Extensor Digitorum Longus Tendon Research Articles

Hallux Valgus Correction in a Patient with Metatarsus Adductus with Multiple Distal Oblique Osteotomies

Metatarsus adductus is a structural foot deformity that is rarely associated with hallux valgus deformity. Surgical treatment is challenging, and multiple osteotomies are often required to correct both deformities. However, surgical impact must be considered, especially in elderly patients. We present a clinical case of a 76-year-old woman affected by hallux valgus and metatarsus adductus deformity. Multiple distal oblique osteotomies were performed on the first, second, and third metatarsals, coupled with Z-lengthening of the extensor digitorum longus tendons.

Composite flap transfer from the foot for treatment of multi-finger complex soft tissue defects

Objective To introduce the clinical application of composite flap transfer from the foot for treatment of multi-finger complex soft tissue defects. Methods This method was applied to treat 7 cases and 19 fingers. All the cases involved complex dorsal soft tissue defect of 2 to 4 fingers with extensor tendons missing and phalanx or interphalangeal joint exposed. The combined soft tissue defect area was 5.0cm×1.5cm to 9.0 cm× 2.5 cm. The flaps were designed along the axis extending from the fibular and plantar margin of the great toe to the interspace between the first and second metatarsal bones. The flap was slightly larger than the dorsal finger defect combined and the shape of the flap was the same as the combined defect. The greater saphenous vein, dorsal digital veins and dorsal metatarsal or plantar metatarsal artery and nerves were included in the flap. They were sutured with dorsal digital veins, digital artery and nerves, respectively. Extensor digitorum brevis tendons and extensor digitorum longus tendons were included in the flap to reconstruct the missing tendons. Results All the flaps survived with good texture and good appearance. Two-point discrimination recovered 6 to 8 mm. Finger extension function was restored, and active finger flexion and extension recovered satisfactorily. The donor feet were with slight scar, good appearance and normal function. Conclusion Combined dorsalis pedis,toe web and great toe fibular flap including extensor digitorum brevis and extensor digitorum longus tendon is a good option to treat multi-finger dorsal complex defects. Key words: Surgical flaps; Finger injuries; Tendon injuries; Transplantation

Initial experience with visualizing hand and foot tendons by dual-energy computed tomography

Purpose To assess the feasibility of visualizing hand and foot tendons by dual-energy computed tomography (CT). Methods and materials Twenty patients who suffered from hand or feet pains were scanned on dual-source CT (Definition, Forchheim, Germany) with dual-energy mode at tube voltages of 140 and 80 kV and a corresponding ratio of 1:4 between tube currents. The reconstructed images were postprocessed by volume rendering techniques (VRT) and multiplanar reconstruction (MPR). All of the suspected lesions were confirmed by surgery or follow-up studies. Results Twelve patients (total of 24 hands and feet, respectively) were found to be normal and the other eight patients (total of nine hands and feet, respectively) were found abnormal. Dual-energy techniques are very useful in visualizing tendons of the hands and feet, such as flexor pollicis longus tendon, flexor digitorum superficialis/profundus tendon, Achilles tendon, extensor hallucis longus tendon, and extensor digitorum longus tendon, etc. It can depict the whole shape of the tendons and their fixation points clearly. Peroneus longus tendon in the sole of the foot was not displayed very well. The distal ends of metacarpophalangeal joints with extensor digitoium tendon and extensor pollicis longus tendon were poorly shown. The lesions of tendons such as the circuitry, thickening, and adherence were also shown clearly. Conclusion Dual-energy CT offers a new method to visualize tendons of the hand and foot. It could clearly display both anatomical structures and pathologic changes of hand and foot tendons.

Augmentation of Tendon–Bone Interface Healing With Low-intensity Pulsed Ultrasound

The capacity of low-intensity pulsed ultrasound to accelerate the integration of grafted tendon-within-bone tunnel was evaluated. The extensor digitorum longus tendons of 20 New Zealand white rabbits were transplanted into bone tunnels in both proximal tibias. One side was chosen randomly to receive low-intensity pulsed ultrasound. The other side served as control. Six rabbits each were sacrificed at 2 and 3 weeks postoperatively for biomechanical testing, and 2 rabbits each were sacrificed at 1, 3, 6, and 12 weeks postoperatively for histological study. At 2 weeks postoperatively, the mean maximal tensile strength in the ultrasound-treated group (30.676 N) was significantly stronger (P<.05) than the control group (17.924 N). There was no significant difference of the maximal tensile strength (33.674 vs 33.340 N; P=.753) between the ultrasound-treated and control groups at 3 weeks postoperatively. In the ultrasound-treated group, the histological study revealed the interface filled with denser granulation tissue and diffuse perpendicular anchored fibers in the 1- and 3-week specimens, and interface new bone formation in the 6- and 12-week specimens. The biomechanical and histological studies demonstrated that the low-intensity pulsed ultrasound enhanced the healing of grafted tendon-to-bone tunnel in the early stages. Our findings indicate that low-intensity pulsed ultrasound is a potentially promising mechanical tool to accelerate early tendon healing to bone tunnel.

The effects of bone marrow or periosteum on tendon-to-bone tunnel healing in a rabbit model

The purpose of this study was to investigate whether a grafting technique using either periosteum or bone marrow as an adjunct, would reconstitute more favorable tendon anchorage morphology with improved tensile strength in a bone tunnel model. We hypothesized that autogenous bone marrow aspirate can enhance the tendon-bone attachment as well as a freshly harvested periosteum, because both tissues contain pluripotent cells. Thirty-six skeletally mature New Zealand white rabbits were utilized. For the tendon graft healing in a bone tunnel model, the extensor digitorum longus tendon was detached from its femoral insertion and transplanted through a bone tunnel into the proximal tibia. Three groups were compared. For the group P (periosteum), a periosteum-wrapped tendon was fixed into the tunnel through the proximal tibial metaphysis. For the group BM (bone marrow), instead of periosteum augmentation, fresh bone marrow was injected into the tendon graft that would sit inside the tunnel. For the group C (control), the limb underwent a similar operation with neither the periosteum enveloping nor bone marrow injecting the tendon. At 6 and 12 weeks after surgery, two rabbits were used for light and electron microscopic examinations, and ten rabbits were used for biomechanical tests in each group. The interface tissue between bone and tendon was thicker and less organized in group C compared to groups P and BM at 6 weeks. Ultra-structurally, the interface tissue was loosely organized in group C, compared to others. Bone ingrowth into tendon was more obvious in groups P and BM, compared to group C. The proliferation of cartilage islands was observed within bone tunnels of both groups P and BM; but a well-defined fibrocartilage zone was noted only in group BM at the interface at week 12. Biomechanical findings: (1) at 6 weeks, the average failure load of group P was significantly higher than the others (P < 0.01). At same time point, in terms of stiffness, while group P was significantly higher than the other groups (P < 0.01), group BM was also significantly higher than that of group C (P < 0.05); (2) at 12 weeks, in terms of failure loads, there was a statistical significant difference only between groups BM and C (P < 0.05). At the same time point, stiffness values were not statistically different among the three groups. Based on the histological and biomechanical findings, the present study demonstrated that periosteum had a positive effect when compared to bone marrow and control groups on the tendon-to-bone healing at an early time point (6 weeks), and bone marrow was also effective at 12 weeks time point compared to the control group in an extra-articular bone tunnel in rabbits. The presence of pluripotent cells in both the bone marrow and the periosteum may be the possible mechanism for enhanced healing. Periosteum had a positive effect at an early time point (6 weeks). Bone marrow was more effective at 12 weeks. Therefore, it is possible that a combination of wrapping periosteum and injecting bone marrow to the tendon graft would have a synergistic effect (early and strong). To prove this hypothesis, future studies which would combine both methods are needed.

New Tendon Transfer for Correction of Drop-foot in Common Peroneal Nerve Palsy

Common peroneal nerve palsy has been reported to be the most frequent lower extremity palsy characterized by a supinated equinovarus foot deformity and foot drop. Dynamic tendon transposition represents the gold standard for surgical restoration of dorsiflexion of a permanently paralyzed foot. Between 1998 and 2005, we operated on a selected series of 16 patients with traumatic complete common peroneal nerve palsy. In all cases, we performed a double tendon transfer through the interosseous membrane. The posterior tibialis tendon was transferred to the tibialis anterior rerouted through a new insertion on the third cuneiform and the flexor digitorum longus was transferred to the extensor digitorum longus and extensor hallucis longus tendons. All 16 patients were reviewed at a minimum followup of 24 months (mean, 65 months; range, 24-114 months). The results were assessed using the Stanmore system questionnaire and were classified as excellent in eight, good in five, fair in two, and poor in one. Postoperative static and dynamic baropodometric evaluations also were performed. The proposed procedure, which provides an appropriate direction of pull with adequate length and fixation, is a reliable new method to restore balanced foot dorsiflexion correcting the foot and digit drop and producing a normal gait without the use of orthoses. Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Simulation of Contact Gait in the Cadaveric Lower Extremity using a Novel Below Knee Simulator

Research into gait characteristics has led to the creation of experimental gait simulators. The aim of this work was the development of a Contact Gait Simulation System (CGSS) to generate realistic plantar pressures for the contact phase of gait. The simulator seeks to create muscle loads which guide the foot through the entire loaded contact phase. Two simulations, mid stance only (n=8) and full contact gait (n=7) were applied to cadaveric lower extremities disarticulated at the knee. The Achilles, extensor digitorum, and extensor hallucis longus tendons were clamped for the application of muscular loads while axial loads were applied to the proximal tibia and plantar pressures were measured. Live subjects (n=7) were recorded traversing the plantar pressure sensor, for regional (fore, mid, and hind foot) pressure comparisons. By loading muscle tendons in proportion to live gait, the generated patterns of loading across the fore, mid and hind foot were representative of that found in live subjects. Hindfoot pressures dominated during the initial loading response, while forefoot pressures dominated during the terminal stance phase of gait. Regional trends showed strong similarity in timing and proportion to live gait. The CGSS developed is capable of simulating live plantar pressures in the cadaveric model. Further manipulation of simulator control signals may improve accuracy, but as gait characteristically exhibits broad trends, exact agreement is not necessary. We believe this System can be used to efficiently investigate the alterations to foot/ankle function resulting from injuries and surgical corrective procedures.

Lipoma Arborescens of the Suprapatellar Bursa and Extensor Digitorum Longus Tendon Sheath

Lipoma arborescens (diffuse articular lipomatosis) is a rare intra-articular lesion consisting of subsynovial villous proliferation of mature fat cells. The usual clinical presentation is painless swelling. The aim of this series was to emphasize the importance of gray scale and color Doppler sonography through the investigation of chronic joint swelling. Lipoma arborescens of the knee and extensor digitorum longus tendon sheath at the ankle region are described. The latter is extremely rare. We examined 2 patients with sonography before using cross-sectional modalities. Gray scale sonography revealed hyperechoic irregular villous and frondlike projections within prominent joint effusion. A wavelike motion of the projections was shown by dynamic compression and manipulation of the effusion. We observed moderate vascularity on color Doppler sonography. Spectral analysis revealed a low-resistance arterial waveform. Gray scale sonography is a useful diagnostic modality that can be performed to evaluate chronic joint swelling before the use of cross-sectional and more expensive modalities.

Extensor Digitorum Longus Tenosynovitis Caused by Talar Head Impingement in an Ultramarathon Runner: A Case Report

Stenosing tenosynovitis of the extensor digitorum longus tendon is an injury related to ultramarathon running. A 32-year-old male ultramarathon runner developed chronic tenosynovitis of the ankle dorsiflexors. He was diagnosed with extensor digitorum longus tenosynovitis caused by talar head impingement associated with exostosis. He failed to respond to non-operative management and decided to undergo tenosynovectomy of the extensor digitorum longus tendon. The pain was relieved without functional disturbance of the foot and ankle, and the patient returned to running 3 weeks postoperatively. At the 2-year follow-up, he was participating fully in ultramarathons.

Closed rupture of the extensor digitorum longus tendon: A case report and biomechanical analysis of rupture mechanism

Closed subcutaneous rupture of the extensor digitorum longus tendon (EDL) has been rarely documented. We present a case report of a patient with closed subcutaneous rupture of EDL. To identify the site of tendon rupture, three-dimensional computed tomography (3D-CT) was performed. The 3D-CT (volume rendering) images indicated tendon rupture of EDL on the dorsal region of the left foot. To identify the mechanisms of EDL rupture we also performed a biomechanical study using three cadavers. The patient granted permission for submission of personal data for publication. From biomechanical findings, pressure of the EDL on the inferior extensor retinaculum was 4.9–10.7 times higher in plantar flexion than in dorsal flexion of the ankle. Therefore, we believe that EDL rupture occurred with a passive flexion force pressing onto the toe tip in the plantar flexion position of the ankle joint.

Dimensions of the anterior tarsal tunnel and features of the deep peroneal nerve in relation to clinical application

The aim of this study was to demonstrate anatomical features of the anterior tarsal tunnel and the deep peroneal nerve and to discuss the importance of these structures for the anterior tarsal tunnel syndrome and some other surgical approaches to minimize the injury risk. Lower limbs of 18 formalin fixed cadavers were examined. The limbs showed no evidence of pathology or trauma. The lateral length of the tunnel was 21.7 +/- 4.3 mm and the medial length of the tunnel was 55.0 +/- 9.0 mm. The width of the tunnel at the inferior border between the extensor hallucis longus and extensor digitorum longus tendons was 12.6 +/- 2.1 mm. The location of the deep peroneal nerve bifurcation was in the anterior tarsal tunnel in 31 specimens (86.1%) and distal to the tunnel in two specimens (5.6%). In three specimens (8.3%) there was no bifurcation because of the absence of the medial terminal branch of the deep peroneal nerve. In these three specimens, the superficial peroneal nerve distributed to the adjacent sides of the great and second toes. Bifurcation above the tunnel was not observed in our specimens. There was connection between the deep peroneal nerve and the superficial peroneal nerve in 10 specimens (27.8%) in the first interdigital space. During the observations, the presence of a fibrous band over the nerve and vessel was noted in 22 specimens (61.1%). We believe that a detailed anatomic knowledge of the anterior tarsal tunnel and the deep peroneal nerve will be of help during surgical approaches to this area and the diagnosis of the problems related to the peripheral nerves on the dorsum of the foot.

SPONTANEOUS TIBIALIS ANTERIOR TENDON RUPTURE: A RARE CAUSE OF FOOT DROP

Tibialis anterior tendon (TAT) rupture is an uncommon musculoskeletal condition that is rarely encountered by neurologists.1 Most patients present with foot drop and pain and may be misdiagnosed as a peroneal mononeuropathy or L5 radiculopathy. Clinical recognition and distinction of this entity from other causes of foot drop are important for neurologists. We describe two patients with spontaneous TAT ruptures who presented for neurologic consultation for suspected peroneal neuropathies. ### Case 1. A 73-year-old man with a history of atrial fibrillation and hypertension was walking on his treadmill when he noted a painless “pop” in his right anterior ankle followed by “flopping” of his foot. A few days later, he noted swelling on the anterior aspect of his ankle and difficulty dorsiflexing his right foot. He denied back pain and bladder dysfunction. Neurologic examination demonstrated mild weakness in right ankle dorsiflexion with normal strength in all other muscles including toe extension and ankle eversion and inversion. There was swelling on the anterior surface of the right ankle (figure, A). The extensor hallucis longus and digitorum longus tendons were intact, but the TAT was not palpable …

Limb-salvage operation for synovial sarcoma of the foot

Abstract A 17-year-old male suffered from a continuously increasing size and painless mass on his left medial dorsal foot for many years. The result of a needle biopsy with ultrasound guidance was a high grade synovial sarcoma. The tumour staging was AJCC stages IIC or Enneking stage IIA. Tenodesis of the anterior tibialis tendon to the navicular bone was performed in order to maintain the extensor mechanism of ankle and internal fixation of tarso-metatarsal and midtarsal joints with multiple pins to avoid instability of the midfoot and hind foot. A radial forearm free fasciocutaneous flap was harvested about 10cm×8cm in size and covered the massive soft tissue defect by microsurgery. Dorsiflexion function of the ankle was reconstructed and preserved by the anterior tibials tenodesis to the medial aspect of the navicular bone. Lesser toes extension function was preserved by sparing excision of the extensor digitorum longus tendons but the peritendon was excised. The extensor hallux longus and brevis tendons are widely resected with the residual tendon stumps sutured to the fasciocutaneous flap due to the more medial location of the tumour in this patient. He received six courses of chemotherapy. Local radiotherapy was performed 33 times. There was no recurrence or distant metastasis during a follow-up period of 42 months. The most common treatment for this type of cancer in the dorsal foot is below-knee amputation. If the patient or the patient's family refuse amputation treatment, limb-salvage operation with microsurgical free fascioutaneous flap reconstruction can be considered.

ANATOMICAL STUDY OF THE ANKLE WITH VIEW TO THE ANTERIOR ARTHROSCOPIC PORTALS

This article evaluates the risk of interference with the neurovascular structures in the four anterior ankle arthroscopic portals, described on each side of the extensor tendons: anteromedial, medial midline, anterocentral and anterolateral. Complications after ankle arthroscopies have been described in up to 17%, most being neurovascular. To quantify the neurovascular risks we dissected 68 cadaveric feet and evaluated the correlations between tendons, vessels and nerves. The mean distance between tibialis anterior and extensor hallucis longus and between extensor hallucis longus and extensor digitorum longus is 4 mm, but in 10-20% these tendons are in apposition or are overlapped. The tibialis anterior vascular bundle was absent in 11.8%, was located between the tibialis anterior and the extensor hallucis longus in 3% and between the extensor hallucis longus and the extensor digitorum longus in 64.7%. A peroneal vascular bundle or branches of the tibialis anterior vascular bundle were located lateral to the extensor digitorum longus/peroneus tertius tendon in 88.2%. Transverse vascular branches were identified in 41.2% over the medial side of the joint line and in 52.9% over the lateral side. The deep peroneal nerve was located between the extensor hallucis longus and the extensor digitorum longus tendons in 58.8%. The superficial peroneal nerve had branches located between the tibialis anterior and the extensor hallucis longus tendons in 2.9%, between the extensor hallucis longus and the extensor digitorum longus tendons in 23.5% and lateral to the extensor digitorum longus/peroneus tertius tendon in 32.4%. These results show that the anteromedial and medial midline portals are the safest. The anterolateral portal should be noted not only for the risks to the superficial peroneal nerve, but also to the peroneal vessels.

Magic angle effect in MR imaging of ankle tendons: influence of foot positioning on prevalence and site in asymptomatic subjects and cadaveric tendons

The influence of foot positioning on prevalence of the magic angle effect (MAE) in ankle tendons was investigated. In 30 asymptomatic volunteers and five cadaveric feet, MR imaging of the ankle was performed in the supine (neutral position of the foot) and prone (plantar-flexed foot) position. MAE was considered if increased T1-weighted signal at a certain site was seen in one position only. Histological correlation was obtained at 25 sites of the cadaveric posterior tibialis tendons (PTT). MAE occurred in 6/30 vs 1/30 (supine vs prone) anterior tibialis tendons (ATT), 30/30 vs 0/30 extensor hallucis longus and 27/30 vs 0/30 extensor digitorum longus tendons, 29/30 vs 0/30 PTTs, 30/30 vs 0/30 flexor digitorum and flexor hallucis longus tendons, 30/30 vs 1/30 peroneus brevis and 23/30 vs 1/30 peroneus longus tendons. At 12/25 cadaveric PTT sites where MAE was exclusively responsible for the increased signal, histology revealed normal tissue (11/12) or minimal degeneration (1/12). In conclusion, the supine body position with neutral position of the foot, a high prevalence (77-100%) of MAE in ankle tendons except for the ATT (20%) is seen. MAE is almost absent in the prone body position with plantar flexion of the foot.

Anatomic Study of Blood Supply of the Dorsum of the Foot and Ankle

This project was to study the different patterns of the anterior tibal and dorsalis pedis arteries in relation to the blood supply of the dorsum of the foot and ankle. A reliable sample of 150 human embalmed cadavers was dissected. Four different patterns were identified. The dorsalis pedis artery was most frequently (287 cases, 95.7%) found to be the continuation of the anterior tibial artery distal to the ankle, and lay between the tendon of extensor hallucis and the first tendon of extensor digitorum longus. The other 13 cases (4.3%) showed 3 variant patterns of the anterior tibial-dorsalis pedis vascular axis: the anterior tibial artery took a more lateral course, passing in front of the lateral malleolus (6 cases, 2%); the perforating branch of the peroneal artery assumed the expected course of the dorsalis pedis artery (4 cases, 1.3%); the anterior tibal artery gave a lateral branch that replaced the perforating branch of the peroneal artery to supply the lateral aspect of the ankle (3 cases, 1%). Arterial variations of the anterior tibial-dorsalis pedis axis occurred in almost 5% of cases. An awareness of the existence of such variations is helpful during a preoperative assessment and could prevent injury during surgery.

Morphology of peroneus tertius muscle

Peroneus tertius (PT) muscle is peculiar to man, and man is the only member among the primates in whom this muscle occurs. The muscle is variable in its development and attachment. Because of functional demands of bipedal gait and plantigrade foot, part of extensor digitorum brevis (EDB) has migrated upwards into the leg from the dorsum of foot. PT is a muscle that evolution is rendering more important. In a total of 110 cadavers, extensor compartment of leg and dorsum of foot were dissected in both the lower limbs and extensor digitorum longus (EDL), and PT muscles were dissected and displayed. PT was found to be absent in 10.5% limbs, the incidence being greater on the right side. The remaining limbs in which the PT muscle was present had a very extensive origin from lower 3/4th of extensor surface of fibula (20% on right and in 17% on left), and the EDL was very much reduced in size. In approximately 12%, the tendon of PT was thick or even thicker than the tendon of EDL. In 4%, the tendon extended beyond fifth metatarsal up to metatarsophalangeal joint of fifth toe, and in 1.5%, it extended up to the proximal phalanx of little toe. In two cases (both on the right side), where PT was absent, it was replaced by a slip from lateral margin of EDL. We conclude that PT, which is preeminently human, is extending its purchase both proximally and distally.

Autologous Pedal Extensor Tendon for Frontalis Suspension in the Correction of Blepharoptosis with Poor Levator Function

Introduction: Blepharoptosis with poor levator function is commonly repaired with a frontalis suspension procedure. A variety of suspension materials have been used, including autologous fascia lata, banked fascia lata, Supramid, Gortex, silicone, and Mersilene. Autologous materials offer the advantage of less rejection and granuloma formation, and lower rates of ptosis recurrence. Autologous fascia lata, although commonly used, has been associated with hemorrhage, scar problems, pain, and muscle herniation over the harvest site. Additionally, sufficiently long autogenous fascia is sometimes not readily available. We describe the use of autologous pedal extensor (extensor digitorum longus) tendon for frontalis suspension. Materials and Methods: In a retrospective study, the authors evaluate 19 frontalis sling suspension surgeries using pedal extensor tendon in 17 consecutive patients with ptosis with poor levator function. The method of harvesting the pedal extensor tendon is described in detail. Results: Of 19 ptotic eyelids, 18 were successfully corrected with good final lid position. One eyelid was undercorrected. No recurrence of ptosis was encountered. No wound infection, eyelid contour abnormality, or ptosis overcorrection occurred. One eye developed exposure keratopathy that resolved with conservative treatment. There were no major complications associated with the pedal extensor tendon donor site. Discussion: Frontalis suspension with an autogenous pedal extensor tendon appears to be cosmetically sound and an effective treatment for ptosis with poor levator function. Its use as an alternative material to fascia lata for frontalis sling surgery can be considered.

Skimboarder's Toe: Findings on High-Field MRI

Our purpose is to report hyperdorsiflexion injuries of the metatarsophalangeal joints associated with the sport of skimboarding and to describe the MRI appearance of these injuries. Skimboarding can be associated with hyperdorsiflexion injuries of the metatarsophalangeal joint. MRI shows that such injuries are associated with hyperdorsiflexion of the extensor hallucis longus or extensor digitorum longus tendon, causing tear of the extensor expansion. Unlike turf toe, in which the plantar plate is involved, skimboarder's toe involves structures dorsal to the metatarsophalangeal joint.

Remitting seronegative symmetrical synovitis with pitting edema (RS3PE) syndrome: ultrasonography as a diagnostic tool

Remitting seronegative symmetrical synovitis with pitting edema (RS3PE) syndrome is characterized by symmetrical synovitis and swelling of both the upper and lower extremities. The anatomical determinant of RS3PE is predominantly extensor tenosynovitis as revealed by magnetic resonance imaging (MRI). Given the cost constraints, time, and expertise required in carrying out MRI and ease in diagnosing tenosynovitis by ultrasound, we utilized high-frequency ultrasonography (USG) for evidence of tenosynovitis of the distal tendons in patients with RS3PE. Diagnosis of tenosynovitis was made on the basis of anechoic or hypoechoic signals around the tendon sheaths in both transverse and longitudinal planes. Flexor and extensor tendons at the wrist and metacarpal heads and extensor digitorum longus (EDL) tendons at the ankle were evaluated with a 7.5-10-MHz linear probe. There were ten patients (seven males) with a mean age of 59.5 years (range: 52-78 years) and mean disease duration of 6.1 months (range: 1.5-12 months). Disease onset was acute in all of the cases. Pitting edema of the hands was present in all except two patients whereas four patients, in addition, had edema of the feet. Edema was symmetrical in seven patients. Inability to make a complete fist was noted in all. Tenosynovitis of extensor and flexor tendons at the wrist and the metacarpal heads was documented in all patients with edema of the hands. In seven cases extensor tendon tenosynovitis was more prominent compared to the flexor tendons. Tenosynovitis of EDL tendons was detected in six cases. Dramatic relief with low-dose prednisolone was noted in all patients within 6 weeks of therapy. At a mean follow-up of 10.1 months all patients had marked relief in edema of extremities and improvement in the grip strength. Our study confirms that tenosynovitis of both flexor and extensor tendons at the wrist and extensor tendons of the feet is the hallmark of RS3PE syndrome. USG is a reliable and cost-effective modality for evaluation of patients with suspected RS3PE.