Association between joint effusions and concomitant structural injuries (tendinitis and structural injury) on MRI in ankle trauma without fracture

Abstract

Background

The evaluation of correlations among joint effusion, ligament injuries, tenosynovitis and osteochondral lesion of talus (OLT) in the ankle joint is important for developing a treatment plan and predicting prognosis.

Purpose

To evaluate correlations among tibiotalar (anterior) and talocalcaneal (posterior) joint effusion, tenosynovitis of major flexor tendons, ligaments, and OLT in a group of patients with ankle trauma.

Material and Methods

This retrospective study included 101 patients with ankle trauma who underwent magnetic resonance imaging. Two radiologists assessed the presence and amount of effusion in the tibiotalar and talocalcaneal joints from grade 0 to 2, according to the amount of capsular distension. Concomitant structural injuries were assessed in the tibialis posterior (TP), flexor digitorum longus, flexor hallucis longus, and peroneus tendons, and the anterior talofibular ligament, calcaneofibular ligament, anteroinferior tibiofibular ligament, posteroinferior tibiofibular ligament, and OLT.

Results

The proportion of anterior and posterior joint effusion according to grade was 67.3% for anterior joint effusion grade 0, 22.8% for grade 1, and 9.9% for grade 2; for posterior joint effusion, grade 0 was 74.2%, grade 1 was 22.8%, and grade 2 was 3.0%. We found statistically significant correlations between posterior joint effusion and tenosynovitis of TP (P < 0.05) and between posterior joint effusion and OLT (P < 0.05).

Conclusion

Posterior joint effusion is correlated with TP injury and OLT; however, tendon injuries have no correlation with other structural injuries of the ankle joint in a general population with ankle trauma.

Keywords

Magnetic resonance imaging ankle effusion ligament tendon

Introduction

Ankle sprains are considered to be one of the most common injuries experienced during sport, exercise, and daily activity (1). The inversion mechanism of sprain frequently causes lateral ankle ligament injuries and potentially additional associated structural damage (2 –4). As concomitant structural injuries associated with ligament sprain may impact their prognosis, such as syndesmotic injuries, or osteochondral lesion of talus (OLT), early diagnosis is crucial for the prevention of chronic instability of the ankle joint (4 –6). The presence of tibiotalar (anterior) and talocalcaneal joint (posterior) effusion in ankle sprain is associated with increased risk for severe concomitant structural injuries such as anterior talofibular ligament (ATFL) injury, syndesmotic injury, and OLT (4). However, the correlation of pathology around the ankle joint in ankle trauma and other structural injuries remains unclear. Therefore, the evaluation of correlations among joint effusion, ligament injuries, tenosynovitis, and OLT is important for developing a treatment plan and predicting prognosis.

The aim of the present study was to evaluate correlations among anterior and posterior joint effusions, tenosynovitis of major flexor tendons, ligaments, and OLT in a group of patients with ankle trauma.

Material and Methods

Selection of cases

We retrospectively evaluated 150 consecutive patients with ankle trauma who underwent magnetic resonance imaging (MRI) between April 2018 and January 2020. The institutional review board of Kangbuk Samsung Hospital approved the study and waived the requirement for consent due to the retrospective design. We excluded patients with fracture (n = 25), infection (n = 2), osteoarthritis (n = 18), or preceding operations of the ankle (n = 4). Therefore, we included 101 patients.

MRI acquisition

MRI was performed using a 3.0-T MRI scanner (Achieva; Philips, Best, The Netherlands) with an eight-channel SENSE ankle coil. The sequences and imaging parameters are summarized in Table 1.

Table 1.

MRI sequences and parameters.

Imaging parameter	Axial PD FSE	Axial FS T2 FSE	Coronal T2 FSE	Coronal FS T2 FSE	Sagittal FS T2 FSE	Sagittal T1 FSE	Sagittal FS PD FSE
TR (ms)	3000–4000	4000–6000	2000–3000	3000–4500	2000–3000	600–800	2000–3000
TE (ms)	30	70	100	70	80	20	30
Flip angle (°)	90	90	90	90	90	90	90
Matrix size (pixels)	400 × 385	455 × 280	515 × 500	515 × 400	350 × 200	330 × 215	370 × 360
Field of view (mm)	16	16	15	15	15	15	15
Slice thickness (mm)	3	3	4	4	3	3	3
Interslice gap (mm)	0.5	0.5	1	1	0.5	0.5	0.5
Bandwidth (kHz)	290	220	260	215	215	400	510
Echo train length	12	6	16	12	5	4	18
Signal average	1	1	1	1	2	2	2
Scan time (min:s)	3:05	3:40	2:30	2:40	2:25	2:30	2:30

FS, fat-saturated; FSE, fast spin-echo; MRI, magnetic resonance imaging; PD, proton density.

Image analysis

MRI findings were interpreted by two experienced musculoskeletal radiologists (fellowship-trained musculoskeletal radiologists with 18 and 10 years of experience, respectively). The two radiologists worked independently without access to previous radiologic reports. The following anatomic and pathologic structures were assessed using definitions that were developed from pre-existing literature (7).

The presence and amount of effusion in the tibiotalar and talocalcaneal joints were scored separately using sagittal fat-saturated T2-weighted (T2W) images or proton density sagittal images, from 0 to 2, according to the amount of capsular distension: grade 0 was minimal physiological amounts of intra-articular fluid or none; grade 1 was effusion with < 50% of maximum capsular distension; grade 2 was effusion with ≥50% of maximum capsular distension (Figs. 1 and 2) (4). The tendons assessed were the tibialis posterior (TP), flexor digitorum longus (FDL), flexor hallucis longus (FHL), and peroneus tendons. Tendon injury was diagnosed when intermediate or uniformly increased signal intensity within the tendons on T1-weighted (T1W) and fat-suppressed T2W images was observed (8). To avoid the magic angle phenomenon, tendons were considered intact despite high signal intensity on T1W imaging if there was an absence of abnormal signal intensity on T2W imaging and a lack of morphologic changes in the tendon (8). Enlargement or swelling of the tendon and abnormal fluid collection in the tendon sheath were also considered tendon injury. Here, abnormal fluid collection in the tendon sheath was defined as the presence of circumferential fluid within the tendon sheath with a maximal width >3 mm (8,9).

Fig. 1.

A 37-year-old man with ankle pain after a fall. (a) Sagittal proton fat-saturated imaging (TR/TE = 3000/30 ms) shows grade 2 posterior effusion (arrow). (b) Axial T2-weighted fat-saturated imaging (TR/TE = 4040/70 ms) shows a tibialis posterior tendon injury (arrow).

Fig. 2.

A 29-year-old man with ankle pain after a soccer game. (a) Sagittal proton fat-saturated imaging (TR/TE = 3000/30 ms) shows grade 1 posterior effusion (arrow). (b) Coronal T2-weighted fat-saturated imaging (TR/TE = 4252/70 ms) shows an osteochondral lesion in the medial talar dome (arrow).

Assessed ligaments were the anterior talofibular ligament (ATFL), calcaneofibular ligament (CFL), anteroinferior tibiofibular ligament (AiTFL), and posteroinferior tibiofibular ligament (PiTFL). Ligament injury was diagnosed when discontinuity, a wavy or curved contour, or increased signal intensity within the ligament were seen on T1W and fat-suppressed T2W imaging (10).

OLT was diagnosed when subchondral edema, cysts, or bony fragments were seen in the talar dome on coronal and sagittal T2W and fat-suppressed T2W images.

Statistical analysis

First, we determined the inter-observer agreement of MRI findings between the two interpreters using the kappa statistics. A κ value > 0.8 was considered to indicate almost perfect agreement, while that in the range of 0.6–0.8 was substantial, that of 0.4–0.6 was moderate, that of 0.2–0.4 was fair, that of 0.01–0.2 was slight, and that < 0.01 was poor (11). The Cochran-Armitage Trend test was performed to assess the aforementioned ankle ligament/tendinous structure injury and OLT with regard to the different grades of anterior/posterior effusion (grades 0, 1, and 2). In addition, the correlation between the aforementioned ankle ligament and tendinous structure injury and OLT was analyzed through chi-square or Fisher exact tests. Statistical analysis was performed using PASW software version 18.0 (IBM, Armonk, NY, USA). A P value ≤ 0.05 was considered statistically significant.

Results

A total of 101 ankles in 101 patients (56 boys/men [55.4%], 45 girls/women [44.6%]; mean age = 38 ± 14 years; age range = 7–67 years) were included. The mean time from injury to MRI was 5.7 ± 4.8 days (range = 1–26 days). The proportion of anterior joint effusion according to grade was 67.3% (n = 68) for grade 0, 22.8% (n = 23) for grade 1, and 9.9% (n = 10) for grade 2; for posterior joint effusion, grade 0 was 74.2% (n = 75), grade 1 was 22.8% (n = 23), and grade 2 was 3.0% (n = 3). When applying kappa statistics, inter-reader reliability ranged from 0.790 (peroneus tendon) to 1.00 (anterior and posterior effusion, TP, FDL, FHL, ATFL, CFL, AiTFL, PiTFL, OLT) (Table 2). Correlations among grades of each joint effusion and structural injury severity are presented in Table 3. We found statistically significant correlations between posterior joint effusion and TP (P < 0.05) and between posterior joint effusion and OLT (P < 0.05). No correlations were found with other pathologies. There were no correlations between tendon injuries and other structural injuries (Table 4).

Table 2.

Inter-observer agreement of each MRI finding by kappa value.

MRI finding	Anterior effusion	Posterior effusion	TP tendon injury	FDL tendon injury	FHL tendon injury	Peroneus tendon injury	ATFL injury	CFL injury	AiTFL injury	PTFL injury	OLT
Kappa value	0.979	1.000	1.000	1.000	1.000	0.79	1.000	0.958	1.000	1.000	1.000
95% CI	0.975–0.983	1.000–1.000	1.000–1.000	1.000–1.000	1.000–1.000	0.762–0.818	1.000–1.000	0.952–0.964	1.000–1.000	1.000–1.000	1.000–1.000
P value	<0.001	<0.001	<0.001	<0.001	<0.001	<0.001	<0.001	<0.001	<0.001	<0.001	<0.001

Values are given as kappa values: poor (k < 0.01), slight (0.01 ≤ k ≤ 0.2), fair (0.2 < k ≤ 0.4), moderate (0.4 < k ≤ 0.6), substantial (0.6 < k ≤ 0.8), and almost perfect (0.8 < k ≤ 1).

AiTFL, anterointerior talofibular ligament; ATFL, anterior talofibular ligament; CFL, calcaneofibular ligament; FDL, flexor digitorum longus; FHL, flexor halluces longus; OLT, osteochondral lesion of talus; PTFL, posterior tibiofibular ligament; TP, tibialis posterior;

Table 3.

Correlation of joint effusion and ankle structural injury pathology (P values).

Joint effusion	Observer	TP	FDL	FHL	PT	ATFL	CFL	AiTFL	PiTFL	OLT
Anterior effusion	Reader 1	0.098	0.367	0.755	0.596	0.291	0.125	0.197	–	0.649
Anterior effusion	Reader 2	0.088	0.377	0.987	0.761	0.223	0.189	0.207	–	0.605
Posterior effusion	Reader 1	0.003	0.421	0.616	0.866	0.568	0.196	0.416	–	0.031
Posterior effusion	Reader 2	0.003	0.421	0.616	0.539	0.568	0.730	0.416	–	0.031

AiTFL, anteroinferior tibiofibular ligament; ATFL, anterior talofibular ligament; CFL, calcaneofibular ligament; FDL, flexor digitorum longus; FHL, flexor hallucis longus; OLT, osteochondral lesion of talus; PiTFL, posteroinferior tibiofibular ligament; PT, peroneus tendon; TP, tibialis posterior. The values in bold mean statistically significant.

Table 4.

Correlation of tendon injury and concomitant structural injuries (P values).

Tendon injury	Observer	ATFL	CFL	AiTFL	PiTFL	OLT
TP	Reader 1	1.000	0.736	1.000	–	0.611
TP	Reader 2	1.000	0.476	1.000	–	0.611
FDL	Reader 1	1.000	1.000	1.000	–	1.000
FDL	Reader 2	1.000	1.000	1.000	–	1.000
FHL	Reader 1	0.556	0.310	0.535	–	0.253
FHL	Reader 2	0.556	0.166	0.535	–	0.253
PT	Reader 1	0.621	1.000	0.154	–	1.000
PT	Reader 2	0.211	0.673	0.224	–	0.590

Discussion

Assessment of injury severity in acute ankle sprain is crucial for treatment planning and rehabilitation of athletes and may help in determining recovery times after injury (12,13). Accurate assessment of structural injury severity after acute ankle sprain using only clinical examination is limited, especially when testing syndesmosis, for which clinical tests demonstrated low sensitivity for the detection of injuries. Furthermore, it was demonstrated that clinical examination in the acute phase of first-time lateral ankle sprain shows limited predictive value for the development of chronic ankle instability (4,14). The occurrence of OLT associated with ankle sprain may also impact treatment decision and prognosis, the presence and severity of such involvement being extremely difficult to assess through clinical examination only (15). MRI is the imaging modality that best evaluates the structure of ankle joints. Previously, studies on the relationship between ankle joint effusion amount and ankle structural injury in acute ankle sprain showed a significant correlation between joint effusion degree, ligament injury, and osteochondral involvement (4). Crema et al. (4) reported that both anterior and posterior joint effusion are associated with an increased risk of ATFL and AiTFL injury. However, in the present study we found statistically significant correlations between posterior joint effusion and TP injury (P = 0.003) (Table 3 and Fig. 1). The origins behind such a difference in results remain unclear. One hypothesis is that the population of our study varies from Crema et al. Their participants were professional athletes who were registered with a national organization. Our study was conducted on the general population with ankle trauma. In a group of athletes, trauma can be produced with more energy, and there are often severe ankle effusions and structural injuries. The exact correlation between TP injury and posterior joint effusion is not clear. One possible theory is that TP injury is closely related to sinus tarsi abnormalities (16). Sinus tarsi is connected to the talocalcaneal joint, so posterior joint effusion can occur in the case of sinus tarsi abnormalities.

They also suggested a correlation between joint (anterior and posterior) effusion and OLT, while we found statistically significant correlations between posterior effusion and OLT (P = 0.031) (Table 3 and Fig. 2). These results were the same for both readers. This is thought to be due to the difference in study population, similar to that discussed above. As a result, our study group had a fairly different frequency of positive joint effusion and a different incidence of high-grade joint effusion compared to previous studies.

The present study has some limitations. First, this was a single-center retrospective study. Second, systematic longitudinal clinical follow-up was not available, and for that reason, the relevance of the MRI findings with regard to prognosis, including recovery time, could not be investigated.

In conclusion, posterior joint effusion is correlated with TP injury and OLT; however, tendon injuries are not correlated with other structural injuries of the ankle joint in a general population with ankle trauma. Therefore, if posterior joint effusion is present in a patient with ankle trauma on ultrasound or MRI, TP injury and OLT should be considered.

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iDs

Hee Jin Park

Myung Sub Kim

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