Tag Archives: tenosynovitis

Retained foreign body in the foot presenting as tenosynovitis of the flexor digitorum longus tendon

by Muhammad Haseeb¹, Muhammad Farooq Butt², Khurshid Ahmad Bhat³

The Foot and Ankle Online Journal 10 (1): 2

Tenosynovitis of the foot and ankle is an uncommon condition, and may stem from several causes resulting in foot/ankle pain. Additionally, infectious tenosynovitis resulting from retained foreign bodies distant from the tendon is rarely reported. In this paper we report a case of a young male presenting with a short history of swelling and pain of the ankle. Clinical examination suggested tenosynovitis of the flexor digitorum longus tendon. There were no systemic symptoms and blood parameters within normal limits. Non-response to conservative treatment prompted imaging of the foot which revealed a foreign body, which had been lying there for many years and forgotten about by the patient. The patient underwent removal of foreign body and made a complete recovery. Foreign bodies can be difficult to diagnose and should be considered in the differential diagnosis of unexplained pain, even in the absence of recalled trauma. Puncture wounds of the foot through rubber soled sandals or shoes have been described to leave behind pieces of the sole material as foreign bodies. Ultrasonography is particularly helpful in confirming such diagnoses.

Keywords Foreign body, tenosynovitis, ultrasonography, sole

ISSN 1941-6806
doi: 10.3827/faoj.2017.1001.0002

1 – Registrar, Department of Orthopaedics Government Medical College, Jammu, India
2 – Lecturer, Department of Orthopaedics Government Medical College, Jammu, India
3 – Registrar, Department of Orthopaedics Government Medical College, Jammu, India
* – Corresponding author: quicksilver.hsb@gmail.com


oot and ankle pain is one of the common complaints with which patients present in an orthopaedic clinic. Non-traumatic foot and ankle pain stems from a wide variety of causes which need to be excluded by detailed history and clinical examination to arrive at a correct diagnosis and institute effective treatment. Tenosynovitis is a relatively uncommon entity causing foot and ankle pain and most cases have a specific etiology for the condition. We present the case of a young patient who had tenosynovitis of the flexor digitorum longus that remained unresponsive to treatment for a long time because the etiology could not be established.

Case Report

A 20-year-old male presented in the clinic in January 2016 with a history of pain and swelling just proximal to the medial aspect of the right ankle of one month duration. Examination revealed a soft to fluctuant swelling behind the medial malleolus merging imperceptibly with the soft tissue of the calf above and the foot below. The swelling was tender with some mobility in a side to side direction. The pain increased with movement of the toes. There was no history of fever, joint pains or stiffness, trauma to the ankle, or any significant drug history.  A clinical diagnosis of tenosynovitis was made and the patient was prescribed anti-inflammatory medication and cold compresses. Blood parameters were ordered at the same time.  The total leukocyte count was  8500/mm3. ESR was 12mm and CRP was low positive. Serology for rheumatoid arthritis was negative.  Symptomatic treatment and physical therapy was continued but the patient did not improve. Over a period of one month the symptoms worsened. Plain radiographs were normal. An MRI was ordered and a local steroid injection of the tendon sheath was planned. MRI showed tenosynovitis of the flexor digitorum longus (FDL) tendon with collection in the tendon sheath at the ankle. At the time of steroid injection, initial aspiration yielded pus. Injection was abandoned, and the pus was sent for culture and sensitivities. Possible causes of pyogenic tenosynovitis were sought. The patient was asked again about any penetrating injuries in the region. He recalled a penetrating wound in the sole (from a nail) that he had suffered 4 years back, which had healed uneventfully. Present examination of the sole was normal. An ultrasonography of the foot and ankle was ordered. Ultrasound revealed an echogenic foreign body in the midsole at a depth of about 1 cm from the skin surface, and about 3 mm in each dimension (Figure 1). Fluid collection was also found behind the medial malleolus, extending into the subcutaneous tissue.

Figure 1 Ultrasonographic image showing the foreign body.

Surgery was planned and two incisions were made. The incision in the sole at the site marked by the sonologist   revealed a red rubber foreign body, about 3 mm by 2 mm inside a loculus of pus (Figure 2). Another incision made behind the medial malleolus was used to drain the pus in the FDL tendon sheath and the surrounding tissue. The foreign body was a piece from the slipper sole that the nail had pushed inside. At that time, treatment with antibiotics and analgesics had probably resulted in healing of the wound, and the foreign body had become walled off. Now infection had reactivated and pus had travelled up along the sheath of the FDL, presenting as swelling at the ankle. Following incision and drainage, and administration of culture specific antibiotics, the wounds healed uneventfully and the patient had complete resolution of symptoms. He was asymptomatic at the time of last follow up, at eight months after surgery (Figure 3).

Figure 2 Note the red piece of rubber found on exploration of the plantar foot.

Figure 3 Complete healing of both wounds at eight month follow-up.


An Australian study concluded that almost 1 in 5 people in the community suffer from foot and ankle pain of nontraumatic origin [1].  Cases of nontraumatic foot and ankle pain are relatively frequent in our practice as well. Effective treatment of these cases depends on establishment of a diagnosis by accurate history and clinical examination, along with investigations and imaging. Among the common causes of such presentations are tendinitis, tendon rupture, bone spurs, bursitis, flatfeet, infections, rheumatoid arthritis and gout [2].

Our patient was a young and healthy male, with a relatively short duration of symptoms. In the absence of any fever or systemic signs, infection was not high up among our differential diagnoses. We ruled out inflammatory arthritis with clinical findings, serology and blood parameters. Some drugs like fluoroquinolones have been reported to cause tenosynovitis [3], but our patient had no significant drug history.

Foreign bodies can be difficult to diagnose and should be considered in the differential diagnosis of unexplained pain, even in the absence of recalled trauma[4]. If there is no recent history of trauma (skin puncture), and if the foreign body is radiolucent, the diagnosis is often difficult with plain radiographs [5,6]. Such foreign bodies can present later with a myriad of manifestations like local abscess, persistent pain, periostitis, osteomyelitis, bursitis, monoarthritis, synovitis, lytic lesions and even appear as neoplasms [4,6-9]. Even though MRI is very informative about soft tissue conditions of the foot, ultrasonography has now become the investigation of choice in diagnosing and locating retained foreign bodies in the extremities when they are radiolucent [10,11,12]. Harris [5] reported the misinterpretation of MRI, and final diagnosis with the help of ultrasonography, as in our case.

Puncture wounds of the foot through rubber soled sandals or shoes have been described to leave behind pieces of the sole material as foreign bodies [13,14]. A high index of suspicion is required when the patient presents late after the initial injury and does not volunteer information about the puncture wound. This is especially important in a case like ours where the area of presentation (distal leg) was away from the region of the puncture (plantar foot).

To conclude, even in the absence of a recent history of penetrating trauma, the possibility of a foreign body must be considered and investigated. Our case is unique because of the long duration between the injury and the presentation, and also the peculiar presentation of tenosynovitis above the ankle when the offending agent was present in the plantar foot. We further affirm that ultrasonography can be alternate imaging technique after plain radiography for all patients with suspected foreign bodies.


  1. Hill CL, Gill TK, Menz HB, Taylor AW. Prevalence and correlates of foot pain in a population-based study: the North West Adelaide health study. J Foot Ankle Res. 2008; 1: 2.
  2. Foot pain. Causes. Mayo Clinic Staff. Available at: http://www.mayoclinic.org/symptoms/foot-pain/basics/causes/sym-20050792. Accessed September 16, 2016.
  3. Kayabas U, Yetkin F, Firat AK, Ozcan H, Bayindir Y. Ciprofloxacin-induced urticaria and tenosynovitis: a case report. Chemotherapy. 2008;54(4):288-90.
  4. Jones MD, Sweet KJ, Hoffer ZS. Retained viable plant material in the calcaneus: a case report of a 22-year-old soldier with atypical heel pain. J Am Podiatr Med Assoc. 2015 Jan-Feb;105(1):92-5.
  5. Harris EJ Retained Hawthorn fragment in a child’s foot complicated by infection: diagnosis and excision aided by localization with ultrasound. J Foot Ankle Surg. 2010 Mar-Apr;49(2):161-5.
  6. I. El Bouchti, F. Ait Essi, I. Abkari, M. Latifi, and S. El Hassani, “Foreign Body Granuloma: A Diagnosis Not to Forget,” Case Reports in Orthopedics, vol. 2012, Article ID 439836, 2 pages, 2012.
  7. Suresh SS. Orthopaedic Manifestations of Date Thorn Injury: Case series. Sultan Qaboos Univ Med J. 2008 Nov;8(3):347-52.
  8. Suresh SS. Periostitis of the metatarsal caused by a date palm thorn in a child: a case report. J Foot Ankle Surg. 2011 Mar-Apr;50(2):227-9.
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  14. Chang HC, Verhoeven W, Chay WM. Rubber foreign bodies in puncture wounds of the foot in patients wearing rubber-soled shoes. Foot Ankle Int. 2001 May;22(5):409-14.

Tuberculous Tenosynovitis of Ankle with Rice Bodies

By K P Raju, Dr J Mohan Kumar, Dr Roshan Shettypdflrg

The Foot and Ankle Online Journal 6 (10): 1

Tuberculosis (TB) is still endemic in many developed countries. Involvement of the ankle at presentation is extremely rare, and the diagnosis is often missed. Tuberculosis can involve pulmonary as well as extrapulmonary sites. The musculoskeletal system is involved in 1–3% of patients with TB. Although musculoskeletal TB has become uncommon in the Western world, it remains a huge problem in India . Isolated soft tissue TB is extremely rare. Early diagnosis and prompt treatment are mandatory to prevent serious destruction of joints. Due to the nonspecific and often indolent clinical presentation, the diagnosis may be delayed. Radiological assessment is often the first step in the diagnostic workup of patients with musculoskeletal TB and further investigations are decided by the findings on radiography. Both the radiologist and the clinician should be aware of the possibility of this diagnosis. The authors encountered a rare case of tubercular tenosynovitis of ankle with rice bodies.

Key words: Tuberculosis, tenosynovitis, ankle, rice bodies, fibrin.

Accepted: September, 2013
Published: October, 2013

ISSN 1941-6806
doi: 10.3827/faoj.2013.0610.001

Address correspondence to: Dr K P Raju, Dr J Mohan Kumar, Dr Roshan Shetty, BGS Global Hospital & BGS GIMS, Bengaluru,India.
Email: drjmohankumar@yahoo.co.in

Tuberculous tenosynovitis was first described by Acrel in 1777. Particles are named “rice body”, due to their resemblance to shiny rice grains, was first described by Reise in1895.[1] Rice body formation may occur with a systemic inflammatory disease or alone in localized form. While it is mostly seen in patients with rheumatoid arthritis,[2] it may also be accompanied by juvenile rheumatoid arthritis,[3,4] tuberculous arthritis, tuberculous tenosynovitis and tuberculous bursitis,[5] atypical mycobacterial tenosynovitis,[7,8] osteoarthritis,[9] in addition to nonspecific arthritis, tenosynovitis, and bursitis.[10]

Rice body formation may occur in intra-articular structures, at tendon insertions and synovial structures like periarticular bursa of the shoulder, knee, wrist and ankles, which are the most common sites of involvement.[2,5] Both primary tuberculous bursitis and tenosynovitis are rare conditions.[6] Diagnosis with classical radiography is challenging. Arthrography, bursography, ultrasonography (USG) and magnetic resonance imaging (MRI) are useful techniques in preoperative diagnosis. The histological structure usually comprises an amorphous core of necrotic cells in the center, surrounded by a layer of fibrin and collagen.[11]

ricebodies1a ricebodies1b

Figure 1A and 1B T1-weighted sagittal image showing hypointense mass with slightly hyperintense septaes. (A) T2-weighted image showing hyperintense liquid with nodular, diffuse hypointense structures lined in a thick capsular mass.(B)

We present a case of rice body formation in tubercular tenosynovitis of ankle, without any systemic disease.

Case report

A 25-year-old woman presented with a mass in her right ankle, which had been present for 2 years. She experienced a mild pain during long walks and going up and down the stairs. She had no history of trauma, tuberculosis or systemic inflammatory disease. On physical examination there was an immobile soft tissue mass of 7×3×2 cm in her right ankle. The mass was tender on palpation and there was no redness or increase in warmth of the skin. There was no limitation in the motion of the ankle joint despite the pain. The laboratory tests were within normal limits and chest radiograph did not reveal any abnormality. Ankle radiograph showed a soft tissue shadow. On MRI images there was a lobulated mass with peripheral contrast enhancement around the lateral aspect of ankle. The mass had neat contours, consisted of numerous, small nodular regions and had no connection with the tibiotalar joint. There was no effusion or a space occupying lesion within the joint. T1-weighted sagittal image showed a hypointense mass with slightly hyperintense septaes, and T2-weighted image a hyperintense liquid with nodular, diffuse hypointense structures with a thick capsule. (Fig. 1A and 1B)

Surgical treatment was advised for chronic, nonspecific bursitis. Numerous, shiny and grainy particles were removed following the incision of the tenosynovium around the peroneal tendon. (Fig. 2A and 2B)

Pathological examination of the excised particles revealed synovial necrosis and fibrin deposition in the center, surrounded by scores of granulomatous structures with giant cells, in addition to apparent inflammatory infiltration of lymphocytes, plasma cells and macrophages. (Fig 3A and 3B)

ricebodies2a ricebodies2b

Figure 2A and 2B Surgical exploration reveals a large, nodular mass along the course of the peroneal tendon. (A) Inside the mass were numerous, grainy particles or rice bodies rich in fibrin and collagen. (B)

The case was diagnosed as rice body formation secondary to tubercular tenosynovitis of peroneal tendon, based on the MRI findings, intraoperative appearance, and histopathological report. Antituberculous treatment was started as soon as the identification of M. tuberculosis was confirmed. After one year of treatment the patient had full range of motion without pain. Recurrence was not observed during the two year follow-up period.

ricebodies3a ricebodies3b

Figure 3A and 3B Microscopic evaluation reveal synovial necrosis and fibrin deposition (center) surrounded by scores of granulomatous structures with giant cells, in addition to apparent inflammatory infiltration of lymphocytes, plasma cells and macrophages. (A) Numerous rice bodies isolated from the mass. (B)


Rice bodies are free particles that have a cartilage-like shiny appearance, can reach high numbers, and are of synovial origin.[12] There is no consensus on the etiology. The condition is believed to develop as a nonspecific response to synovial inflammation.[3] Synovial ischemia and necrosis due to hypoxia, caused by the disruption of microcirculation, are thought to be the triggering factors. Rice bodies are formed by the necrotized particles which break away from the synovium and adhere to the fibrin in the joint space, tendon sheath or inside the bursa. After phagocytosis by the macrophages they are denatured in phagolysosomes and by acting like collagen antigens they lead to an auto-immune response.[11] Another hypothesis suggests that collagen, newly synthesized by synovial cells, can lead to formation of rice bodies. It should be, however, kept in mind that the condition might be misinterpreted as synovial chondromatosis. In the literature, it is emphasized that pathological misdiagnosis is possible and there is no evidence of cartilage tissue presence in rice bodies. Histopathological examination of our case, likewise, presented no sign of cartilage tissue in the bodies.

Some authors have advocated that the emergence of rice bodies is due to a new formation caused by the progressive growth of fibronectin and fibrin aggregates in the synovial fluid, independent from the synovial elements.[11,13] While 47% of the synovial protein is composed of collagen in rheumatic diseases, in rice body proteins this percentage is only 10%. Rice bodies are richer in fibrin.

However, Popert, et al., have shown the particles are not homogenous.[13] While some rice bodies are mostly formed of fibrin, some are composed of synovial membrane. Some others are formed of synovial core surrounded by fibrin.[11,12] Muirhead et al., in their ultrastructural study, reported that rice bodies can be of multiple origins based on their localizations.[10]

In our study, pathological examination of the excised bodies presented a structure with synovial necrosis and fibrin deposition in the center.

Chen et al., [14] in their case study, discussed the probability of correct preoperative diagnosis and emphasized the importance of T2-weighted MRI.They reported that rice bodies were seen in the hyperintense bursal fluid as numerous hypointense areas. This view is slightly hyperintense compared to skeletal muscle.[14] Likewise, in our case, preoperative T2-weighted MRI images with sagittal sections showed hyperintense synovial fluid with nodular and diffuse hypointense structures that had a thick capsule, surrounding the peroneal tendon. In addition, two entities stand out in differential diagnosis: pigmented villonodular synovitis and synovial osteochondromatosis. Rice bodies differ from villonodular synovitis with the absence of hemosiderin deposits, and from osteochondromatosis with the absence of radiographic evidence of ossification in the soft tissues. Synovial chondromatosis was a differential diagnosis in this case. This rarely involves a synovium lined bursa[15] and has an unmineralised metaplastic cartilage.[16] In unossified synovial chondromatosis, MRI will be helpful in the differential diagnosis. As rice bodies are rich of fibrous structures, they appear darker (hypointense) in T2-weighted images, close to the intensity of muscles. In contrast, synovial chondromatoses are rich in cartilage and appear more hyperintense, compared to rice bodies.[3,17]

Looking at the MR images of our case and other patients, we believe the T2-weighted images can be an important criterion in diagnosis and differential diagnosis. Although symptomatic improvements with long-acting steroids, aspiration and lavage have been reported, basic approach in the treatment is surgical excision.[13,18] No recurrence was observed in the follow-up period of two years, following the excision of rice bodies in our case. It should be kept in mind that rice bodies can be seen in an extra-articular localization and with no association with a systemic inflammatory disease. Clinical examination and MRI are of great importance in diagnosis and surgical excision will provide a safe and definitive treatment.


1. Reise H. Die Reiskorpschen in tuberculserkrankensynovalsacken. Deutsche Zeitschrift für Chirurgie, vol. 42, p. 1, 1895 (German).
2. Kataria RK, Chaiamnuay S, Jacobson LD, Brent LH. Subacromial bursitis with rice bodies, as the presenting manifestationof rheumatoid arthritis. J Rheumatol 2003 30: 1354-1355. [PubMed]
3. Chung C, Coley BD, Martin LC. Rice bodies in juvenile rheumatoid arthritis. AJR Am J Roentgenol 1998 170:698-700.[PubMed]
4. Cuomo A, Pirpiris M, Otsuka NY. Case report: biceps tenosynovial rice bodies. J Pediatr Orthop B 2006 15: 423-425.
5. Suso S, Peidro L, Ramon R. Tuberculous synovitis with “rice bodies” presenting as carpal tunnel syndrome. J Hand Surg Am 1988 13: 574-576. [PubMed]
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8. Sanger JR, Stampfl DA, Franson TR. Recurrent granulomatous synovitis due to Mycobacterium kansasii in a renal transplant recipient. J Hand Surg Am 1987;12: 436-441. [PubMed]
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10. Muirhead DE, Johnson EH, Luis C. A light and ultrastructural study of rice bodies recovered from a case of date thorn-induced extra-articular synovitis. Ultrastruct Pathol 1998 22: 341-347. [PubMed]
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14. Chen A, Wong LY, Sheu CY, Chen BF. Distinguishing multiple rice body formation in chronic subacromial-subdeltoid bursitis from synovial chondromatosis. Skeletal Radiol 2002 31:119-21. [PubMed]
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