Adult with acute ankle and foot injury but negative findings on the Ottawa ankle and foot rules (OAR)
Consider radiographs only of patients excluded from the OAR:
- Multiple injuries
- Isolated skin injury
- 10 days since injury
- Obvious deformity of ankle or foot
- Altered sensorium: cognitive or sensory impairment (neurologic deficit), head trauma, intoxicated
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Radiographs not routinely indicated [B] |
Adult with acute ankle and foot injury and positive findings on the Ottawa ankle and foot rules (OAR)
- Ankle (positive OAR)
Radiographs required only if there is pain in the malleolar zone and any of these findings:
- Bone tenderness of distal fibula along posterior edge or tip of lateral malleolus (distal 6 cm)
- Bone tenderness of distal tibia along posterior edge or tip of medial malleolus (distal 6 cm)
- Inability to bear weight both immediately and in clinic
Also consider taking ankle radiographs in:
- Older patients with malleolar tenderness and pronounced soft tissue edema
- Presence of positive OAR foot findings
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Ankle radiographs indicated [B] AP ankle, 20° medial oblique (mortise views) and lateral (include base of fifth metatarsal)
Additional views [D]: Stress radiographs after fibular fracture helpful pre-operatively to determine deltoid ligament status in orthopedic setting.
Special investigations [D]
- MRI or CT appropriate in presence of significant pain and disability and negative radiographs
- Fluoroscopic stress examination under anesthesia to assess ankle instability
- NM for persisting symptoms to exclude stress fracture
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- Foot (positive OAR)
Radiograph required only if there is pain in the midfoot zone and any of these findings:
- Bone tenderness of base of fifth metatarsal
- Bone tenderness of navicular bone
- Unable to bear weight both immediately and in clinic
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Foot radiographs indicated [B]
When feasible, weight-bearing foot AP, lateral, medial oblique views
Comparison views (normal foot) may be helpful.
Additional view: Tangential view of calcaneus for heel trauma cases
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Adult with acute toe injury
Consider obtaining foot radiographs in presence of significant metatarsal pain (see OAR-Foot)
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Radiographs indicated (GPP): AP, oblique, and lateral views limited to the toes |
Adult with chronic ankle and tarsal pain
Specific indications for radiographs include:
- Suspected osteochondral lesion/stress fracture
- Suspected tendinopathy with possible inflammatory arthritis
- Possible ankle instability. Single-leg jump test as clinical indicator of functional instability
- Noninvestigated chronic ankle and tarsal pain
- Multiple sites of degenerative joint disease as visualized on radiographs
- Possible operative candidate
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Radiographs indicated [D]
AP ankle, lateral, medial oblique (mortise) views
(Medial oblique view helps evaluate the talocalcaneal relationship and lateral malleolus.)
Additional view: Stress radiographs may be considered, but little agreement exists as to which technique.
Special investigations [D]
MRI is the gold standard for musculoskeletal assessment if radiography is positive or if unrelieved by 4 weeks of conservative care.
- Contrast-enhanced, fat-suppressed, 3D, fast-gradient MRI may be useful in diagnosing synovitis and soft tissue impingement.
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Specific Clinical Diagnoses |
1. Impingement syndromes
Findings most strongly associated with abnormality at arthroscopy:
- Anterolateral tenderness
- Swelling
- Pain on single-leg squatting
- Pain on ankle dorsiflexion and eversion
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Radiographs indicated [D]
AP ankle, lateral and mortise views
Special investigations [D]
For all suspected impingement syndromes with positive radiographs or unrelieved by 4 weeks of conservative care:
- Contrast-enhanced, fat-suppressed, 3D, fast-gradient MRI may be indicated depending on pain severity and disability.
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- Anterolateral impingement
Clinical features:
- Mechanism: inversion injury
- Pain and localized tenderness in region of anteroinferior tibiofibular and/or anterior talofibular ligament
- Positive impingement sign
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Radiographs indicated [D]
AP, lateral, and mortise ankle views
Additional view: [D]
Stress radiographs may be considered.
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- Anterior impingement
Clinical features:
- Mechanism: supination or repeated dorsiflexion injury
- Anterior pain
- Painful and restricted dorsiflexion
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Radiographs indicated [D]
AP, lateral, and mortise ankle views
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- Anteromedial impingement
Clinical features:
- Mechanism: inversion injury or ankle/talar fracture
- Anteromedial pain and tenderness
- Swelling
- Pain and restriction on dorsiflexion and supination
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Radiographs indicated [D]
AP, lateral, and mortise ankle views
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- Posterior impingement
Clinical features:
- Mechanism: impingement of os trigonum between talus and posterior tibia
- Common in ballet dancers
- Pain elicited with full weight-bearing in maximum plantar flexion, especially when os trigonum is present
- Tenderness behind lateral malleolus
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Radiographs indicated [D]
AP, lateral, and mortise ankle views
Special investigations [D]
MRI for os trigonum syndrome
- Pain with passive plantar flexion
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2. Peroneal tendinosis
Clinical features:
- Lateral hindfoot pain
- Cavovalgus foot deformity
- Frequently affected in RA
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Radiographs not routinely indicated [D]
Unless unrelieved by 4 wk of conservative care or patient has a suspected inflammatory arthritis
Special investigations [D]
- MRI or US if there are signs of popping or clicking with foot eversion
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3. Lateral premalleolar bursitis
Clinical features:
- Adventitious bursa develops in people sitting with inverted and plantar flexed feet
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Radiographs not routinely indicated [GPP]
Special investigations [GPP]
US if unrelieved by 4 weeks of conservative care
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4. Tarsal tunnel syndrome
Clinical features:
- Tingling pain and burning over the sole of the foot after prolonged standing or walking
- Worse at night in some
- Positive Tinel sign
- Positive nerve compression test
- 2-Point discrimination
- Hypoesthesia on sole of foot
- Rare weakness of toe flexion
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Radiographs not routinely indicated [D]
Special investigations [D]
- US or MRI for nerve and other soft tissue visualization
- CT for bony abnormalities
- Sensory conduction velocity and distal motor latency useful for diagnosis and treatment progression
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Adult with chronic foot pain |
Radiographs generally indicated [C]
Non–weight-bearing AP, lateral, medial, and lateral oblique views
Additional views:
- Lateral views for toes
- Axial and lateromedial tangential views for sesamoid bones
Special investigations [D]
- NM, MRI, US, arthrography may be useful
- Laboratory investigations (blood and synovial fluid) recommended
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A. Hindfoot-Heel pain |
Radiographs indicated [D]
AP, lateral, and medial oblique views of the foot
Additional views:
Tangential view of the calcaneus and lateral calcaneus view
Special investigations [D]
- MRI if unrelieved by 4 weeks of conservative care or before referral for medical care or to podiatrist
- Achilles enthesopathy: power Doppler sonography may show neovascularization, which may be the cause of pain
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Specific Clinical Diagnoses |
A1. Plantar fasciitis (PF) and calcaneal enthesosphyte (spur)
Clinical features:
- PF is one of the most common soft tissue foot disorders
- Hyperesthesia over the plantar fascia
- Risk factors:
- Decreased ankle dorsiflexion (≤0°)
- Being on their feet most of working day
- Obesity (body mass index >30 kg/m2)
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Radiographs not routinely indicated except in young athlete [B]
AP, lateral, and oblique views
Special investigations [D]
- US may be initial step for advanced imaging (readily available, highly sensitive, low-cost, and radiation-free).
- Doppler/power US improves US value
- US, MRI, and bone scan are more sensitive in showing inflammatory changes and thickening of the plantar aponeurosis in PF
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A2. Sinus tarsi syndrome
Clinical features:
- Mechanism: inversion injury or inflammatory joint diseases
- Lateral foot pain
- Perceived foot instability
- Tenderness of the sinus tarsi
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Radiographs not initially indicated [D]
Special investigations [D]
MRI if unrelieved by 4 weeks of conservative care: may be helpful for detecting subtle unilateral deformities
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B. Midfoot pain (nontraumatic)
Midfoot pain usually self-limiting.
Differential diagnosis:
- RA
- Psoriatic arthritis
- Reactive arthritis (Reiter disease)
- Diabetic neuroarthropathy/Charcot joints
- Gout
- Diabetic infection
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Radiographs indicated if unrelieved by 4 weeks of conservative care or in suspected inflammatory arthritis [D] AP, medial oblique, and lateral views of the foot
Additional views: Weight-bearing ankle series may be useful
Special investigations if radiography is positive or if unrelieved by 4 weeks of conservative care [GPP]
CT or MRI warranted in suspected or proven disease, but negative/equivocal radiographs
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Specific Clinical Diagnoses |
B1. Acquired flat foot with posterior tibial tendon dysfunction/rupture
Clinical features:
- Medial ankle/foot pain initially
- May lead to disabling weight bearing symptoms
- Talonavicular subluxation
- Difficulty or inability to perform single-limb heel rise
- Weak resisted inversion of fully flexed foot
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Radiographs indicated if unrelieved by 4 weeks of conservative care or in suspected inflammatory arthritis [D]
AP, medial oblique, and lateral foot radiographs
Additional views: Weight-bearing ankle series may be useful
Special investigations [D]
- MRI better at differential diagnosis of medial ankle/foot pain
- US may be useful
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B2. Navicular tuberosity pain and tenderness (Auleley et al, 1998)
Potential painful normal variants such as accessory navicular bone (4%-21% of the population) have been described.
Painful fibro-osseous junction of the accessory bone
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Radiographs indicated if unrelieved by 4 weeks of conservative care [C]
AP, medial oblique, and lateral foot views
Special investigations [GPP]
- MRI to differentiate accessory navicular from an avulsion fracture
- NM may be useful to help identify or confirm site of pain
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B3. Complex regional pain syndrome
Synonyms:
- Reflex sympathetic dystrophy
- Sudek's atrophy
Clinical features:
- Pain
- Tenderness
- Swelling
- Diminished motor function
- Vasomotor and sudomotor instability
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Radiographs indicated [D]
AP, lateral, and medial oblique views of the foot
Special investigations [D]
- MRI is useful in detecting numerous soft tissue and earlier bone and joint processes that are not depicted or as well characterized with other imaging modalities
- 3-Phase NM scan recommended if radiograph is not diagnostic
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C. Forefoot pain
See recommendations for the following specific clinical diagnoses:
C1. Metatarsal bursitis
C2. Morton neuroma
C3. Stress fracture
C4. Avascular necrosis (osteonecrosis)
C5. Hallux rigidus and hallux valgus
C6. Sesamoiditis
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Radiographs not routinely indicated unless unresponsive to 4 weeks of conservative care or if inflammatory or infectious etiology suspected [B]
AP and lateral foot views
Special investigations [D]
MRI useful in differential diagnosis of forefoot pain such as stress fracture, metatarsophalangeal synovitis, and intermetatarsal bursitis
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C1. Metatarsal bursitis |
Radiographs not routinely indicated unless unresponsive to 4 weeks of conservative care, or if inflammatory or infectious etiology suspected [GPP]
AP and lateral foot views
Special investigations [GPP]
MRI useful in differential diagnosis of forefoot pain
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C2. Morton neuroma
Clinical features:
- Most commonly found in the 3-4 web space
- Pain hyperesthesia or paresthesia radiation to the toes
- Differential diagnosis from metatarsophalangeal joint (MTP) arthritis may be difficult
- Positive forefoot neuroma squeeze test
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Radiographs indicated [C]
AP, lateral, with or without oblique
Special investigations [D]
MRI
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C3. Stress (fatigue or insufficiency) fracture
Clinical features:
Pain and tenderness present in the:
- Second and third metatarsal
- Calcaneus
- First metatarsal
- Medial sesamoid
- Navicular
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Radiographs indicated [D]
AP and lateral foot views with or without medial oblique specific to the area of complaint
Special investigations [C]
- High-field MRI with fat suppression or inversion recovery protocol. As sensitive as NM
- CT still uncertain; some centers use US
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C4. Osteonecrosis of metatarsal head (Freiberg infraction)
Clinical features:
- Adolescent patient
- Pain
- Tenderness
- Swelling
- Limitation of movement at metatarsal head
- Second or third head most commonly affected
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Radiographs indicated [C]
AP, lateral, with or without medial oblique of the foot
Special investigations [C]
- MRI modality of choice to evaluate bone marrow changes in early stages
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C5. Hallux rigidus and hallux valgus (first metatarsophalangeal [MTP] joint) |
Radiographs not routinely indicated unless unresponsive to 4 weeks of conservative care [D]
Lateral view most useful for dorsal osteophyte on the metatarsal head and possible osseous fragments
Additional view: Weight-bearing series to quantify degree of valgus deformity
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C6. Sesamoiditis
Painful inflammatory condition caused by repetitive injury; reactive tendinitis, synovitis, or bursitis common
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Radiographs not routinely indicated unless unresponsive to 4 weeks of conservative care [D]
Additional view: Lateromedial tangential views for sesamoid bones
Special investigations [GPP]
- MRI to differentiate from turf toe
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