543363
research-article2014
FASXXX10.1177/1938640014543363Foot & Ankle SpecialistMONTH MONTH XXXXvol. X no. XFoot & Ankle Specialist
vol. 7 / no. 5
Foot & Ankle Specialist
〈 Evolving Techniques 〉 Sonographically Guided Therapeutic Injections in the Meniscoid Lesion in Patients With Anteromedial Ankle Impingement Syndrome Abstract: We describe a sonographically guided technique to perform therapeutic injections for anteromedial ankle impingement syndrome. Scans are carried out using a high-frequency small footprint linear array transducer, positioned along the anteromedial aspect of the tibiotalar joint. A 25 gauge needle is advanced under direct sonographic guidance into the “meniscoid lesion” (area of scarring), and a standardized therapeutic mixture is injected extraarticularly. Image-guided injections have a positive influence on clinical decision making by improving patient management, increasing the accuracy of diagnosis, and decreasing patient pain. Sonography allows confirmation of correct injection placement, resulting in increased accuracy and more successful patient outcomes. Levels of Evidence: Therapeutic, Level V, Expert Opinion Keywords: ankle sonography; sonographically guided injection;
anteromedial ankle impingement syndrome; musculoskeletal ultrasound; meniscoid lesion
I
Jean Jose, DO, Tarun Mirpuri, MD, Bryson Lesniak, MD, and Lee Kaplan, MD
ultrasound. Sonographic findings mirror those of magnetic resonance imaging and arthroscopy, including identification of marginal osseous spurs and of an anteromedial “meniscoid” lesion, which is the result of synovitis, as well as chronic partial tearing and scar
mpingement syndromes of the ankle have long been described in the medical literature, first by Morris1 in 1943, and then by McMurray2 in Diagnosis of anteromedial ankle 1950, who coined the impingement is reliably made with term Footballer’s ankle. These syndromes refer to ultrasound.” conditions whereby ankle motion at the tibiotalar joint is limited by pain and altered mechanics secondary to soft remodeling of the anteromedial tibiotalar tissue and osseous overgrowth, and it is capsule and the anterior tibiotalar now recognized as a cause of ankle pain component of the deltoid ligament in the general population.3 (Figures 1-3). Ankle impingement syndromes are Image-guided injections improve categorized by their anatomic patient management and outcomes by relationship to the tibiotalar joint: increasing the accuracy of diagnosis and anterior, anteromedial, anterolateral, and decreasing patient pain. “Blind” injections posterior. have overall decreased accuracy and Diagnosis of anteromedial ankle carry the rare potential side effects of impingement is reliably made with osteonecrosis, chondrolysis, and septic
“
DOI: 10.1177/1938640014543363. From the Departmenst of Radiology (JJ, TM) and Orthopedics (BL, LK), Jackson Memorial Hospital, University of Miami Miller School of Medicine, Miami, Florida. Address correspondence to: Jean Jose, DO, Musculoskeletal Imaging Section, Department of Radiology (R-109), Jackson Memorial Hospital, University of Miami Miller School of Medicine, 1611 NW 12th Ave, West Wing 279, Miami, FL 33136; e-mail: [email protected]. For reprints and permissions queries, please visit SAGE’s Web site at http://www.sagepub.com/journalsPermissions.nav. Copyright © 2014 The Author(s)
Downloaded from fas.sagepub.com at CAMBRIDGE UNIV LIBRARY on January 10, 2015
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Oct 2014
Foot & Ankle Specialist
Sonographic Technique
Figure 1. Sagittal (A) and transverse (B) ultrasound images of ankle demonstrate marginal osseous spurs (closed arrows) along the anteromedial margin of the distal tibia and talar neck. Notice the “meniscoid” lesion caused by scarring and chronic partial tearing of the tibiotalar joint capsule and anterior tibiotalar (deep deltoid) ligament (open arrows). The hypoechoic band covering the talar head is articular cartilage (curved arrows).
Figure 2. Axial proton density (A) and axial T2 weighted fat suppressed (B) images of an ankle demonstrate prominent focal area of capsular and ligamentous scarring, reflecting the “meniscoid lesion” (arrows).
Ultrasounds are performed using a 15-7 MHz small footprint linear array (“hockey stick”) transducer on an IU22 scanner (Philips Medical Systems, Bothell, WA). Patients are placed in a supine position, with the foot plantar flexed, with the scan plane corresponding to the anatomic axial plane. The transducer is placed along the anteromedial aspect of the ankle. Skin anesthesia is obtained with injection of 1 mL of 1% lidocaine through a 25 gauge, 1.5 inch hypodermic needle under sterile technique. The same needle is then advanced under direct sonographic guidance into the “meniscoid lesion” (Figures 4 and 5). The needle is placed within the area of scarring, extra-articularly, away from the tibiotalar joint space.
Injection Materials Once the 25 gauge needle is in correct position, the therapeutic mixture is then delivered under real-time observation (Figure 5). Our standard anesthetic/ corticosteroid injection mixture consists of 1 mL (40 mg/mL) of triamcinolone (Kenalog; Apothecon, Bristol-Myers Squibb Company, Princeton, NJ), 0.5 mL of 1% lidocaine, and 0.5 cc of 0.5% bupivacaine (Sensorcaine; AstraZenica Pharmaceuticals, Wilmington, DE).
Discussion
arthritis.4-9 We believe that the incidence of potential side effects can be reduced by extra-articularly injecting the area of scarring directly under ultrasound guidance, keeping the needle tip away from the tibiotalar joint and therefore decreasing the total intra-articular dose. Increased accuracy of needle tip positioning afforded by sonographic guidance also functions as a diagnostic test, in that if the patient does not experience improvement of ankle pain
following injection, then an alternate diagnosis needs to be considered (ie, osteochondral lesions within the talar dome, tibial nerve neuroma, etc). At our institution we perform anesthetic and steroid injections under ultrasound guidance, as it allows real-time direct visualization of the anteromedial “meniscoid” lesion, as well as more accurate placement of the needle tip into the area of scarring (Figures 4 and 5).
The classic findings of anteromedial impingement syndrome include hypertrophic spurs, reactive fibrosis, and synovial proliferation along the anteromedial gutter of the tibiotalar joint; however, the exact cause is still not known. Several theories exist to explain the condition, including the development of tibial and talar osteophytes secondary to capsular traction during repetitive kicking movements,2 chronic microtrauma with periosteal hemorrhage, as well as entrapment and/or tearing of the anteromedial joint capsule and tibiotalar ligament due to inversion, eversion (pronation), and dorsiflexion injuries.10
Downloaded from fas.sagepub.com at CAMBRIDGE UNIV LIBRARY on January 10, 2015
vol. 7 / no. 5
Foot & Ankle Specialist
Figure 3. (A) Diagnostic ankle arthroscopy viewing through anterolateral portal demonstrating a large talar spur (closed arrow), loose body (arrow head), and synovitis (curved arrows). (B) Restoration of anterior tibiotalar articulation with removal of the loose body. (C) Restoration of the normal articular contour of the dorsal talar neck (closed arrows).
Figure 4. Color diagram showing the relative positions of the foot, probe, and syringe. The transducer is placed in transverse position and the needle is guided from a medial approach into the “meniscoid” lesion.
An uncommon cause of ankle pain, anteromedial impingement, rarely occurs in isolation, with injuries often also observed in the lateral capsule. Clinical findings are therefore often inconsistent, with symptoms overlapping those of other ligamentous injuries. Nevertheless, the diagnosis of anteromedial ankle impingement is usually a clinical one. Tenderness at the anteromedial ankle joint line, over the anterior tibiotalar fibers of the deltoid ligament, is sometimes seen. Additionally, other nonspecific symptoms can be observed, including swelling and pain worsening with ambulation or athletic activity.11,12 Clinical examination often reveals restriction of movement at the tibiotalar joint, particularly dorsiflexion, with palpable marginal osteophytes. Soft
tissue thickening may or may not be appreciable clinically.3 Standard anteroposterior and lateral radiographs of the ankle are usually the first studies obtained, but are often not helpful and may not detect the presence of osteophytes. When anteromedial impingement is suspected, a so-called oblique anteromedial impingement view is recommended, as it has high sensitivity for detecting anteromedial tibial (93%) and talar (67%) osteophytes3,11 (Figure 6). Magnetic resonance imaging may be used to confirm the diagnosis of anteromedial ankle impingement and to rule out other causes of chronic ankle pain, such as osteochondral lesions within the talar dome. Positive findings include posttraumatic synovitis, synovial hyperplasia, tibiotalar joint anteromedial
Downloaded from fas.sagepub.com at CAMBRIDGE UNIV LIBRARY on January 10, 2015
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Figure 5. (A) Sagittal ultrasound image of an ankle demonstrates injection of steroid and anesthetic mixture into the area of scarring and osseous spurring (closed arrow) along the anteromedial margin of the ankle. Open arrows show steroid mixture within the meniscoid lesion, away from the joint. (B) Transverse ultrasound image shows the needle tip (closed arrow) within the meniscoid lesion (open arrow).
Figure 6. Oblique anteromedial impingement radiograph of the ankle demonstrates prominent osseous spurs along the anteromedial rim of the tibia and talar neck (arrows).
capsular thickening, scarring of the deep deltoid ligament, and surrounding hypertrophic bone spur formation (Figure 2). Of the constituents of the deltoid ligament, the anterior tibiotalar ligament is most often affected.13-15 Treatment for anteromedial ankle impingement in its early stages is centered on conservative therapy, including
physical rehabilitation and heel lifts to improve ankle joint biomechanics.12,16,17 Injection of steroids into the area of synovitis and scarring along the anteromedial margin of the tibiotalar joint is an effective treatment option.16,17 The algorithm we use at our institution is to first perform an anesthetic-only injection at the area of presumed extra-articular impingement and to have the patient assess their response over the next 1 to 5 hours, often including a repeat physical exam by the referring clinician during this period. Those patients who demonstrate a favorable response in terms of pain and mobility then return for a steroid injection. Those with limited or no response then return for an intra-articular injection with anesthetic alone, again to be seen by the referring clinician. This distinction is important, as patients with magnetic resonance imaging or ultrasound evidence of a meniscoid lesion also often have intra-articular sources of pain (cartilage lesions, etc) and the cause of pain is not clearly apparent clinically. This is of value in planning any subsequent open or arthroscopic repair. For patients with refractory symptoms following conservative and minimally invasive interventions, osteophyte and
soft tissue debridement is considered definitive treatment. Both open and arthroscopic debridement and excision of exostoses has been described and reported in the literature. Open excision of anterior talar and tibial osteophytes and soft tissue lesions has favorable results. At an average follow-up of 7.3 years, Coull et al noted 92% good or excellent results in patients with minimal ankle arthritis on plain film preoperatively.16 In addition, 79% of athletes were able to return to sports at the same level.16 Arthroscopic debridement of anterior tibial and talar involves utilizing burrs and resectors to remove the pathologic tissues (Figure 3). The use of smaller incisions when compared to an open arthrotomy allows for faster recovery, decreased “return to play” time, and fewer complications.10,17-20
Conclusion Anteromedial ankle impingement has recently been recognized as a distinct clinical entity, a part of the variety of ankle impingement syndromes that were initially described in 1943. Though it is mainly a diagnosis based on clinical findings and patient symptoms, a multitude of radiographic tools exists to aid the clinician not only in confirming the diagnosis but also to create an appropriate treatment plan for the patient. Ultrasound guidance provides direct visualization of the “meniscoid lesion” of anteromedial impingement syndrome and confirmation of correct injection placement, resulting in increased accuracy and more successful patient outcomes. Sonographic guidance lowers the risk of inadvertently placing the steroid mixture intra-articularly, decreasing the rare potential side effects of osteonecrosis, chondrolysis, and septic arthritis. Increased accuracy of needle tip positioning afforded by sonographic guidance also functions as a diagnostic test, in that if patients do not experience improvement of ankle pain following injection, then an alternate diagnosis needs to be considered.
Downloaded from fas.sagepub.com at CAMBRIDGE UNIV LIBRARY on January 10, 2015
vol. 7 / no. 5
Foot & Ankle Specialist
References
8. Chu CR, Coyle CH, Chu CT, et al. In vivo effects of single intra-articular injection of 0.5% bupivacaine on articular cartilage. J Bone Joint Surg Am. 2010;92:599-608.
1. Morris LH. Athlete’s ankle. J Bone Surg. 1943;25:220. 2. McMurray TP. Footballer’s ankle. J Bone Joint Surg Br. 1950;32:68-69. 3. Hopper M, Robinson P. Ankle Impingement Syndromes. Radiol Clin North Am. 2008;46:957-971. 4. Chu CR, Izzo NJ, Coyle CH, Papas NE, Logar A. The in vitro effects of bupivacaine on articular chondrocytes. J Bone Joint Surg Br. 2008;90:814-820. 5. Chu CR, Izzo NJ, Papas NE, Fu FH. In vitro exposure to 0.5% bupivacaine is cytotoxic to bovine articular chondrocytes. Arthroscopy. 2006;22:693-699.
9. Grishko V, Xu M, Wilson G, Pearsall AW. Apoptosis and mitochondrial dysfunction in human chondrocytes following exposure to lidocaine, bupivacaine, and ropivacaine. J Bone Joint Surg Am. 2010;92:609-618. 10. Murawski C, Kennedy J. Anteromedial impingement in the ankle joint: outcomes following arthroscopy. Am J Sports Med. 2010;38:2017-2024. 11. Umans H, Cerezal L. Anterior ankle impingement syndromes. Semin Musculoskelet Radiol. 2008;12:146-153. 12. Van Dijk C, van Bergen C. Advancements in ankle arthroscopy. J Am Acad Orthop Surg. 2008;16:635-646.
6. Greis PE, Legrand A, Burks RT. Bilateral shoulder chondrolysis following arthroscopy. A report of two cases. J Bone Joint Surg Am. 2008;90:1338-1244. 7. Gomoll AH, Kang RW, Williams JM, Bach BR, Cole BJ. Chondrolysis after continuous intra-articular bupivacaine infusion: an experimental model investigating chondrotoxicity in the rabbit shoulder. Arthroscopy. 2006;22:813-819.
13. Chhabra A, Subhawong T, Carrino J. MR imaging of deltoid ligament pathologic findings and associated impingement syndromes. Radiographics. 2010;30: “751-761. 14. Robinson P, White LM, Salonen D, OgilvieHarris D. Anteromedial impingement of the
ankle: using MR arthrography to assess the anteromedial recess. AJR Am J Roentgenol. 2002;178:601-604. 15. Cerezal L, Llopis E, Canga A, Rolón A. MR arthrography of the ankle: indications and technique. Radiol Clin North Am. 2008;46:973-994. 16. Coull R, Raffiq T, James E, Stephens M. Open treatment of anterior impingement of the ankle. J Bone Joint Surg Br. 2002;85:550-553. 17. Edmonds EW, Chambers R, Kaufman E, Cambers HG. Anterolateral ankle impingement in adolescents: outcomes of nonoperative and operative treatment. J Pediatr Orthop. 2010;30:186-191. 18. Nihal A, Rose D, Trepman E. Arthroscopic treatment of anterior ankle impingement syndrome in dancers. Foot Ankle Int. 2005;26:908-912. 19. Scranton PE, McDermott JE. Anterior tibiotalar spurs: a comparison of open versus arthroscopic debridement. Foot Ankle. 1992;13:125-129. 20. Manoli A II. Anteriomedial impingement of the ankle in athletes. Sports Health. 2010;2:495-502.
Downloaded from fas.sagepub.com at CAMBRIDGE UNIV LIBRARY on January 10, 2015
413
research-article2014
FASXXX10.1177/1938640014543363Foot & Ankle SpecialistMONTH MONTH XXXXvol. X no. XFoot & Ankle Specialist
vol. 7 / no. 5
Foot & Ankle Specialist
〈 Evolving Techniques 〉 Sonographically Guided Therapeutic Injections in the Meniscoid Lesion in Patients With Anteromedial Ankle Impingement Syndrome Abstract: We describe a sonographically guided technique to perform therapeutic injections for anteromedial ankle impingement syndrome. Scans are carried out using a high-frequency small footprint linear array transducer, positioned along the anteromedial aspect of the tibiotalar joint. A 25 gauge needle is advanced under direct sonographic guidance into the “meniscoid lesion” (area of scarring), and a standardized therapeutic mixture is injected extraarticularly. Image-guided injections have a positive influence on clinical decision making by improving patient management, increasing the accuracy of diagnosis, and decreasing patient pain. Sonography allows confirmation of correct injection placement, resulting in increased accuracy and more successful patient outcomes. Levels of Evidence: Therapeutic, Level V, Expert Opinion Keywords: ankle sonography; sonographically guided injection;
anteromedial ankle impingement syndrome; musculoskeletal ultrasound; meniscoid lesion
I
Jean Jose, DO, Tarun Mirpuri, MD, Bryson Lesniak, MD, and Lee Kaplan, MD
ultrasound. Sonographic findings mirror those of magnetic resonance imaging and arthroscopy, including identification of marginal osseous spurs and of an anteromedial “meniscoid” lesion, which is the result of synovitis, as well as chronic partial tearing and scar
mpingement syndromes of the ankle have long been described in the medical literature, first by Morris1 in 1943, and then by McMurray2 in Diagnosis of anteromedial ankle 1950, who coined the impingement is reliably made with term Footballer’s ankle. These syndromes refer to ultrasound.” conditions whereby ankle motion at the tibiotalar joint is limited by pain and altered mechanics secondary to soft remodeling of the anteromedial tibiotalar tissue and osseous overgrowth, and it is capsule and the anterior tibiotalar now recognized as a cause of ankle pain component of the deltoid ligament in the general population.3 (Figures 1-3). Ankle impingement syndromes are Image-guided injections improve categorized by their anatomic patient management and outcomes by relationship to the tibiotalar joint: increasing the accuracy of diagnosis and anterior, anteromedial, anterolateral, and decreasing patient pain. “Blind” injections posterior. have overall decreased accuracy and Diagnosis of anteromedial ankle carry the rare potential side effects of impingement is reliably made with osteonecrosis, chondrolysis, and septic
“
DOI: 10.1177/1938640014543363. From the Departmenst of Radiology (JJ, TM) and Orthopedics (BL, LK), Jackson Memorial Hospital, University of Miami Miller School of Medicine, Miami, Florida. Address correspondence to: Jean Jose, DO, Musculoskeletal Imaging Section, Department of Radiology (R-109), Jackson Memorial Hospital, University of Miami Miller School of Medicine, 1611 NW 12th Ave, West Wing 279, Miami, FL 33136; e-mail: [email protected]. For reprints and permissions queries, please visit SAGE’s Web site at http://www.sagepub.com/journalsPermissions.nav. Copyright © 2014 The Author(s)
Downloaded from fas.sagepub.com at CAMBRIDGE UNIV LIBRARY on January 10, 2015
409
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Oct 2014
Foot & Ankle Specialist
Sonographic Technique
Figure 1. Sagittal (A) and transverse (B) ultrasound images of ankle demonstrate marginal osseous spurs (closed arrows) along the anteromedial margin of the distal tibia and talar neck. Notice the “meniscoid” lesion caused by scarring and chronic partial tearing of the tibiotalar joint capsule and anterior tibiotalar (deep deltoid) ligament (open arrows). The hypoechoic band covering the talar head is articular cartilage (curved arrows).
Figure 2. Axial proton density (A) and axial T2 weighted fat suppressed (B) images of an ankle demonstrate prominent focal area of capsular and ligamentous scarring, reflecting the “meniscoid lesion” (arrows).
Ultrasounds are performed using a 15-7 MHz small footprint linear array (“hockey stick”) transducer on an IU22 scanner (Philips Medical Systems, Bothell, WA). Patients are placed in a supine position, with the foot plantar flexed, with the scan plane corresponding to the anatomic axial plane. The transducer is placed along the anteromedial aspect of the ankle. Skin anesthesia is obtained with injection of 1 mL of 1% lidocaine through a 25 gauge, 1.5 inch hypodermic needle under sterile technique. The same needle is then advanced under direct sonographic guidance into the “meniscoid lesion” (Figures 4 and 5). The needle is placed within the area of scarring, extra-articularly, away from the tibiotalar joint space.
Injection Materials Once the 25 gauge needle is in correct position, the therapeutic mixture is then delivered under real-time observation (Figure 5). Our standard anesthetic/ corticosteroid injection mixture consists of 1 mL (40 mg/mL) of triamcinolone (Kenalog; Apothecon, Bristol-Myers Squibb Company, Princeton, NJ), 0.5 mL of 1% lidocaine, and 0.5 cc of 0.5% bupivacaine (Sensorcaine; AstraZenica Pharmaceuticals, Wilmington, DE).
Discussion
arthritis.4-9 We believe that the incidence of potential side effects can be reduced by extra-articularly injecting the area of scarring directly under ultrasound guidance, keeping the needle tip away from the tibiotalar joint and therefore decreasing the total intra-articular dose. Increased accuracy of needle tip positioning afforded by sonographic guidance also functions as a diagnostic test, in that if the patient does not experience improvement of ankle pain
following injection, then an alternate diagnosis needs to be considered (ie, osteochondral lesions within the talar dome, tibial nerve neuroma, etc). At our institution we perform anesthetic and steroid injections under ultrasound guidance, as it allows real-time direct visualization of the anteromedial “meniscoid” lesion, as well as more accurate placement of the needle tip into the area of scarring (Figures 4 and 5).
The classic findings of anteromedial impingement syndrome include hypertrophic spurs, reactive fibrosis, and synovial proliferation along the anteromedial gutter of the tibiotalar joint; however, the exact cause is still not known. Several theories exist to explain the condition, including the development of tibial and talar osteophytes secondary to capsular traction during repetitive kicking movements,2 chronic microtrauma with periosteal hemorrhage, as well as entrapment and/or tearing of the anteromedial joint capsule and tibiotalar ligament due to inversion, eversion (pronation), and dorsiflexion injuries.10
Downloaded from fas.sagepub.com at CAMBRIDGE UNIV LIBRARY on January 10, 2015
vol. 7 / no. 5
Foot & Ankle Specialist
Figure 3. (A) Diagnostic ankle arthroscopy viewing through anterolateral portal demonstrating a large talar spur (closed arrow), loose body (arrow head), and synovitis (curved arrows). (B) Restoration of anterior tibiotalar articulation with removal of the loose body. (C) Restoration of the normal articular contour of the dorsal talar neck (closed arrows).
Figure 4. Color diagram showing the relative positions of the foot, probe, and syringe. The transducer is placed in transverse position and the needle is guided from a medial approach into the “meniscoid” lesion.
An uncommon cause of ankle pain, anteromedial impingement, rarely occurs in isolation, with injuries often also observed in the lateral capsule. Clinical findings are therefore often inconsistent, with symptoms overlapping those of other ligamentous injuries. Nevertheless, the diagnosis of anteromedial ankle impingement is usually a clinical one. Tenderness at the anteromedial ankle joint line, over the anterior tibiotalar fibers of the deltoid ligament, is sometimes seen. Additionally, other nonspecific symptoms can be observed, including swelling and pain worsening with ambulation or athletic activity.11,12 Clinical examination often reveals restriction of movement at the tibiotalar joint, particularly dorsiflexion, with palpable marginal osteophytes. Soft
tissue thickening may or may not be appreciable clinically.3 Standard anteroposterior and lateral radiographs of the ankle are usually the first studies obtained, but are often not helpful and may not detect the presence of osteophytes. When anteromedial impingement is suspected, a so-called oblique anteromedial impingement view is recommended, as it has high sensitivity for detecting anteromedial tibial (93%) and talar (67%) osteophytes3,11 (Figure 6). Magnetic resonance imaging may be used to confirm the diagnosis of anteromedial ankle impingement and to rule out other causes of chronic ankle pain, such as osteochondral lesions within the talar dome. Positive findings include posttraumatic synovitis, synovial hyperplasia, tibiotalar joint anteromedial
Downloaded from fas.sagepub.com at CAMBRIDGE UNIV LIBRARY on January 10, 2015
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Foot & Ankle Specialist
Figure 5. (A) Sagittal ultrasound image of an ankle demonstrates injection of steroid and anesthetic mixture into the area of scarring and osseous spurring (closed arrow) along the anteromedial margin of the ankle. Open arrows show steroid mixture within the meniscoid lesion, away from the joint. (B) Transverse ultrasound image shows the needle tip (closed arrow) within the meniscoid lesion (open arrow).
Figure 6. Oblique anteromedial impingement radiograph of the ankle demonstrates prominent osseous spurs along the anteromedial rim of the tibia and talar neck (arrows).
capsular thickening, scarring of the deep deltoid ligament, and surrounding hypertrophic bone spur formation (Figure 2). Of the constituents of the deltoid ligament, the anterior tibiotalar ligament is most often affected.13-15 Treatment for anteromedial ankle impingement in its early stages is centered on conservative therapy, including
physical rehabilitation and heel lifts to improve ankle joint biomechanics.12,16,17 Injection of steroids into the area of synovitis and scarring along the anteromedial margin of the tibiotalar joint is an effective treatment option.16,17 The algorithm we use at our institution is to first perform an anesthetic-only injection at the area of presumed extra-articular impingement and to have the patient assess their response over the next 1 to 5 hours, often including a repeat physical exam by the referring clinician during this period. Those patients who demonstrate a favorable response in terms of pain and mobility then return for a steroid injection. Those with limited or no response then return for an intra-articular injection with anesthetic alone, again to be seen by the referring clinician. This distinction is important, as patients with magnetic resonance imaging or ultrasound evidence of a meniscoid lesion also often have intra-articular sources of pain (cartilage lesions, etc) and the cause of pain is not clearly apparent clinically. This is of value in planning any subsequent open or arthroscopic repair. For patients with refractory symptoms following conservative and minimally invasive interventions, osteophyte and
soft tissue debridement is considered definitive treatment. Both open and arthroscopic debridement and excision of exostoses has been described and reported in the literature. Open excision of anterior talar and tibial osteophytes and soft tissue lesions has favorable results. At an average follow-up of 7.3 years, Coull et al noted 92% good or excellent results in patients with minimal ankle arthritis on plain film preoperatively.16 In addition, 79% of athletes were able to return to sports at the same level.16 Arthroscopic debridement of anterior tibial and talar involves utilizing burrs and resectors to remove the pathologic tissues (Figure 3). The use of smaller incisions when compared to an open arthrotomy allows for faster recovery, decreased “return to play” time, and fewer complications.10,17-20
Conclusion Anteromedial ankle impingement has recently been recognized as a distinct clinical entity, a part of the variety of ankle impingement syndromes that were initially described in 1943. Though it is mainly a diagnosis based on clinical findings and patient symptoms, a multitude of radiographic tools exists to aid the clinician not only in confirming the diagnosis but also to create an appropriate treatment plan for the patient. Ultrasound guidance provides direct visualization of the “meniscoid lesion” of anteromedial impingement syndrome and confirmation of correct injection placement, resulting in increased accuracy and more successful patient outcomes. Sonographic guidance lowers the risk of inadvertently placing the steroid mixture intra-articularly, decreasing the rare potential side effects of osteonecrosis, chondrolysis, and septic arthritis. Increased accuracy of needle tip positioning afforded by sonographic guidance also functions as a diagnostic test, in that if patients do not experience improvement of ankle pain following injection, then an alternate diagnosis needs to be considered.
Downloaded from fas.sagepub.com at CAMBRIDGE UNIV LIBRARY on January 10, 2015
vol. 7 / no. 5
Foot & Ankle Specialist
References
8. Chu CR, Coyle CH, Chu CT, et al. In vivo effects of single intra-articular injection of 0.5% bupivacaine on articular cartilage. J Bone Joint Surg Am. 2010;92:599-608.
1. Morris LH. Athlete’s ankle. J Bone Surg. 1943;25:220. 2. McMurray TP. Footballer’s ankle. J Bone Joint Surg Br. 1950;32:68-69. 3. Hopper M, Robinson P. Ankle Impingement Syndromes. Radiol Clin North Am. 2008;46:957-971. 4. Chu CR, Izzo NJ, Coyle CH, Papas NE, Logar A. The in vitro effects of bupivacaine on articular chondrocytes. J Bone Joint Surg Br. 2008;90:814-820. 5. Chu CR, Izzo NJ, Papas NE, Fu FH. In vitro exposure to 0.5% bupivacaine is cytotoxic to bovine articular chondrocytes. Arthroscopy. 2006;22:693-699.
9. Grishko V, Xu M, Wilson G, Pearsall AW. Apoptosis and mitochondrial dysfunction in human chondrocytes following exposure to lidocaine, bupivacaine, and ropivacaine. J Bone Joint Surg Am. 2010;92:609-618. 10. Murawski C, Kennedy J. Anteromedial impingement in the ankle joint: outcomes following arthroscopy. Am J Sports Med. 2010;38:2017-2024. 11. Umans H, Cerezal L. Anterior ankle impingement syndromes. Semin Musculoskelet Radiol. 2008;12:146-153. 12. Van Dijk C, van Bergen C. Advancements in ankle arthroscopy. J Am Acad Orthop Surg. 2008;16:635-646.
6. Greis PE, Legrand A, Burks RT. Bilateral shoulder chondrolysis following arthroscopy. A report of two cases. J Bone Joint Surg Am. 2008;90:1338-1244. 7. Gomoll AH, Kang RW, Williams JM, Bach BR, Cole BJ. Chondrolysis after continuous intra-articular bupivacaine infusion: an experimental model investigating chondrotoxicity in the rabbit shoulder. Arthroscopy. 2006;22:813-819.
13. Chhabra A, Subhawong T, Carrino J. MR imaging of deltoid ligament pathologic findings and associated impingement syndromes. Radiographics. 2010;30: “751-761. 14. Robinson P, White LM, Salonen D, OgilvieHarris D. Anteromedial impingement of the
ankle: using MR arthrography to assess the anteromedial recess. AJR Am J Roentgenol. 2002;178:601-604. 15. Cerezal L, Llopis E, Canga A, Rolón A. MR arthrography of the ankle: indications and technique. Radiol Clin North Am. 2008;46:973-994. 16. Coull R, Raffiq T, James E, Stephens M. Open treatment of anterior impingement of the ankle. J Bone Joint Surg Br. 2002;85:550-553. 17. Edmonds EW, Chambers R, Kaufman E, Cambers HG. Anterolateral ankle impingement in adolescents: outcomes of nonoperative and operative treatment. J Pediatr Orthop. 2010;30:186-191. 18. Nihal A, Rose D, Trepman E. Arthroscopic treatment of anterior ankle impingement syndrome in dancers. Foot Ankle Int. 2005;26:908-912. 19. Scranton PE, McDermott JE. Anterior tibiotalar spurs: a comparison of open versus arthroscopic debridement. Foot Ankle. 1992;13:125-129. 20. Manoli A II. Anteriomedial impingement of the ankle in athletes. Sports Health. 2010;2:495-502.
Downloaded from fas.sagepub.com at CAMBRIDGE UNIV LIBRARY on January 10, 2015
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