Ankle Effusion Research Articles

Ankle And Heel Pain - Dirt Bike Rider

HISTORY: 28-year-old male with history of chronic hepatitis C complains of left ankle and bilateral heel pain for the past month causing difficulties with walking. The pain started shortly after he rode his dirt bike for hours without wearing his protective foot gear. During this time he also developed bilateral knee effusions. No other complaints including low back, hip or knee pain, numbness or tingling sensation of the lower extremities. PHYSICAL EXAMINATION: Large left ankle effusion with palpable warmth, slight erythema, non-specific tenderness, and limited range of motion (ROM) to 10' dorsiflexion, 20' plantarflexion. Moderate right ankle effusion without warmth or eythema, mild tenderness. Significant tenderness to palpation bilaterally over the calcaneus medial tubercle and longitudinal arch at the proximal plantar fascia. Pain worsened by passive ankle dorsiflexion. Moderate bilateral knee effusions without tenderness to palpation, full ROM. DIFFERENTIAL DIAGNOSIS: 1. Traumatic injury of the lower extremities (stress fracture, sprain) 2. Rheumatologic condition (Rheumatoid Arthritis, Gout, Reactive Arthritis) 3. Septic Arthritis 4. Hepatitis C Cryoglobulinemia with associated arthritis TEST AND RESULTS: Left foot X-ray (official reading): Small subtle area of periosteal reaction at the medial aspect of the distal 2nd metatarsal shaft raises the possibility of stress reaction. Correlate with clinical presentation. Normal CBC, Creatinine, U/A, Uric Acid, TSH, AST, ALT, Bilirubin, Albumin Negative Gonorrhea (urine), HIV, Hep B, RPR, ANA, RF, anti CCP, Lyme antibodies Positive Chlamydia (urine) and HLA B-27 Elevated Sed Rate (103), CRP (12.6) Knee joint aspirate: WBC 4554 N 46% L 54%, no crystals, negative culture for bacteria & yeast FINAL WORKING DIAGNOSIS: Reactive arthritis TREATMENT AND OUTCOMES: 1. Doxycycline Hyclate 100 mg two times a day for 3 months. 2. Indomethacin 50 mg three times daily 3. Rheumatologic Consult 4. Patient overall condition slowly improved over the course of 4 months. 5. Persistent bilateral plantar fasciitis persisted despite conservative management with marked improvement after steroid injections.

Index of Suspicion

Index of Suspicion

Ultrasound of the ankle.

Ultrasound of the ankle.

Accuracy of plain films, and the effect of experience, in the assessment of ankle effusions.

To investigate the accuracy of plain radiographs, and the effect of observer experience, in the assessment of ankle effusions compared with an MRI gold standard. Anteroposterior (AP) and lateral radiographs of the ankle of 39 patients were evaluated by four observers, ranging from first-year radiology resident to an attending musculoskeletal radiologist. Observers independently graded the lateral films from 0 to 5 at one sitting, and the AP films at a second sitting. All patients had an MRI scan performed within 48 h of the ankle radiographs, on which distention of the anterior recess was used as the gold standard for an effusion. Lateral radiographs had variable sensitivity (range 17-63%), but specificity (81-94%) was usually high. AP radiographs similarly had variable sensitivity (15-55%), but their specificity (63-75%) was surprisingly good. Overall, sensitivity and specificity were inversely proportional and more related to individual variability than experience (observer 1, 53% and 81%; observer 2, 17% and 94%; observer 3, 63% and 88%; observer 4, 21% and 94%); however, individual sensitivity and specificity were consistent between AP and lateral radiographs (observer 1, 53% and 81%, 50% and 65%; observer 2, 17% and 94%, 15% and 75%), observer 3, 63% and 88%, 55% and 63%; observer 4, 21% and 94%, 25% and 70%). Positive predictive value was reasonably good for lateral radiographs (range 75-86%); however, it was fairly low for AP radiographs (38-61%). Negative predictive value was low for both lateral (50-67%) and AP (47-58%) radiographs. Accuracy was low for both AP (45-59%) and lateral (53-74%) radiographs. As expected, individual accuracy was consistently higher for lateral radiographs than for AP radiographs (observer 1, 65% and 58%; observer 2, 53% and 45%; observer 3, 74% and 59%; observer 4, 54% and 48%). For the diagnosis of ankle effusions the overall accuracy of radiographs was surprisingly low. Quite surprisingly, the diagnosis of effusions on AP radiographs was not much poorer than on lateral films. Results, however, varied little with experience and training.

Heel Pain-Basketball

1050 HISTORY: A 10 year old female basketball player presents with right heel pain that began 9 months ago when she stepped on a pebble playing basketball barefoot. It bothers her with prolonged walking or after 5 minutes of running. She limps after running. Pain is present first thing in the morning but does not awaken her at night. She has no left heel complaints. She has been taking 800 mg of Advil before practices and games with no relief. An earlier evaluation had found normal calf flexibility and the recommended viscoelastic heel pads improved symptoms somewhat. PHYSICAL EXAMINATION: She walks with an antalgic gait. Her right heel is broadened compared with her left heel. She has slight right calf atrophy and mild heel cord contractures with only a few degrees of dorsiflexion noted bilaterally. No ankle effusion is present. She has a cavus foot type with normal ankle and subtalar motion. There is tenderness about the entire posterior calcaneus. Her skin is normal in appearance and distal sensation and circulation are intact. DIFFERENTIAL DIAGNOSIS: Neoplasm/lipoma/cyst Calcaneal apophysitis Calcaneal fracture Retained foreign body Puncture wound with low grade infection TEST AND RESULTS: Lateral and axial views right heel Calcaneal apophysis widened at the lateral and proximal aspects Apophysis slipped superiorly and laterally Comparison left heel views Normal appearance FINAL/WORKING DIAGNOSIS: Slipped right calcaneal apophysis TREATMENT AND OUTCOMES: Pneumatic Air Cast walking boot with viscoelastic heel insert. Secondary to continued pain in boot, crutches used and weight bearing as tolerated. No sports or gym class Aggressive stretching, stationary bike, therapeutic strengthening exercises stared after 3 weeks. Gait retraining to stop her from coming down hard on heel strike. Weaned out of boot while indoors to sneakers, Air Cast stirrup and silicone heel pad after 1 month. Still using boot for outside activities. Participated with medical limitations in National Basketball championship after 7 weeks. Wore lateral stabilizing brace secondary to continued peroneal weakness. Family moved to Houston and transferred care at 10 weeks. Long-term follow-up 2 years later, no further symptoms. Still growing and still playing highly competitive basketball.

Arthrogenic muscle response to a simulated ankle joint effusion

Background: Arthrogenic muscle inhibition (AMI) is a continuing reflex reaction of the musculature surrounding a joint after distension or damage to the structures of that joint. This phenomenon has been...

Ankle effusions following acute ankle injury.

We prospectively studied 56 patients with an acute ankle injury and an effusion to determine the significance of the ankle effusion to functional outcome. The average size of effusion was 15 mm. Most injuries occurred following a fall (73%) and most (73%) were inversion injuries. At 6 months all but two patients had returned to their normal activities with no further problems. No correlation was found with size of effusion and the functional and clinical outcome. We conclude that an ankle effusion does not reliably distinguish which injuries require further investigations and unless there are clinical indications further investigations are not indicated.

Ankle effusions following acute ankle injury: N.K. Makwana, P.A. Evans, D. Finlay and W.M. Harper (Leicester, UK)

Ankle effusions following acute ankle injury: N.K. Makwana, P.A. Evans, D. Finlay and W.M. Harper (Leicester, UK)

Improving the detection of radiographically occult ankle fractures: Positive predictive value of an ankle joint effusion

Objective: To assess the value of an ankle effusion on plain radiographs as a predictor of radiographically occult fracture after acute ankle trauma. Patients: Consecutive patients with acute ankle trauma and radiographic evidence of an ankle joint effusion. Patients were excluded if ankle trauma was sustained more than 48 h previously or if a fracture was visible on initial photographs Methods: All subjects ( n = 26) underwent computed tomography (CT) of the ankle in sagittal and coronal planes. Ankle effusion size was measured from initial lateral ankle radiographs. Results: Twelve patients (46%) had radiographically occult fractures identified with CT. Fracture sites included: posterior or lateral malleoli ( n = 4), calcaneus ( n = 1), or talus ( n = 7). Ankle effusion size was 11.2 mm in the group without fracture and 17.1 mm in the group with fracture ( P < 0.0001). The positive predictive value of an effusion 15 mm or greater was 83%. CT detected significant soft-tissue injuries in four (15%) patients including peroneal retinaculum tear ( n = 1), anterior talofibular ligament avulsion ( n = 1), and tears of the peroneus longus ( n = 1) and tibialis posterior ( n = 1) tendons. Conclusions: The presence of a large ankle effusion of radiographs after acute ankle trauma suggests an underlying fracture. An ankle effusion of ≥15 mm is a reasonable threshold to prompt additional imaging. Computed tomography provides good visualization of subtle bone injuries and may detect clinically imported soft-tissue injuries.

Occult ankle fracture detected by an ankle effusion on plain radiography: A case report

Subtle ankle fractures may escape detection on plain radiography. These occult fractures can cause prolonged disability and pain. We present a case of blunt ankle trauma where plain radiography failed to reveal any bony abnormalities. The recognition of an ankle effusion on plain radiographs prompted us to perform a computed tomography (CT) scan of the ankle. The CT scan demonstrated an anterior plafond fracture of the distal tibia, which required surgical fixation. Had the fracture not been identified, our patient would have been treated inappropriately for a ligament sprain. An occult fracture should be suspected if an ankle is grossly swollen after blunt trauma, and plain radiography demonstrates an effusion. In this circumstance, performance of further imaging studies, such as conventional or CT, are advised to rule out an occult ankle fracture.

Using Tomography to Diagnose Occult Ankle Fractures

Study objectives: To determine the incidence of occult ankle fractures and to determine whether an ankle effusion identified radiographically correlated with the presence of an occult fracture. Methods: Attending physicians in the emergency department of a university hospital prospectively identified patients with acute ankle injuries that produced ecchymosis or edema over two or more major ligaments of the ankle. Plain radiographs of these patients demonstrated ankle effusions without fractures. A consecutive sample of patients with acute ankle injuries was selected. Thirty-six of 1,151 patients were eligible to enter the study; 2 of these patients subsequently were excluded from the data analysis. All eligible patients underwent plain ankle tomography at 3-mm intervals in the coronal and sagittal planes. The types and frequencies of occult ankle fractures identified on plain film tomography were noted. The distention of the ankle joint capsule of enrolled patients was measured to determine if the degree of effusion correlated with the presence of an occult fracture. Results: The minimum incidence of occult fractures in the general population with ankle injuries was 1%. Twelve of 34 patients (35%) with acute, severe injuries had occult fractures. Depending on the size, an effusion was correlated with the presence of an occult fracture in 35% to 85% of the study population. Conclusion: Plain film tomography should be used when evaluating ankle injuries if both edema or ecchymosis over two or more stabilizing ligaments and radiographic evidence of an effusion are present simultaneously. [Ho K, Connell DG, Janzen DL, Grunfeld A, Clark TIW: Using tomography to diagnose occult ankle fractures. Ann Emerg Med May 1996;27:600-605.]

Magnetic resonance imaging in the management of diabetic foot infection

A prospective study was carried out of 22 patients admitted with 25 diabetic foot infections. All had cellulitis, 12 had discharging ulcers and eight had digital gangrene. In one case magnetic resonance imaging (MRI) was unhelpful owing to patient movement. Thirteen scans suggested deep-seated infection, including abscess (ten), osteomyelitis (seven) and ankle effusion (one). Overall, imaging provided a specificity of 77 per cent, a positive predictive value of 77 per cent, a sensitivity of 91 per cent and a negative predictive value of 91 per cent. MRI is valuable in determining the presence and extent of infection, which allows appropriate planning of surgical intervention.

Detection of radiographically occult ankle fractures following acute trauma: positive predictive value of an ankle effusion.

The purpose of our study was to determine if the presence of an ankle effusion on plain radiographs after acute ankle trauma is predictive of occult ankle fracture when no fracture is visible on the standard radiographic series. The ankle radiographs of 1153 patients with acute ankle trauma were examined for fracture and for the presence and extent of anterior and posterior capsular distension. Patients with ankle effusions but no detectable fracture subsequently underwent sagittal and coronal complex-motion tomography. Eleven of 33 patients with ankle effusions and otherwise normal plain radiographs had occult fractures identified with tomography. The fracture sites were as follows: osteochondral fracture of talar dome (n = 4), neck of talus (n = 1), medial malleolus (n = 1), anterior tibial rim (n = 1), posterior tibial rim (n = 1), tibial plafond (n = 1), lateral malleolus (n = 1), and anterior process of calcaneus (n = 1). The radiographic size of an ankle effusion was predictive of occult fracture. An ankle effusion measuring 13 mm or more in anterior plus posterior capsular distension had an 82% sensitivity and 91% specificity for underlying fracture in our series. The positive predictive value of an ankle effusion 13 mm or greater was 82%. The presence of an ankle effusion on plain radiographs following acute ankle trauma is suggestive of an underlying fracture. An ankle effusion of 13 mm or greater in total capsular distension has a positive predictive value of 82% for occult fracture and is a reasonable threshold to prompt additional imaging.

Non-gouty arthritis in sickle cell disease: report of 37 consecutive cases.

Arthritis in association with sickle cell disease was seen in 37 patients in a 21/2-year period. Cases of gout and of avascular necrosis of the femoral head were excluded. In 12 patients a non-inflammatory effusion occurred during the course of a painful crisis, in 12 patients an ankle effusion occurred in association with spontaneous development or deterioration of leg ulceration, and in 13 patients there was a group of miscellaneous arthritides. Ankle arthritis with leg ulceration has not been previously recognised, and its association with spontaneous ulceration, which is presumed to have a vaso-occlusive origin, is compatible with ischaemic synovial damage. The aetiology may therefore be similar to that believed to account for effusions in association with the painful crisis.

Teardrop sign: plain film recognition of ankle effusion.

Ankle effusions may be detected on lateral radiographs by observing a teardrop-shaped density extending anteriorly from the ankle joint along the neck of the talus. The normal and abnormal radiographic appearances of the ankle are discussed and the teardrop sign is identified.