USC 606 Unit 5 Imaging of the Ankle and Foot PDF

Imaging of the Ankle and Foot Kimiko Yamada, PT, DPT, OCS, ATC, CLT  Objectives You will continue to use and understand common imaging terminology. You will be able to apply the evidence-based guidelines for ankle and foot imaging to make the most appropriate imaging a fo...

Imaging of the Ankle and Foot Kimiko Yamada, PT, DPT, OCS, ATC, CLT  Objectives You will continue to use and understand common imaging terminology. You will be able to apply the evidence-based guidelines for ankle and foot imaging to make the most appropriate imaging a for specific clinical conditions. You will identify normal ankle and foot anatomy on commonly clinically used diagnostic imaging. Live Session: You will review anatomy and identify basic ankle and foot pathology using the systematic reading processes for diagnostic imaging.  Ankle and Foot Imaging Guidelines for Ordering Clinical decision rules (CDRs) American College of Radiology (ACR) Appropriateness Criteria Diagnostic imaging pathways Clinical Decision Rules (CDRs) The Ottawa Ankle Rules  CDRs for the Ankle and Foot The Ottawa Ankle Rules ANKLE FOOT radiograph radiograph Foot Stiell I, et al. BMJ. 1995;311:594–597. Ankle and midfoot rules presented similar accuracies. Homogeneous and high for sensitivity and negative likelihood ratios (99.4%) Poor and heterogeneous for specificity and positive likelihood ratios (35.3%) ACR Appropriateness Criteria: Ankle and Foot (Table)  ACR Appropriateness Criteria for the Ankle and Foot Presentations researched Six variations for acute trauma to the foot Seven variations for chronic ankle pain Not covered in this unit: Six variations for chronic foot pain (2020 update) Not covered Six variations for acute trauma to the ankle (2020 update) Three variations for suspected osteomyelitis of the foot in patients with diabetes mellitus  Six Variants for Acute Trauma to the Foot ACR Appropriateness Criteria for (Revised 2019) Acute Trauma to the Foot Clinical variants of acute Usually appropriate May be appropriate trauma to the foot 1. Adult or child above five years of age; acute trauma to the foot; Ottawa rules can be evaluated without exclusionary criteria; Ottawa rules are negative; no suspected ____________ ____________ abnormalities in regions not evaluated by the Ottawa rules; initial imaging 2. Adult or child above five years of age; acute trauma to the Radiography foot foo;. Ottawa rules can be evaluated without exclusionary Radiography foot with ____________ criteria; Ottawa rules are positive; initial imaging weightbearing 3. Adult or child above five years of age; acute trauma to the foo;. Ottawa rules cannot be evaluated due to Radiography foot CT foot without IV contrast exclusionary criteria; initial imaging https://acsearch.acr.org/docs/70546/Narrative/  Six Variants for Acute Trauma to the Foot (cont.) ACR Appropriateness Criteria for (Revised 2019) Acute Trauma to the Foot Clinical variants of acute Usually appropriate May be appropriate trauma to the foot 4. Adult or child above five years of age; acute trauma to the Radiography foot CT foot without IV contrast foot; Ottawa rules can be evaluated without exclusionary Radiography foot with criteria; Ottawa rules are negative; suspected pathology weightbearing in an anatomic area not addressed by Ottawa rules (not involving the midfoot; e.g., metatarsophalangeal (MTP) joint, metatarsal, toe, tendon, etc.); initial imaging. 5. Adult or child above five years of age; acute trauma to the CT foot without IV contrast US foot foot; suspect Lisfranc injury, tendon injury, or occult MRI foot without IV contrast fracture or dislocation; radiographs are normal or equivocal; next imaging study 6. Adult or child five years of age; acute trauma to the foot; US foot CT foot without IV contrast suspect penetrating trauma with a foreign body; MRI foot without IV contrast radiographs of the foot are negative; next imaging study  T2 MRI Lisfranc injury: ligamentous or boney injury to the midfoot Greenberg ET, Queller HR. Tarsometatarsal (Lisfranc) joint injury in an athlete with persistent foot pain. Journal of Orthopaedic and Sports Physical Therapy. 2016;46(6):494. doi:10.2519/jospt.2016.0408 ACR Appropriateness Criteria for Chronic Ankle Pain Clinical variants of chronic Usually May be appropriate ankle pain appropriate 1. Chronic pain of any origin; best X-ray radiographs ankle initial study 2. Multiple sites of degenerative joint Image-guided anesthetic injection disease in the hindfoot detected by hindfoot/ankle ankle radiographs; next study MRI hindfoot/ankle without contrast CT hindfoot/ankle without contrast 3. Ankle radiographs normal; MRI ankle without contrast CT arthrography ankle suspect osteochondral MR arthrography ankle injury; next study CT ankle without contrast Bone scan with SPECT or SPECT/CT ankle 4. Ankle radiographs normal or MRI ankle without contrast US-guided anesthetic injection ankle nonspecific; suspect tendon US ankle tendon abnormality; next study https://acsearch.acr.org/docs/69422/Narrative/ Copyright © 2014 F. A. Davis Company www.fadavis.com  T2 MRI Osteochondral defect of the talus: focal areas of articular damage with cartilage damage and injury of the adjacent subchondral bone Stockton BJ, Boyles RE. Osteochondral lesion of the talus. Journal of Orthopaedic & Sports Physical Therapy. 2010;40(4):238. https://doi.org/ ACR Appropriateness Criteria for Chronic Ankle Pain (cont.) Clinical variants of chronic ankle Usually appropriate May be appropriate pain 5. Ankle radiographs normal or MRI ankle without contrast US ankle nonspecific; suspected ankle MR arthrography ankle X-ray ankle stress views instability; next study CT arthrography ankle Copyright © 2014 F. A. Davis Company www.fadavis.com  Imaging Indications: Ankle and Foot Specific Magnetic resonance arthrogram (MRA) to visualize intra-articular distension of tibiotalar joint capsule, osteochondral defects of the talus, and loose bodies MR arthrogram CT arthrogram Radiograph for ankle instability Stress radiographs https://musculoskeletalkey.com/radiology-in-foot-and-ankle/ ACR Appropriateness Criteria for Chronic Ankle Pain (cont.) Clinical variants of chronic ankle pain Usually May be appropriate appropriate 6. Ankle radiographs normal or nonspecific; MRI ankle MR arthrography ankle suspect ankle impingement syndrome; without contrast US ankle next study CT arthrography ankle MRI ankle without contrast 7. Ankle radiographs normal; pain of uncertain MRI ankle CT ankle etiology; next study without contrast Bone scan with SPECT or SPECT/CT ankle Image-guided anesthetic injection US ankle Copyright © 2014 F. A. Davis Company www.fadavis.com ACR Appropriateness Criteria: Ankle and Foot (Flow Chart)  ACR Appropriateness Criteria for the Ankle and Foot Presentations researched Six variations for acute trauma to the foot Seven variations for chronic ankle pain Not covered in this unit: Six variations for chronic foot pain (2020 update) Six variations for acute trauma to the ankle (2020 update) Three variations for suspected osteomyelitis of the foot in patients with diabetes mellitus  ACR Appropriateness Criteria https://acsearch.acr.org/docs/70546/Narrative/ Initial Acute Trauma to the Foot imaging for Ottawa foot rules Ottawa foot Suspected pathology in an Variant 4 negative. No Ottawa foot rules cannot be anatomic area not addressed adult or suspected rules evaluated due to by Ottawa rules (not involving positive. exclusionary the midfoot; eg, child > abnormalities in Radiographs criteria metatarsalphalangeal joint, regions not 5 yrs evaluated by the of foot in non- weight bearing Radiograph of metatarsal, toe, tendon, etc). the foot old Ottawa rules. and weight Radiographs of foot in non-weight No imaging bearing [Maybe: CT foot] bearing and weight bearing Variant 1 Variant 2 Variant 3 [Maybe: CT foot] Suspect Lisfranc Suspected injury, tendon injury, penetrating trauma or occult fracture or with a foreign body. dislocation. Radiographs of foot Advance Radiographs normal are negative. or equivocal. imaging CT or MRI foot US foot [Maybe: CT or MRI foot] [Maybe: US foot] Variant 5 Variant 6  ACR Appropriateness Criteria https://acsearch.acr.org/docs/70546/Narrative/ Initial Acute Trauma to the Foot imaging for Ottawa foot rules Ottawa foot Suspected pathology in an Variant 4 negative. No Ottawa foot rules cannot be anatomic area not addressed adult or suspected rules positive. evaluated due to by Ottawa rules (not involving child > abnormalities in exclusionary the midfoot; eg, Radiographs of criteria metatarsalphalangeal joint, regions not 5 yrs evaluated by the foot in non- weight bearing Radiograph of metatarsal, toe, tendon, etc). the foot old Ottawa rules. and weight [Maybe: CT foot] Radiographs of foot in non-weight bearing and weight bearing No imaging bearing Variant 1 Variant 2 Variant 3 [Maybe: CT foot] Suspect Lisfranc injury, tendon injury, Suspected penetrating or occult fracture or trauma with a foreign dislocation. body. Radiographs of Radiographs normal foot are negative. Advance or equivocal. imaging CT or MRI foot US foot [Maybe: CT or MRI foot] [Maybe: US foot] Variant 5 Variant 6  Gaping in the tarsal joint Fluid Sensitive MRI Lisfranc injury: ligamentous or boney injury to the midfoot Greenberg, E. T., Queller, H. R. (2016). Tarsometatarsal (Lisfranc) joint injury in an athlete with persistent foot pain. Journal of Orthopaedic & Sports Physical Therapy, 46(6):494. doi:10.2519/jospt.2016.0408  ACR Appropriateness Criteria https://acsearch.acr.org/docs/69422/Narrative/ Chronic ankle Initial imaging pain Ankle Radiograph Variant 1 Ankle radiographs Multiple sites of normal degenerative Advance imaging joint disease in the hindfoot on Suspect Suspect ankle Pain of ankle osteochondral Suspect tendon Suspect ankle impingement uncertain radiographs lesion abnormality instability syndrome etiology None MRI ankle MRI or US MRI ankle MRI ankle [Maybe: Image- [Maybe: CT or ankle MRI ankle or MR [Maybe: MR or [Maybe: CT guided MR arthrography CT arthrogram, [Maybe: US ankle, Bone scan anesthetic arthrography, ankle CT ankle w/o guided with SPECT or injection,MRI, or Bone scan with [Maybe: US ankle, contrast, SPECT/CT ankle, CT ankle and SPECT or anesthetic X-ray radiograph Image-guided Image-guided hindfoot] SPECT/CT injection ankle stress views, CT anesthetic anesthetic ankle, CT w/o tendon arthrography] injection, US injection, US Variant 2 contrast] sheath] ankle] ankle] Variant 3 Variant 4 Variant 5 Variant 6 Variant 7  ACR Appropriateness Criteria https://acsearch.acr.org/docs/69422/Narrative/ Chronic ankle Initial imaging pain Ankle Radiograph Variant 1 Ankle radiographs Multiple sites of normal degenerative Advance imaging joint disease in the hindfoot on Suspect Suspect ankle Pain of ankle osteochondral Suspect tendon Suspect ankle impingement uncertain radiographs lesion abnormality instability syndrome etiology None MRI ankle MRI or US MRI ankle MRI ankle [Maybe: Image- [Maybe: CT or ankle MRI ankle or MR [Maybe: MR or [Maybe: CT guided MR arthrography CT arthrogram, [Maybe: US ankle, Bone scan anesthetic arthrography, ankle CT ankle w/o guided with SPECT or injection,MRI, or Bone scan with [Maybe: US ankle, contrast, SPECT/CT ankle, CT ankle and SPECT or anesthetic X-ray radiograph Image-guided Image-guided hindfoot] SPECT/CT injection ankle stress views, CT anesthetic anesthetic ankle, CT w/o tendon arthrography] injection, US injection, US Variant 2 contrast] sheath] ankle] ankle] Variant 3 Variant 4 Variant 5 Variant 6 Variant 7