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Diagnostic guidelines for chronic ankle pain. From loose bodies to joint venture

Verhagen, R.A.W.

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Citation for published version (APA):Verhagen, R. A. W. (2004). Diagnostic guidelines for chronic ankle pain. From loose bodies to joint venture.

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Download date: 16 Sep 2020

Chapter r

T hee a n t e r i or ank le i m p i n g e m e nt s y n d r o m e:: d iagnos t ic va lue of ob l i que

r a d i o g r a p hs s

J.L.. Tol, R.A.W. Verhagen, R. Krips, M. Maas, R.W. Wessel, M.G.W.. Dijkgraaf, C.N. van Dijk

FootFoot Ankle Int 2004;25(2):63-8

Thee anterior ankle impingement syndrome

Abstract t Background Background

Thee diagnostic value of an oblique radiograph in addition to a lateral radiograph, for detecting

osteophytess in the anterior ankle impingement syndrome was evaluated in a prospective

study.. The hypothesis was that the application of a lateral radiograph is insufficient to detect

osteophytess that are located in the anteromedial aspect of the ankle joint. Oblique anteromedial

impingementt (AMI ) radiographs were hypothesized to be a relevant adjunct, because of their

utilit yy to detect these anteromedially located osteophytes.

Methods s

Thee presence or absence of tibial and talar osteophytes on both radiographs was compared

withh the combined findings of CT, MRI scan and arthroscopic surgery. Estimates of test

characteristicss were obtained for 60 consecutive patients with an anterior ankle impingement

syndrome. .

Results s

Itt was shown that the sensitivity of lateral radiographs for detecting anterior tibial and talar

osteophytess was 40% and 32%, respectively (specificity, 70% and 82%). When the lateral

radiographh was combined with an oblique AMI radiograph, these figures increased to 85%

andd 73%, respectively (specificity decreased to 45% and 68%). This increase was due to the

highh sensitivity of the oblique AMI radiographs for detecting anteromedial osteophytes (93%

forr tibial and 67% for talar osteophytes).

Conclusion n

AA lateral radiograph is insufficient to detect all anteriorly located osteophytes. An oblique

AMII radiograph is a useful adjunct to routine radiographs and is recommended to detect

anteromediall tibial and talar osteophytes.

42 2

Chapterr 4

Introductio n n Thee anterior ankle impingement syndrome is a common cause of chronic ankle pain. Patients

presentt with anterior ankle pain induced by activity, especially forced dorsiflexion. The pain

iss caused by compression in dorsiflexion of a soft tissue or bony impediment in between the

anteriorr aspect of the distal tibia and the opposite talar neck.1"8 Physical examination reveals

recognizablee tenderness on palpation of the anterior aspect of the ankle joint with slightly

limitedd painful forced dorsiflexion. The clinical differentiation between anterolateral and

anteromediall impingement is generally accepted.910 Patients with chronic mechanical laxity

inn particular frequently display osteophytic formations and degenerative changes in the medial

compartmentt of the ankle.11,12 Standard AP and lateral radiographs are used to detect the presence

off these osteophytes.13 In patients with anterior talar and/or tibial spurs, these spurs are regarded

ass being the cause of the anterior impingement syndrome. Due to their location they lead to a

"kissing"" phenomenon and concomitant pinching of hypertrophic synovial tissue.

Becausee of the anteromedial notch,14 anteromedial osteophytes are undetected by standard

radiographss in a substantial number of patients with anterior impingement complaints.15 In a

cadaverr study, it was shown that anteromedial tibial osteophytes up to 7.3 mm in size,

originatingg from the anteromedial border, remain undetected due to superposition or

overprojectionn of the more prominent anterolateral border of the distal tibia.15 Medially located

talarr osteophytes remain undetected due to overprojection or superposition of the lateral part

off the talar neck and body.15 In these patients with clinical anterior ankle impingement syndrome,

thee diagnosis of soft tissue impingement wil l be made, despite the fact that anteromedial

osteophytes,, ossicles, or posttraumatic calcification may be present. Detection of the osteophytes

iss important for preoperative planning. Several authors have stated that surgical distinction

betweenn bony and soft tissue normal variants and pathologic conditions is difficult, because

off subtle variations in joint anatomy.141617 Inpatients with accompanying synovial reflections

overlyingg the concealed osteophytes, anteromedial bony spurs are poorly visualized

arthroscopicallyy and can be missed.14 Radiographic classification of spur formation correlates

withh the outcome of surgery.10,1318

AA new oblique radiograph was introduced to detect medially located tibial and talar

osteophytes.. In this oblique anteromedial impingement (AMI ) view, the beam is tilted in a

45°° craniocaudal direction with the leg in 30° external rotation and the foot in plantarflexion,

inn relation to the standard lateral radiograph position (Fig. 1).

Thee aim of the present prospective study was to evaluate the diagnostic value of the oblique AMI

view,, in addition to the lateral view, in detecting osteophytes in the anterior ankle impingement

syndrome.. We hypothesized that in patients with an anterior ankle impingement syndrome:

1.. Standard lateral radiographs are insufficient to detect all anterior ankle osteophytes, due

too underdetection of anteromedial osteophytes.

43 3

Thee anterior ankle impingement syndrome

Fig.. 1 A.. 45/30 AMI ankle view: position of the foot relative too the x-ray beam. Starting from a standard lateral view,, the x-ray beam is tilted into a 45° craniocaudal positionn with the lower extremity externally rotated 30°. .

B.. The patient is asked to place the foot in the maximal plantarflexedd position. The heel is placed on a 2-cm-highh shelf.

C.. The x-ray beam is rotated 10° parallel to the anterior contourr of the foot and ankle, and is centered just anteriorr to the lateral malleolus. A high-contrast mammographyy film is used (one-sided emulsion film). Thiss film is underexposed to 50% of the normal value forr a standard ankle radiograph.

2.. Oblique (AMI ) radiographs are a useful and relevant adjunct for imaging anterior ankle

osteophytes. .

3.. In patients with a clinical anterolateral impingement lesion, lateral radiographs are sensitive

enoughh to detect anterolateral osteophytes.

4.. In patients with a clinical anteromedial impingement lesion, oblique (AMI ) radiographs

aree sensitive enough to detect anteromedial osteophytes.

44 4

Chapterr 4

Material ss and Methods Thee study was part of a prospective study design of different diagnostic strategies in patients

withh chronic anterior ankle pain. It was approved by our medical ethical committee and the

subjectss included had given informed consent. Al l patients failed to respond to a minimum 6-

monthh period of non-operative treatment. Patients were included if they presented with

anteriorr ankle pain with painful dorsiflexion during or after activity, tenderness on palpation

off part of the anterior joint line, swelling, and limited dorsiflexion. If at physical examination

tendernesss on palpation at the anterior joint line was predominantly located medial to the

anteriorr tibial tendon, the diagnosis was anteromedial impingement. If tenderness on palpation

att the anterior joint line was predominantly located lateral to the extensor digitorum longus

tendon,, the diagnosis was anterolateral impingement. Patients with both anteromedial and

anterolaterall palpation pain had combined anteromedial and anterolateral impingement.10

Sixtyy consecutive patients (36 men and 24 women) with an average age of 33 years (range,

18-68)) were evaluated. The left ankle was involved in 26 patients and the right ankle in 34

patients.. The average duration of the complaints was 1.3 years (0.5-8 years). Thirty-eight

patientss (63%) experienced one or more supination traumas. Forty-nine patients (82%) were

involvedd in sports. On physical examination all patients had localized swelling or showed

signss of local synovitis when compared to the unaffected ankle.

Inn all patients, standard AP and lateral weight bearing radiographs of both ankles, an AMI

radiograph,, a CT scan (Helical dual; Twin Flash, Elscint, Israel or MX Twin Flash, Picker,

USA),, and a MRI scan (1.5 Tesla; Vision System Siemens, Erlangen, Germany) were performed.

Al ll patients had arthroscopic surgery within 12 weeks after inclusion. The lateral and oblique

radiographss were blinded and independently scored for the presence or absence of osteophytes

onn the tibia and/or talus by three experienced observers. The observers were not informed

aboutt the preoperative diagnosis. The AP and lateral radiographs were scored according to

ann osteoarthritic classification (Table l).8 In case of disagreement, the radiographs were

collectivelyy discussed and consensus was reached.

Al ll arthroscopic procedures were performed by the same surgeon as a day surgery procedure

underr spinal or general anaesthesia, as described in earlier reports.10 During arthroscopy, the

distall tibia and talus were accurately inspected for presence or absence of osteophytes.

Arthroscopicc treatment consisted of removal of any soft tissue and/or bony impediments.

Tablee 1 Classification of osteoarthritic changes of the ankle joint on plain radiography8

Gradee 0 Normal joint or subchondral sclerosis II Osteophytes without joint space narrowing III Joint space narrowing with or without osteophytes II II Subtotal or total disappearance or deformation of the joint line

45 5

Thee anterior ankle impingement syndrome

Presencee or absence of osteophytes was scored and compared to the findings on the lateral

andd oblique radiographs. Estimates of the sensitivity, specificity, positive predictive value,

andd negative predictive value were obtained for:

The lateral radiographs for detecting anterior osteophytes;

Thee combination of lateral and oblique AMI radiographs for detecting anterior osteophytes;

Thee lateral radiographs for detecting anterolateral osteophytes; and

Thee oblique AMI radiographs for detecting anteromedial osteophytes in patients with

isolatedd anteromedial impingement.

Comparisonn between lateral and AMI radiographs in detecting osteophytes was evaluated

withh the McNemar test. Statistical significance was assumed for Rvalues of less than 0.05.

Results s Patientt Characteristics

Basedd on clinical examination there were 27 anterolateral, 29 anteromedial, and four combined

lesions.. Range of dorsiflexion was diminished by an average of 7° (range, 3° - 18°) compared

too the uninjured side. Eleven patients (18%) had a 1+ positive anterior drawer sign, but none

off these patients had functional symptomatic instability.

Accordingg to the radiographic osteoarthritic ankle classification, there were 33 (55%) grade

0,199 (32%) grade I, eight (13%) grade II, and no grade II I lesions.8 During arthroscopic surgery,

theree were 30 anteromedial tibia, 24 anterolateral tibial, 21 anteromedial talar, and six

anterolaterall talar osteophytes detected (total 81 osteophytes). Anterior synovitis was present

inn all ankles.

Testt Characteristics

Thee test characteristics for the lateral and AMI radiographs for detecting anterior located

osteophytess are given in Table 2. The sensitivity was greater and the specificity lower, with

Tablee 2 Test characteristics for the lateral radiograph and the combination of lateral and oblique AM I radiographs,, for detecting anterior tibial and talar osteophytes in 60 patients with anterior ankle impingement t

Radiograph h Sensitivity y Specificity y Positive e Predictive e Value e

Negative e Predictive e Value e

Tibiall osteophytes Lateral l Laterall and oblique

Talarr osteophytes Lateral l Laterall and oblique

0.40 0 0.85 5

0.32 2 0.73 3

0.70 0 0.45 5

0.82 2 0.68 8

0.73 3 0.76 6

0.50 0 0.57 7

0.37 7 0.60 0

0.67 7 0.81 1

46 6

Chapterr 4

thee combination of lateral and oblique AMI radiographs, than lateral radiographs alone.

Thee lateral radiographs were sensitive in detecting lateral tibial osteophytes in 58% of the

ankles,, with a specificity of 78% (Table 3). The sensitivity of the oblique radiographs for

detectingg anteromedial tibial and talar osteophytes was 93% and 67%, respectively (specificity

66%% and 77%) (Table 3, Fig. 2). In 37 ankles with an isolated clinical anteromedial ankle

Tablee 3 Test characteristics for the lateral radiograph for detecting anterolateral osteophytes and oblique radiographh for detecting anteromedial osteophytes

Radiograph h Location n Sensitivity y Specificity y Predictive e Value e

Positive e Predictive e Value e

Negative e

Tibiall osteophytes Lateral l Oblique e

Talarr osteophytes Lateral l Oblique e

Anterolateral l Anteromedial l

Anterolateral l Anteromedial l

0.58 8 0.93 3

0.67 7 0.67 7

0.78 8 0.66 6

0.81 1 0.77 7

0.64 4 0.74 4

0.29 9 0.61 1

0.74 4 0.91 1

0.96 6 0.81 1

Testt characteristics are given for tibial and talar osteophytes in 60 patients with anterior ankle impingement.

Fig.. 2 A 19-year-old female with post-traumatic anteromedial ankle pain. On investigation there was anteromediall swelling, tenderness to palpation, and dorsiflexion limited to 10° compared with 18° on the uninvolvedd side.

Thee standard lateral view (A) shows no abnormality. The oblique view (B) shows spurs both on the anteromediall distal tibia (upper arrow) and medial talar neck (lower arrow) as well as an ossicle (open arrow).. This medially located loose body and medially located osteophytes were successfully removed by arthroscopicc surgery.

47 7

Thee anterior ankle impingement syndrome

impingement,, the lateral radiographs were negative in 27 ankles. In this group, out of 32

anteromediall tibial osteophytes there were 22 false-negative lateral radiographs (69%),

comparedd to two false-negative AMI radiographs (6%).10

Discussion n Anteriorr tibiotalar osteophytes can result in anterior ankle pain with limited and painful

dorsiflexion.1"4,88 Standard lateral radiographs are generally used to detect the presence of

thesee osteophytes.1013 In our 60 patients, the standard lateral projection was, however, capable

off detecting only 40% of the tibial and 32% of the talar osteophytes. It has been postulated

thatt the anteromedial tibial contour and notch could influence the detection of anteromediaUy

locatedd osteophytes with the application of the standard lateral radiograph.1415 With the

combinationn of AMI radiographs, the percentage of detected tibial and talar osteophytes

increasedd to 85% and 73%, respectively, due to the high sensitivity of the AMI radiographs

forr detecting anteromedial osteophytes (specificity, 93% and 67%). In our 37 patients with

anteromediall impingement, there were 32 (86%) anteromedial bony impingement lesions.

Onn the lateral radiograph, 22 (69%) of the 32 osteophytes were missed on the standard

radiographs.. The AMI radiograph showed 30 (94%) of the 32 osteophytes. We conclude that

thee AMI radiograph is a useful adjunct to routine radiographs.

Thesee AMI radiographs have a high accuracy for detecting anteromedially located osteophytes.

Osteophytess that were located anterolaterally were detected by a lateral radiograph in 58%

off the cases. The reason that some of these lateral osteophytes were missed could be caused

byy small variations in positioning of the ankle during radiograph taking. The consequence of

missingg these osteophytes is that these patients would be diagnosed as having a soft tissue

impingementt lesion.910 This could influence the therapeutic decision making. It has been

postulatedd that in patients with an anterior ankle impingement syndrome, the cause of pain

iss the osteophytes itself, but it is the inflamed synovial tissue and/or hypertrophic scar tissue

thatt is compressed between the osteophytes in forced dorsiflexion.6 It could be argued

therefore,, that arthroscopic excision of the soft tissue impediment alone would be sufficient

too relieve the pain. Resection of the soft tissue component may, however, result in haematoma

formation,, inflammation, and formation of new scar tissue that can act as a new impediment.

Thee presence of osteophytes wil l result in a reduced anterior joint space. Compression of this

neww scar tissue impediment may be more likely to take place in such a situation. For this

reason,, it is important to remove all osteophytes, to restore the anterior joint space and to

diminishh the chance of recurrence of impingement symptoms.

Duringg the past decade, helical CT and MRI scans in patients with chronic ankle pain have

beenn increasingly used.1921 Their diagnostic value is thought to be higher than plain

radiographss and they are recommended after a non-diagnostic series of standard ankle

48 8

Chapterr 4

radiographs.166 These imaging techniques cost more and are not widely available, as well as

beingg more time consuming for the patient. The advantage of the oblique AMI radiograph in

detectingg medial osteophytes is its low cost, less complex technology, and usefulness as an

adjunctt to routine radiographs. One can speculate whether it can compete with the CT and

MRII scan regarding sensitivity, specificity, and interpretation dependency. These factors are

currentlyy being analyzed and interpreted in the same cohort of patients.

Detectionn of a bony impediment in a symptomatic patient is helpful to understand and explain

thee cause of pain for both the physician and the patient.1,9 Absence of clear radiographic

evidencee of bony abnormality makes it difficult for the physician to plan arthroscopic surgery,

sincee he has to rely only on his clinical diagnosis. Seeking confirmatory evidence of the

clinicall diagnosis by routine investigations is important for the physician.22 When arthroscopic

surgeryy is planned and performed, osteophytes can be missed, due to secondary accompanying

synoviall reflections overlying the concealed osteophytes. Detection of these osteophytes is

thereforee important.

Acknowledgement t Thee authors are indebted to Mr. H. Eskes, Department of Radiology, for instructing the

radiologyy technicians and for assistance during the radiographic procedures.

49 9

Thee anterior ankle impingement syndrome

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2.2. Ferkel RD, Scranton PE Jr.: Arthroscopy of thee ankle and foot, f Bone Joint Surg [Am] 1993;75-A:1233-42. 1993;75-A:1233-42.

3.. Ogilvie-Harri s DJ, Gilbar t MK, Chomey K: Chronicc pain following ankle sprains in athletes:: the role of arthroscopic surgery. ArthroscopyArthroscopy 1997;13:564-74.

4.. Ogilvie-Harri s DJ, Mahomed N, Demazière A:: Anterior impingement of the ankle treated byy arthroscopic removal of bony spurs. J Bone JointJoint Surg [Br] 1993;75-B:437-40.

5.. Tol JL, Slim E, van Soest AJ, van Dijk CN: Thee relationship of the kicking action in soccerr and anterior ankle impingement syndrome.. A biomechanical analysis. Am J SportsSports Med 2002;30:45-50.

6.. Tol JL, Verheven CP, van Dijk CN: Arthroscopicc treatment of anterior impingementt in the ankle. J Bone Joint Surg [Br][Br] 2001;83-B:9-13.

7.. van Dijk CN, Fiévez A.W.F.M., Heijboer M.P.,, et al.: Arthroscopy of the ankle. Acta OrthopOrthop Scand 1993;64:9(S253).

8.. van Dijk CN, Verhagen RA, Tol JL: Arthroscopyy for problems after ankle fracture. JJ Bone Joint Surg [Br] 1997;79-B:280-4.

9.9. Ferkel RD, Karzel RP, Del Pizzo W, Friedmann MJ, Fischer SP: Arthroscopic treatmentt of anterolateral impingement of the ankle.. Am JSports Med 1991;9:440-6.

10.. van Dijk CN, Tol JL, Verheven CC: A prospectivee study of prognostic factors concerningg the outcome of arthroscopic surgeryy for anterior ankle impingement. Am J SportsSports Med 1997;25:737-45.

11.. Harringto n KD: Degenerative arthritis of the anklee secondary to long-standing lateral ligamentt instability. J Bone Joint Surg [Am] 1979;61-A:354-61. 1979;61-A:354-61.

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