Tag Archives: ultrasound

The Role of High Resolution Ultrasonography in Detection of Neglected or Missed Radiolucent Foreign Body in Foot and Ankle Region

by Reyaz Ahmad Dar (MS)1emailsm, Mubashir Maqbool Wani (MS)2emailsm, pdflrgMubashir Rashid Beig (MS)1, Muzaffer Ahmad Ganaie (MS)1

The Foot and Ankle Online Journal 6 (3): 2

A prospective case series was undertaken to assess the role of high resolution ultrasonography to detect radiolucent foreign bodies in the foot and ankle region. Out of 30 suspected foreign bodies, ultrasonography was able to detect 28 foreign bodies with 2 false negatives. The overall sensitivity was 93.33%. The false negatives were attributed to the foreign body being obscured by bone.

Key words: , foot, ankle, ultrasound,

Accepted: February, 2012
Published: March, 2013

ISSN 1941-6806
doi: 10.3827/faoj.2013.0603.002

Address correspondence to: Department of orthopaedics, SKIMS Medical college Srinagar Kashmir India – Pin 190018

1Department of orthopaedics, SKIMS Medical college Srinagar Kashmir India – Pin 190018
2Hospital for bone and joint surgery Barzulla Srinagar Kashmir India – Pin 190005

Missed or neglected foreign body and subsequent complications in the extremities is a challenging complaint in the orthopedic outpatient department. Most of these cases present with soft tissue mass, granuloma, abscess, corns, osteomyelitis, fasciitis, cellulitis, chronic discharging sinus, and tendon contracture with or without pain.[1,2,3] The initial investigation is usually done with a plain radiograph, which however, cannot detect radiolucent foreign bodies such as those of wood, plastic and rubber.

Of the other imaging modalities, xeroradiography provides better edge enhancement, but it requires special equipment and is inadequate in detecting radiolucent foreign bodies.[4,5]

Computerized tomographic (CT) scan has the ability to detect the radiolucent foreign bodies with limitations of ionizing radiation, cost and poor sensitivity in detecting small foreign bodies.[6,7] Magnetic Resonance Imaging (MRI) can detect radiolucent foreign bodies but has the limitations of being inaccessible, expensive, and a concern regarding magnetic foreign bodies as well as time consuming.


Figure 1 and Figure 2 High-resolution ultrasound of a foot suspected of having a foreign body.

There is an added disadvantage of not detecting foreign bodies with low signal intensity from tissues such as scar tissue, tendon and calcifications.[8,9] Sonography, on the other hand, is easily accessible, inexpensive and a time saving image modality.

We undertook our study on thirty patients who presented to our outpatient department at two hospitals with a definite history of foreign body injury to the foot and ankle region. Patients presented with varied signs and symptoms which included pain, soft tissue mass, abscess, corn, chronic discharging sinus with duration of symptoms ranging from four months to eight years.

Most of these patients were initially managed by primary care givers and missed or often self treated themselves removing only a part of foreign body and subsequently neglected. Our aim was to assess the role of foreign body detection in these patients with high resolution ultra sonography (USG).

Materials and Methods

Thirty symptomatic patients who had a definite history of foreign body injury of the foot and ankle region were included in this study. The symptoms of these patients varied from simple pain to chronic discharging sinus and all had a normal plain radiograph. All of them underwent high resolution ultra sonography of the affected part followed by surgical exploration.

Sonography was conducted by four specialist doctors who had a minimum of four years of experience in the radiology department. Sensitivity of USG was determined with respect to that found on surgical exploration.


Thirty consecutive patients presented to our outpatient departments from May 2008 to May 2012 with history of foreign body injury. Patients presented with persistent pain, soft tissue mass, granuloma, abscess or chronic discharging sinus with a normal radiograph. Nineteen patients were male. Twenty two patients were younger than twenty years of age. Twenty eight patients had symptoms in the foot; two had symptoms in the ankle region. Twenty three patients had a history of nail insertion in the foot through a rubber sole. There was thorn injury in six patients with five having it in the foot and one in the ankle region. One patient had injury to the ankle with a wood. Three patients had multiple surgical interventions for chronic discharging sinuses.

All these patients were sent to radiology for the high resolution ultra sonography of the affected part. In all our cases a frequency of 7.5 MHz to 13 MHz was employed. Foreign bodies were reported as hyperechoic masses with surrounding hypo echoic rim with an acoustic shadow in twenty eight patients (Fig. 1 and Fig. 2).


Figure 3 Foreign body seen at the time of surgery.

Two patients which were reported negative had chronic discharging sinus with one having it on the lateral malleolus and another on the dorsal aspect of the foot. All patients underwent surgical exploration under general or regional anaesthesia with tourniquet control. Preoperative methylene blue injection into the sinus was used in three patients with chronic discharging sinus. Foreign bodies were recovered from all the patients (Fig. 3 and Fig. 4). Two patients who were labeled by the sonologist of not having a foreign body had foreign bodies close to or obscured by the bone. One of the patients had injury to the right lateral malleolar area with a wooden foreign body with persistent sinus discharge, and on exploration the foreign body was found very close to and abutting the cortex. Another patient had a history of nail insertion through the sole of the shoe with persistent sinus discharge on the planter aspect of the foot, and on surgical exploration a piece of rubber was found abutting the second metatarsal shaft cortex on the dorsal aspect. Out of the total thirty suspected radiolucent foreign bodies, high resolution ultra sonography was able to detect the foreign body in 28 patients with two false negatives with an overall sensitivity of 93.33%.


Figure 4 Foreign body after removal.


The basic principle of ultra sound is the use of a transducer to penetrate tissues with ultrasonic waves at various frequencies. When the wave strikes the denser component of tissue, they bounce (echo) back to the transducer. The ultrasound can then interpret the speed and intensity of the sound wave to determine the location and composition of the object. Structures are plotted on the screen based on their depth and location relative to the transducer. Superficial structures are plotted at the top and deeper ones at the bottom of the screen. The larger the surface area toward the transducer the greater it will reflect. Sonographic features of the foreign bodies in the soft tissues have three components. Firstly, the appearance of the foreign body; secondly, the changes in the soft tissues surrounding the foreign bodies. Thirdly, the appearance of soft tissues distal to the foreign bodies.

All foreign bodies on ultrasonography appear as hyperechoic foci. The reflectivity depends on acoustic impedance of the foreign body which in turn varies with the density of the object. In general, metal, mineral, glass, wood, and rubber reflect sound, appearing white on the screen. The changes surrounding the foreign bodies are due to inflammatory reaction which may range from edema to abscess formation.

This reaction takes some time to develop and is shown as hypo echoic rim around the foreign body. Distal to the echo rich foreign body acoustic shadowing is noted. This is due to failure of the ultrasound to pass through the foreign body.[10,11]

Despite their size, foreign bodies are no small matter. When left untreated they cause pain, swelling, infection, nerve and tendon injury.[2,3,12] Although USG has been a well-established diagnostic tool for foreign bodies in the soft tissues, it has been underutilized in this part of the world. While evaluating the usefulness of USG in the detection of unsuspected foreign bodies followed by CT, MRI, bone and labeled red cell Scintigraphy, it has been found that the later investigations added no relevant information and were time consuming and costly.[12] The sensitivity of USG in detecting different foreign bodies has been reported to be 70% to 100%. Cases which turned out to be false negatives had either a very deep foreign body, gas around foreign body, or a foreign body too close to the bone [8,13,14,15] as was the case in two of our patients.

Several studies have demonstrated the effectiveness of USG in detecting non-opaque foreign bodies in the soft tissues. The power of USG is as important as the depth of penetration of wave into soft tissues. The shorter wave length with high frequency penetrates less as most of energy is absorbed by the medium.[15] The authors do not believe that the results could be different if the USG was done by the same radiologists. Differences in the comparative accuracy, sensitivity and specificity of foreign body detection by radiologist and USG technician has not been found to be statistically significant in the previous studies.[16]


The authors do not recommend replacing plain radiography with ultrasonography in the evaluation of suspected foreign bodies of the foot and ankle region. But Sonography should definitely be considered part of diagnostic work up of patients in whom we strongly suspect the presence of radiolucent foreign bodies based on history and symptomatology.


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Investigating Plantar Fasciitis

by Valerie A.J. Potter, MBChB, BSc (Hons), MSc1

The Foot and Ankle Online Journal 2 (11): 4

Plantar fasciitis is a condition caused by inflammation of the plantar aponeurosis and is a common cause of heel pain. The diagnosis is clinical and investigations are generally not required. However, in certain cases such as an atypical presentation or where there is no response to treatment, the clinician may consider further investigation. This review article briefly introduces the condition and goes on to discuss the possible options for investigation. This includes evaluation and usefulness of such tests as blood evaluation, radiographs, ultrasound, bone scintigraphy, magnetic resonance imaging (MRI) and nerve conduction studies.

Key words: Plantar fasciitis, investigations, heel pain, MRI, ultrasound, bone scintigraphy, nerve conduction.

This is an Open Access article distributed under the terms of the Creative Commons Attribution License.  It permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. ©The Foot and Ankle Online Journal (www.faoj.org)

Accepted: October, 2009
Published: November, 2009

ISSN 1941-6806
doi: 10.3827/faoj.2009.0211.0004

Anatomy and etiology of plantar fasciitis

The plantar fascia of the foot refers to the deep fascia of the sole. It arises posteriorly from the calcaneus and divides into bands which divide to enclose tendons. The thick central part of this fascia forms the plantar aponeurosis which is arranged into bands of fibrous connective tissue. The plantar fascia has a number of roles, which include holding parts of the foot together, protecting the plantar surface of the foot from trauma and helping to support the foot’s longitudinal arch. ‘Plantar fasciitis’ refers to inflammation of the plantar aponeurosis. This is a relatively common clinical condition and cause of heel pain resulting from a degenerative process. The exact mechanism is poorly understood but thought to be multifactorial. Mechanical overload is believed to play a key role. [1] Risk factors include age, obesity, biomechanical abnormalities of the foot and particular occupation- related or recreational activities such as aerobics and running particularly in flat or worn shoes.

The chronic form of heel pain is now more commonly termed ‘plantar fasciosis’. Repetitive trauma and overuse leads to microtears, with cycles of tearing and healing causing the release of various chemical mediators. This is thought to lead to myxoid degeneration and weakness of the fascia as well as pain. [2] This is a degenerative fasciosis without inflammation. [3]

Plantar fasciitis can also be associated with various inflammatory systemic conditions such as gout and rheumatoid arthritis. An increased incidence exists in patients with certain HLA B27 sponyloarthropathies in which case the fasciitis often presents at a younger age and carries a poorer prognosis. [4]

Clinical features

Typically the patient presents with pain in one or both plantar aspects of the feet. This has usually been insidious in onset although occasionally can be acute. The pain may be poorly localized particularly initially, but then may become maximal at the origin of the fascia, to the medial calcaneal tuberosity. It tends to be worse in the morning when the foot is first put on the floor or following a period of rest and is relieved on movement during the day. However, it can again be exacerbated by increased weight-bearing activity such as running. It is often described as a ‘tearing’ pain. On inspection, the foot appears normal with either no or slight swelling. [5] Palpating the foot, the practitioner may elicit maximal tenderness at the aforementioned origin of the plantar fascia and pressure here reproduces the pain. Passive dorsiflexion of the toes and ankles can also cause pain by stretching the fascia.6 The clinician must also consider a differential diagnosis for heel pain. (Table 1)

Table 1 Differential diagnosis for plantar fasciitis.

Investigations in plantar fasciitis

The diagnosis of plantar fasciitis is a clinical one based on the history and examination. It is also usually self-limiting and managed conservatively. However, in particular circumstances such as atypical presentations or failing to respond to treatment, the clinician may wish to consider other tests to aid in the diagnosis and differential diagnosis of heel pain syndrome.

Blood tests

In most cases, these do not play a role in diagnosis although occasionally the clinician may wish to perform certain blood tests if considering a systemic condition or alternative cause. A raised erythrocyte sedimentation rate or C-reactive protein may indicate underlying inflammation or infection respectively. Likewise, testing for HLA B27 gene may be helpful if suspecting one of the HLA B27 spondyloarthropathies such as ankylosing spondylitis, psoriatic arthritis, reactive arthritis or enteropathic arthritis. Further examples include gout in which serum uric acid is usually raised and a diagnosis of Paget’s disease is supported by a raised alkaline phosphatase with a normal phosphate and calcium.

Plain radiograph

It is common for a plain lateral radiograph of the foot to be ordered, often to rule out a stress fracture, heel spurs, fractured spurs or some other bony cause of the patient’s heel pain. However, one study involving 215 heels concluded that routine radiographs are of limited use in the initial evaluation of adults presenting with non-traumatic heel pain and should be reserved for those who do not improve or have an unusual history or physical signs. This study also found that radiographs were normal in 17.2% and that incidental radiographic findings were observed in 81.4%; most commonly plantar calcaneal spurs and Achilles spurs (46.5%, 100 of 215). [7]

One may argue that these incidental findings could in some cases explain the patient’s symptoms although a heel spur does not have any diagnostic value. [8] The aforementioned study also found that only 2% of the patients in their study had abnormal findings that prompted further evaluation supporting the conclusion that radiographs are generally of limited use and hence not cost effective. [7]


In difficult cases, the clinician may wish to request an ultrasound of the foot. A number of studies have sought to evaluate usefulness of this modality with respect to diagnosing plantar fasciitis. One such study found that in patients with plantar fasciitis, ultrasound may detect relatively small differences in plantar fascia thickness (2.9mm in patients with unilateral plantar fasciitis, 2.2mm for the contralateral heel and 2.5mm for the control group). [9] A similar conclusion was reached by a Cardinal, et al., who found that increased thickness of the fascia and hypoechoic fascia are sonographic findings of this condition. They concluded that ultrasound may be a valuable non-invasive technique for the diagnosis of plantar fasciitis. [10]

Bone Scintigraphy

Bone scintigraphy is an investigation which uses technetium-99m labelled diphosphonates. It is one of the most frequently performed of all radionuclide procedures. The isotope is injected into the patient intravenously and is then cleared from the blood and taken up by the skeleton. Blood flow and osteoblastic activity determine skeletal uptake. This mode of imaging is not specific but is very sensitive and so is useful in screening for many pathological conditions. It is often used to investigate potential malignant bony lesions but may be requested, as in the context of heel pain, to explore chronic foot pain which is not responding as expected. In cases of musculoskeletal trauma, radionuclide bone imaging is useful for identifying pathologic conditions for which radiographs may be non-diagnostic. [11] It is often used to rule out a stress fracture.
Several studies have sought to determine the value of this modality in the diagnosis of plantar fasciitis. One study compared ultrasonography and bone scintigraphy; both were found to be sensitive and specific diagnostic imaging investigations in this condition. This study found that both confirmed the clinical diagnosis in 25 of 27 heels. However, this again serves to highlight the accuracy of clinical diagnosis supporting the view that imaging is only rarely required. Comparing the two investigations, the differences in sensitivity and specificity were not statistically significant and given the relative ease and non invasiveness of ultrasonography, this would thus seem to be the choice of imaging to employ. [12] Another study found that focal uptake at the medial calcaneal tubercle was present in the majority of patients in their study who had been diagnosed with plantar fasciitis, thus confirming the diagnosis. [13] A third study came to the conclusion that scintigraphy is very useful in diagnosing plantar fasciitis and distinguishing it from other causes of a painful heel after imaging 15 patients with chronic heel pain; 10 demonstrated scan findings consistent with plantar fasciitis whilst 2 were found to have a calcaneal stress fracture. [14]

Magnetic resonance imaging

Magnetic resonance imaging (MRI) is a further possible investigation to perform in difficult cases and is useful in detecting tears or ruptures of the fascia. In plantar fasciitis the MRI may show a widened fascia with increased signal often with some reactive oedema in the adjac ent bone. [15] The normal thickness of the plantar fascia is 4mm; in plantar fasciitis this may be increased to 8mm. In cases of ruptures and tears this thickness can reach 10mm or more and additionally, the MRI will show intrafascial high signal intensity of the T2 weighted image. [16] One study found that maximal thickness of the plantar fascia was significantly increased in patients with plantar fasciitis and that feet with the condition had areas of moderately increased signal intensity in the substance of the fascia. [17]

Although therefore very useful, a study compared the diagnostic accuracy of ultrasound and MRI and found the two comparable and concluded MRI may be reserved for the more complex cases where the diagnosis is not clear. [18] Similarly, another paper found that although MRI is the modality of choice in the morphologic assessment of different plantar fascia lesions, sonography can also serve as an effective tool and may substitute MRI in the diagnosis of plantar fasciitis. [19]

Nerve conduction studies

This is used to look at the ability of electrical conduction of a nerve and so to diagnose nerve damage or dysfunction. It involves the placement of electrodes on the skin at intervals along the nerve in question; a low intensity electrical current is then applied to generate an impulse. Nerve conduction velocity can then be measured by recording the motor response of a muscle to the stimulation of its motor nerve. Nerve conduction studies are rarely required in the context of plantar fasciitis, but may be considered if the clinician is suspecting nerve entrapment as the cause of the patient’s pain. This may include tarsal tunnel syndrome or where an atypical presentation represents a mixed picture. For example, Chang, et al., found that sensory nerve conduction studies were a useful and objective tool in the diagnosis of medical calcaneal neuropathy and that there was an association between this neuropathy and plantar fasciitis. [20] In addition, Baxter’s neuropathy, which is referred to as entrapment of the first branch of the lateral plantar nerve can produce medial heel pain. This can be very similar to that caused by plantar fasciitis and is thought to account for up to 20% of heel pain. [21]


Plantar fasciitis is a common cause of heel and foot pain. In most cases, history and examination provide the diagnosis and treatment can be advised based on severity and duration of symptoms.

If there is doubt as to the cause, investigations, usually rarely indicated, can be considered. Imaging modalities and tests include x-rays, ultrasound, scintigraphy, MRI and nerve conduction studies. The main value of these are in confirming the clinical diagnosis of plantar fasciitis as diagnostic features on imaging do exist and in detecting other causes of the patient’s heel pain. [9] Plain radiography is generally unhelpful; ultrasound appears to be the most useful in difficult cases and has the additional advantages of speed and low cost. MRI, bone scintigraphy and nerve conduction studies are best reserved for when there is a strong clinical suspicious of an alternative diagnosis or when the patient’s heel pain is not responding after 3 months or more of treatment. [6]


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Address correspondence to: East Surrey Hospital, Canada Avenue, Redhill, Surrey, RH1 5RH, U.K.

Acute Stroke Unit, East Surrey Hospital, Canada Avenue, Redhill, Surrey, RH1 5RH, U.K. vpotter@doctors.org.uk

© The Foot and Ankle Online Journal, 2009