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Original Report |
1
Department of Medical Imaging, Mount Sinai Hospital and the University Health
Network, University of Toronto, Toronto, Ontario, Canada M5S 1A1.
2
Present address: Department of Diagnostic Radiology, St. James University
Hospital, Beckett St., Leeds, LS9 7TF, United Kingdom.
3
Department of Orthopaedic Surgery, Toronto Western Hospital, University of
Toronto, Toronto, Ontario, Canada M5S 1A1.
Received July 18, 2001;
accepted after revision September 12, 2001.
Address correspondence to P. Robinson.
Abstract
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CONCLUSION. Anteromedial impingement of the ankle is now being recognized in the orthopedic literature as a distinct entity. MR arthrographic findings of anteromedial impingement include capsular and synovial soft-tissue thickening anterior to the tibiotalar ligaments and any associated osseous abnormality. Although anteromedial impingement is uncommon compared with other impingement syndromes of the ankle, the radiologist should be aware of the diagnosis and possible findings on cross-sectional imaging.
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Two surgical reports have described patients with chronic anteromedial ankle pain who were found to have "meniscoid" lesions in the anteromedial capsular tissues at surgery [12, 13]. We describe the potential MR arthrographic findings of patients with clinical findings of anteromedial impingement by presenting the prospective MR arthrographic evaluations of four patients (two with clinical anteromedial impingement and two control subjects) before arthroscopy was performed.
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Clinical Anteromedial Impingement
The first patient was an 18-year-old man with an 18-month history of right
anteromedial ankle pain resistant to conservative therapy. The patient
described a forced supination (inversion) and internal rotation injury that he
sustained while performing martial arts. Clinical examination found
anteromedial tenderness, swelling, and impingement (i.e., pain and decreased
range of movement on dorsiflexion and supination).
The second patient was a 28-year-old woman with a 24-month history of left anteromedial ankle pain resistant to conservative therapy. The patient described a forced supination (inversion) injury that she sustained while playing field hockey. Clinical examination found anteromedial tenderness and impingement.
Control Subjects
The first patient was a 31-year-old woman with a 12-month history of right
anterolateral and anteromedial ankle pain resistant to conservative therapy.
The patient described a forced supination (inversion) injury that she
sustained while at work. Clinical examination found tenderness over the
anterolateral aspect of the joint, but no swelling, and some lateral
instability. No anteromedial tenderness or swelling was present. A tear of the
anterior talofibular ligament was suspected clinically.
The second patient was a 26-year-old man with an 18-month history of chronic right anteromedial ankle pain resistant to conservative therapy. The patient described a forced supination (inversion) injury that he sustained while running. Clinical examination found no point anteromedial tenderness, swelling, or evidence of impingement, but the patient had pain on dorsiflexion and supination. A medial talar osteochondral defect was suspected clinically.
MR Arthrography
All patients gave informed consent and underwent MR arthrography of the
affected ankle. A 25-gauge needle was guided fluoroscopically into the
tibiotalar joint, and its position was confirmed with 0.5- to 1- mL iodinated
contrast material (diatrizoate meglumine 60%, Hypaque; Nycomed Amersham,
Princeton, NJ). Gadopentetate solution (2 mmol/L, 1 mL in 250 mL normal
saline) (Omniscan; Nycomed Amersham) (range, 8-15 mL) was then injected into
the tibiotalar joint until resistance was felt. The needle was removed, and
the patient was transferred to the MR suite without ambulating. MR imaging
commenced within 40 min of injection. All imaging was performed on a 1.5-T
magnet (Signa; General Electric Medical Systems, Milwaukee, WI) using a
quadrature extremity coil (Medical Advances, Milwaukee, WI) with the ankle in
a neutral position. Axial, sagittal, and coronal T1-weighted, fat-suppressed,
conventional spin-echo (TR/TE, 583/8), axial proton density—weighted
fast spin-echo (3967/32; echo-train length, 12), and sagittal T2-weighted
fat-suppressed, fast spin-echo sequences (3933/80; echo-train length, 8) were
performed through the tibiotalar joint and hindfoot (thickness, 3 mm; spacing,
0; field of view, 19.9 cm). The matrix was 256 x 256 in all sequences
except the axial proton density—weighted sequences, which used a matrix
of 512 x 512.
Image Analysis
All examinations were prospectively assessed in consensus by two
experienced musculoskeletal radiologists. The reviewers were unaware of
patient data and clinical history. The images from the four patients in our
study were reviewed along with 33 other MR arthrography ankle
examinations.
In all patients, assessment included evaluation of the ankle and capsular soft tissues. The anterior tibiofibular, anterior talofibular, calcaneofibular, and deltoid ligaments were classified as normal, intact but thickened or attenuated, or disrupted. The appearances of the anteromedial and anterolateral capsular tissues were assessed on axial images anterior to the respective malleolus and talus. In all patients, the anteromedial and anterolateral capsules were graded as normal (smooth contour) or abnormal incorporating synovitis and scarring (nodular or irregular contour).
A qualitative assessment of distention of the anterior, lateral, and posterior aspects of the joint was also made. distention was graded as either good (having outward distention of both anterior and posterior recesses of the tibiotalar joint) or suboptimal (in the setting of a lack of distention and visual redundancy of the capsular soft tissues).
Arthroscopy
All patients underwent arthroscopy after MR arthrography examination. The
average time from MR arthrography to surgery was 8 days (range, 1-14 days;
median time elapsed, 10 days). In the patients with clinical anteromedial
impingement, an anterolateral portal was used for the initial surgical
approach. At surgery, the appearances of the capsule, ligaments, cartilage,
and bones were recorded. The capsular tissues were recorded as either normal
or abnormal (encompassing synovitis and scar tissue).
Clinical Follow-Up
All patients underwent follow-up clinical assessment at 3 and 6 months
after arthroscopy. Follow-up assessment included evaluation of postoperative
ankle pain and overall function compared with the patient's pain and
disability before surgery. Pain and function were each scored on a scale of 1
to 10, with 10 indicating, respectively, severe pain or severe limitation in
movement.
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Clinical Anteromedial Impingement
In the first patient, MR arthrography showed abnormal appearance of the
anteromedial capsular tissues with irregular thickening of soft tissue
anterior to the tibiotalar ligament and medial malleolus (Fig.
1A,1B).
No notable chondromalacia was seen, and all ligaments were intact. The
anterolateral recess appeared normal. At surgery, an anteromedial capsular
tear with a thick area of dense synovitis anterior to the tibiotalar ligament
was seen. The cartilage and capsular ligaments appeared intact. The
anterolateral recess was normal. Resection of the synovial tissue was
performed.
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In the second patient, MR arthrography revealed abnormal appearance of the anteromedial capsular tissues, with irregular thickening of soft tissue anterior to the tibiotalar ligament (Fig. 2A,2B). Chondromalacia was not seen, and all ligaments were intact, including the tibiotalar ligament (Fig. 2A). Bony abnormality with anteromedial osteophytes was also present (Fig. 2B). The anterolateral recess appeared normal. At surgery, dense anteromedial capsular synovitis anterior to the tibiotalar ligament was found. The tibial and talar osteophytes were confirmed. Capsular ligaments appeared intact, but grade 1 chondromalacia of the lateral talar articular surface that MR arthrography had not detected was revealed. The anterolateral recess was normal. Resection of the synovial tissue and osteophytes was performed. The chondral defect did not require treatment.
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Controls
In the first patient, MR arthrography showed normal appearance of the
anteromedial capsular tissues anterior to the tibiotalar ligament
(Fig. 3). The anterior
talofibular ligament was attenuated but intact. Chondromalacia was not seen,
and all other ligaments were intact, including the deltoid. The anterolateral
synovium appeared normal. At surgery, the anteromedial capsular tissues
anterior to the tibiotalar ligament appeared normal. The anterior talofibular
ligament was intact but lax and attenuated. The anterolateral recess was
normal. The anterior talofibular ligament was dissected and reattached to the
fibula with suture anchors.
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In the second patient, MR arthrography showed normal appearances of the anteromedial capsular tissues anterior to the deltoid (Fig. 4). Grade 2 chondromalacia was present on the posteromedial talus, but all ligaments were intact, including the tibiotalar ligament. The anterolateral recess appeared normal. At surgery, the anteromedial capsular tissues anterior to the tibiotalar ligament were found to be normal. Posteromedial chondromalacia was confirmed, and all ligaments were intact. The anterolateral recess was normal. The chondral defect was débrided and drilled.
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Clinical Follow-Up
All patients showed symptomatic and functional improvement at 3 months and
at 6 months. At 6-month assessment, their preoperative scores on the 10-point
scales for pain and for function were compared with their postoperative
scores. The patients with anteromedial impingement clinically showed the
following changes: For the first patient, severity of pain was reduced from 7
in 10 to 2 in 10; extent of limitation of movement was reduced from 7 to 1.
For the second patient, severity of pain was reduced from 8 to 2; extent of
limitation of movement was reduced from 8 to 2. The control patients showed
the following changes: For the first patient, severity of pain was reduced
from 8 to 2; extent of limitation of movement was reduced from 9 to 3. For the
second patient, severity of pain was reduced from 8 to 1; extent of limitation
of movement was reduced from 8 to 1.
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Another study retrospectively evaluated 11 patients with clinical anteromedial impingement with capsular synovitis and thickening of the anterior fascicles of the tibiotalar ligament [13]. Initially, six of 11 patients had supination (inversion) injuries, and five had fractures as the mechanism of injury [13]. Surgical evaluation of the 11 patients showed anteromedial osteophytes in two patients and thickening of the anterior fibers of the deltoid and a medial osteochondral defect of the talus in six patients. Lateral ligament and capsular synovitis required débridement in five patients. Imaging and clinical accuracy was not formally evaluated: MR imaging was performed in only two patients and was described as inconclusive [13].
The two patients with arthroscopically proven anteromedial impingement in our study were clinically diagnosed prospectively with anteromedial impingement. Both patients described supination (inversion) mechanisms as the precipitating injury, which is more in keeping with the findings of the larger orthopedic series [13]. Given these findings, it seems more likely that anteromedial impingement is a rare complication of a supination (inversion) injury than the result of a rarer pronation (eversion) mechanism of injury [12, 13]. It is not surprising that lateral capsular abnormalities and medial osteochondral defects can occur with such a supination injury. However, neither patient evaluated in our study had anterolateral recess abnormalities, and both had intact deep and superficial components of the deltoid. At arthroscopy, no hypertrophied fascicles were seen. The impingement was found to be the result of an anteromedial synovial mass in one patient and a combination of synovial thickening and anteromedial osteophytes in the other patient. Although anteromedial osteophytes might be considered a variation of anterior impingement, a recent study found that the tibial osteophyte was more commonly lateral to the midline of the joint, whereas the talar osteophyte was situated more medially [11]. These features were not present in our study, with the patient we describe having both tibial and talar osteophytes situated medially only.
Impingement syndromes of the ankle are usually a clinical diagnosis, and radiologic evaluation is not always necessary. Imaging can be of use in revealing osseous and soft-tissue edema in anterior or posterior impingement [3, 4]. However, the place of imaging in anterolateral impingement is more controversial. A number of studies have described false-positive and false-negative imaging findings in patients with this condition [4, 5, 7,8,9]. Arthrographic techniques seem to offer the most accurate means to assess the capsular recesses of the ankle. However, synovial thickening and capsular abnormalities may be seen in individuals who do not have clinical symptoms of impingement [14].
A limitation of this report is the small number of subjects and controls evaluated. However, the aim of our study was to describe initial MR arthrographic findings in patients with this condition and thereby enable radiologists to highlight possible abnormality when the clinical diagnosis is less certain or to provide corroborative anatomic evidence of the nature of anteromedial capsular abnormality in patients with clinical signs and symptoms of impingement syndrome.
Whatever the underlying mechanism of injury, development of anteromedial impingement is rare and may occur in combination with other abnormalities of the ankle. MR arthrography proved to be effective in identifying the soft-tissue and osseous abnormalities in the patients we studied, and these findings were confirmed at arthroscopy. Radiologists should be aware of this condition and of the need to carefully evaluate the components of the deltoid ligament and the anteromedial recess of the joint when imaging is performed in patients with chronic ankle pain.
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