Tag Archives: ultrasonography

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


F

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.

Discussion

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.

References

  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.
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  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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  12. Rockett MS, Gentile SC, Gudas CJ, Brage ME, Zygmunt KH. The use of ultrasonography for the detection of retained wooden foreign bodies in the foot. J Foot Ankle Surg. 1995 Sep-Oct;34(5):478-84;
  13. Rubin G, Chezar A, Raz R, Rozen N. Nail puncture wound through a rubber-soled shoe: a retrospective study of 96 adult patients. J Foot Ankle Surg. 2010 Sep-Oct;49(5):421-5
  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.

Prospective study of plantar fascia thickness correlated to efficacy of conservative treatment for plantar fasciitis using ultrasonography

by Gerald Kuwada, DPM, NMD1*pdflrg

The Foot and Ankle Online Journal 9 (3): 9

The thickness of the plantar fascia is measured using ultrasonography and has been correlated to either success or failure of conservative treatment depending on how thick the fascia is. The research hypothesis is that the thicker the plantar fascia in a patient diagnosed with plantar fasciitis, the higher the incidence of treatment failure. One hundred thirty six patients from our 4 clinics and 7 podiatric physicians made the clinical diagnosis of plantar fasciitis. The patients were divided into 2 groups for this study. Group 1 included all the patients that had a successful outcome with conservative treatment. Group 2 included all the patients who failed to improve after extensive conservative treatment. The mean for Group 1 plantar fascia thickness was .522 mm. Group 2 included 11.7% of feet and the mean plantar fascia thickness was 1.006mm. The range of plantar fascia thickness was .3mm to .97mm for Group 1. The range of plantar fascia thickness for Group 2 was .67mm to 1.22mm. Based on this study, 1.006 mm was measured to be the mean for Group 2 and may be a useful predictor of treatment outcomes.

Keywords: plantar fascia thickness, plantar fasciitis, ultrasonography, conservative treatment

ISSN 1941-6806
doi: 10.3827/faoj.2016.0903.0009

1 – FASA Family Wellness, Tumwater, WA
* – Corresponding author: drgeraldkuwada@hotmail.com


The thickness of the plantar fascia is measured using ultrasonography and has been correlated to either success or failure of conservative treatment depending on how thick the fascia is [1-13]. The research hypothesis is that the thicker the plantar fascia in a patient diagnosed with plantar fasciitis, the higher the incidence of treatment failure. Conservative treatment in this study includes injection therapy, physical therapy modalities like icing, stretching, prefabricated arch supports, massaging, over the counter anti-inflammatory medications, and orthotics. The null hypothesis states that no matter what the thickness of the plantar fascia it has no effect on success or failure of conservative treatment.

What are some of the etiologies of plantar fascia thickness? It has been suspected that inflammation of the fascia occurs. Other etiologies include degenerative changes to the fascia, micro-tearing and scarification of the fascia [14]. Since using ultrasonography, this has been a recent concept in treating plantar fasciitis. In the past, we had no idea there was a thickness issue. According to more recent studies, there is a possible correlation between the thickness of the plantar fascia and the success of conservative treatment [15]. A study published by this author in 1980 found a 90% success rate with conservative treatment and a 10% failure rate. Most of the patient’s in the 10% group elected to proceed with open fascial release to get complete pain relief [16]. Yet, several authors found that a plantar fascia thickness of greater than 4mm was considered thick [15].

Methods

One hundred thirty six patients from our 4 clinics and 7 podiatric physicians made the clinical diagnosis of plantar fasciitis. Each patient had their plantar fascia measured using ultrasonography and the thicknesses were recorded. There were a total of 197 feet with the diagnosis of plantar fasciitis. The success or failure of conservative treatment was recorded for all 136 patients. The feet were divided into 2 groups for this study. Group 1 included all the patients that had a successful outcome with conservative treatment. Group 2 included all the patients who failed to improve after extensive conservative treatment. There was no time limit regarding conservative treatment time. Thus, some patients took several months to complete their conservative treatment, whereas others took much longer. A majority of these patients in Group 2 eventually had endoscopic plantar fasciotomy or open fascial releases performed to eliminate their heel pain. The mean thickness of the plantar fascia was calculated for both groups. Using a T test 2 tailed type with a p value of .001 and 95% confidence intervals was calculated.

Results

The statistical analysis demonstrated that the two groups were significantly different at a p-value of .0001. Group 1 included 88.3% of feet (174/197). The mean for Group 1 plantar fascia thickness was .522 mm. Group 2 included 11.7% of feet and the mean plantar fascia thickness was 1.006mm. The range of plantar fascia thickness was .3mm to .97mm for Group 1. The range of plantar fascia thickness for Group 2 was .67mm to 1.22mm. Thus, the null hypothesis is rejected and our research hypothesis was accepted.

Discussion

This study corroborates the conclusion of several other studies supporting the concept that the plantar fascia thickness is important and may predict patient  conservative treatment outcomes [1-13]. However, the 4mm thickness or greater was not considered significantly thick in this study. Many of the patients in Group 2 had EPF or open fascial release performed. All the patients had no residual heel pain after their surgical sites healed. Others have reported that the plantar fascia in some patients will be thinner after corticosteroid injections [15]. The author plans on doing a study on this topic to determine if this is true or not. Will the thickness also play a role in determining whether the plantar fascia will thin after corticosteroid injections? Will the BMI also be a predictor of outcomes based on thickness of the plantar fascia?

One of the concerns of this study was the inability to control the accuracy of the various podiatric physician measurements of the plantar fascia. There is a steep learning curve in accurately measuring the plantar fascia thickness. This was not tested by having each physician measure the same plantar fascia of a dozen patients and determine accuracy of each podiatric physician.

It has been suggested that diabetes mellitus has a high correlation with increased plantar fascial thickening [15]. This study did not examine this relationship.

Lastly, despite the thickness of the plantar fascia, the patient diagnosed with plantar fasciitis needs to undergo conservative treatment to fulfill the standard of care. How extensive the care is will be determined by the podiatric physician and the patient. Furthermore, there will be exceptions to the findings and conclusions of this study. A patient may be within range of Group 1 yet fail improving after receiving conservative treatment.  Contrarily, a patient within Group 2 range completely  becomes asymptomatic after completing conservative treatment. This is plausible even though it did not occur in this study. Based on this study, 1.006 mm was measured to be the mean for Group 2 and may be a useful predictor of treatment outcomes.

References

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  2. Wearing SC, Smeathers, Sullivan PM, Yates B, Urry SR, Dubois P. Plantar fasciitis: are pain and fascial thickness associated with arch shape and loading? Phys. Ther. 2007:87(8):1002-1008.
  3. Genc H, Saracoglu M, Nacir G, Erdem HR, Kacar M. Long term ultrasonographic follow-up of plantar fasciitis patients treated with steroid injection. Joint Bone Spine. 2005;72(1):61-65. Doi:10.1016/j.jbspin.2004.03006.
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  5. Sabir N, Demirlenk S, Yagei B, Karabulut N, Cubukcu S. Clinical utility of sonography in diagnosing plantar fasciitis. J Ultrasound Med. 2005;24(8):1041-1048.
  6. Wall KR, Harkness MA, Crawford A. Ultrasound diagnosis of plantar fasciitis. Foot Ankle. 1993;14(8):465-470.
  7. Akfirat M, Sen C, Gunes T. Ultrasonographic appearance of the plantar fasciitis. Clin Imaging. 2003;27(5):353-357. DOI: 10.1016/S0899-7071(02)00591-0.
  8. Cardinal E, Chhem RK, Beauregard CG, Aubin B, Pelletier M. Plantar fasciitis: sonographic evaluation. Radiology. 1996;201(1):257-259.
  9. Gibbon WW, Long G. Ultrasound of the plantar aponeurosis (fascia) Skeletal Radiol. 1999;28(1):21-26. Doi: 10.1007/s002560050467.
  10. Vohra PK, Kincaid BR, Japour CJ, Sobel E. Ultrasonographic evaluation of plantar fascia bands. A retrospective study of 211 symptomatic feet. J Am Podiatr Med Assoc. 2002;92(8):444-449.
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  12. Kamel M, Kotob H. High frequency ultrasonographic findings in plantar fasciitis and assessment of local steroid injection. J Rheumatol. 2000;27(9):2139-2141.
  13. Karabay N, Toros T, Hurel C. Ultrasonographic evaluation in plantar fasciitis. J Foot Ankle Surg. 2007;46(6):442-446. doi: 10.1053/j.jfas.2007.08.006.
  14. Walther M, Radke S, Kirschner S, Ettl V, Gohlke F. Power Doppler findings in plantar fasciitis. Ultrasound Med Biol. 2004;30(4):435-440. Doi: 10.1016/j.ultrasmedbio.2004.01.006. PubMed Cross Ref
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  16. McMillan AM, Landorf KB, Barrett JT, Menz HB, Bird AR. Diagnostic Imaging for chronic plantar heel pain: a systematic review and meta-analysis. J Foot Ankle Res. 2009; 2: 32 published online 2009 Nov 13. Doi: 10.1186/1757-1146-2-32.
  17. Kuwada GT, Gormley J. A Retrospective Analysis of calcaneal spur removal and complete fascial release. J Foot Ankle Surg. 1980; 19: 218-222.