsi Syndrome . . . . . . . . . . . 120 Differential Diagnosis of Chronic Hindfoot Pain . . 121 3.3 Bibliography . . . . . . . . . . . . . . . . . . . . . . . . . . .122 vii Contents 4 Midfoot . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .131 4.1 Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .131 R. Degwert and U. Szeimies 4.1.1 4.1.2 4.1.3 4.1.4 4.1.5 Fractures of the Tarsometatarsal Joint Line (Lisfranc Fractures). . . . . . . . . . . . . . . . . . . . . . . . . . . . Lisfranc Ligament Injury . . . . . . . . . . . . . . . . . . . . . . . Navicular Fracture . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cuboid Fracture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cuneiform Fractures. . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Forefoot. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .155 5.1 Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .155 R. Degwert, U. Szeimies, and M. Walther 5.2 Chronic, Posttraumatic, and Degenerative Changes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .164 M. Walther and U. Szeimies 6 Abnormalities of the Plantar Soft Tissues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .178 131 136 139 142 143 4.2 Chronic, Posttraumatic, and Degenerative Changes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .145 U. Szeimies 4.2.1 4.2.2 Osteoarthritis. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145 Instability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149 4.3 Bibliography . . . . . . . . . . . . . . . . . . . . . . . . . . .151 5.3 Bibliography . . . . . . . . . . . . . . . . . . . . . . . . . . .175 A. Roeser and U. Szeimies 6.1 Plantar Fasciitis, Rupture of the Plantar Fascia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .178 6.6 Hallucis longus and Digitorum longus Intersection Syndrome . . . . . . . . . . . . . . . . . .186 6.2 Plantar Heel Spur . . . . . . . . . . . . . . . . . . . . . . .179 6.7 Metatarsalgia . . . . . . . . . . . . . . . . . . . . . . . . . .187 6.3 Ledderhose Disease . . . . . . . . . . . . . . . . . . . . .181 6.8 Plantar Warts . . . . . . . . . . . . . . . . . . . . . . . . . .190 6.4 Atrophy of the Plantar Fat Pad . . . . . . . . . . . .183 6.9 Compartment Syndrome of the Interosseous Muscles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .190 6.5 Plantar Vein Thrombosis . . . . . . . . . . . . . . . . .184 6.10 Bibliography . . . . . . . . . . . . . . . . . . . . . . . . . . .191 7 Neurologic Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .194 M. Walther and U. Szeimies 7.1 Morton Neuroma . . . . . . . . . . . . . . . . . . . . . . .194 7.3 Bibliography . . . . . . . . . . . . . . . . . . . . . . . . . . .200 7.2 Other Nerve Compression Syndromes . . . . . .195 8 Diseases Not Localized to a Specific Site . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .202 U. Szeimies viii 8.1 Reflex Sympathetic Dystrophy, CRPS . . . . . . .202 8.2 Bone Marrow Edema Syndrome . . . . . . . . . . .204 8.3 Overuse Edema. . . . . . . . . . . . . . . . . . . . . . . . .206 8.4 Stress Fractures, Microfractures . . . . . . . . . . .207 8.5 Pediatric Bone Marrow Edema (Tiger-Stripe Pattern). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .209 8.6 Bibliography . . . . . . . . . . . . . . . . . . . . . . . . . . .211