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Appropriateness Criteria

Reference Study Type Patients/Events Study Objective(Purpose of Study) Study Results Study Quality
1. Bachmann LM, Kolb E, Koller MT, Steurer J, ter Riet G. Accuracy of Ottawa ankle rules to exclude fractures of the ankle and mid-foot: systematic review. [Review] [17 refs]. BMJ. 326(7386):417, 2003 Feb 22. Review/Other-Dx 32 studies met inclusion criteria; 27 studies (15,581 patients) for pooled analysis Systematic review to examine the accuracy of OAR for excluding fractures of the ankle and mid-foot. Pooled negative likelihood ratios for the ankle and mid-foot were 0.08 (95% CI, 0.03–0.18) and 0.08 (0.03–0.20), respectively. The pooled negative likelihood ratio for both regions in children was 0.07 (0.03–0.18). Applying these ratios to a 15% prevalence of fracture gave a <1.4% probability of actual fracture in these subgroups. Evidence supports the (OAR) as an accurate instrument for excluding fractures of the ankle and mid-foot. The instrument has a sensitivity of almost 100% and a modest specificity, and its use should reduce the number of unnecessary radiographs by 30%-40%. 4
2. Dowling S, Spooner CH, Liang Y, et al. Accuracy of Ottawa Ankle Rules to exclude fractures of the ankle and midfoot in children: a meta-analysis. Acad Emerg Med. 16(4):277-87, 2009 Apr. Meta-analysis 12 studies (n=3,130) Systematic review to determine the diagnostic accuracy of the OAR to exclude ankle and midfoot fractures in children and the extent to which x-ray use could be reduced without missing significant fractures. Pooled sensitivity was 98.5% (95% CI, 97.3–99.2). 4/10 missed fractures were characterized: 1 Salter-Harris-I, 1 Salter-Harris-IV, and 2 “insignificant fractures” (either Salter-Harris-I or avulsion fractures <3 mm). The pooled estimate for rate of x-ray reduction was 24.8% (95% CI, 23.3%–26.3%; range = 5%–44%). OAR appears to be a reliable tool to exclude fractures in children >5 years of age presenting with ankle and midfoot injuries. Employing the OAR would significantly decrease x-ray use with a low likelihood of missing a fracture. Good
3. Dayan PS, Vitale M, Langsam DJ, et al. Derivation of clinical prediction rules to identify children with fractures after twisting injuries of the ankle. Acad Emerg Med. 2004; 11(7):736-743. Observational-Dx 717 patients To derive maximally sensitive prediction rules for identifying children with significant fractures after acute twisting injuries to the ankle. Data from 717 enrolled patients with a median age of 12.9 years were analyzed. Significant malleolar zone and midfoot zone fractures were diagnosed in 81/682 (11.9%) and 10/173 (5.8%) patients for whom ankle and foot radiographs were obtained. Recursive partitioning identified patients at low risk for malleolar zone fracture if 1) they had no bone tenderness at either malleolus or the region just proximal to the fibula malleolus or 2) they had bone tenderness at either malleolus but were able to walk four steps in the emergency department and had no swelling at either malleolus. The two-part malleolar zone rule had a sensitivity of 100% and specificity of 19.1% on the learning data and 95.1% (95% CI, 87.8% to 98.6%) and 20.0% (95% CI, 16.8% to 23.4%) on the test data. Tenderness either at the proximal fifth metatarsal or cuboid identified midfoot zone fractures with a sensitivity of 100% and specificity of 31.9% on the learning data and 90.0% (95% CI, 55.4% to 99.7%) and 35.0% (95% CI, 27.7% to 42.8%) on the test sample. 3
4. Smith KR, Brown CK, Brewer KL. Can clinical prediction rules used in acute pediatric ankle and midfoot injuries be applied to an adult population?. Am J Emerg Med. 29(4):441-5, 2011 May. Observational-Dx 29 patients To apply the existing clinical prediction rules used to identify children with fractures after twisting injuries of the ankle to a population that includes adults. 68 patients were eligible, and 29 patients were enrolled after exclusion criteria were applied (median age, 34 years). 3 patients were diagnosed with a malleolar zone fracture, and 2 patients were diagnosed with a midfoot zone fracture. Five indicators were found to be 100% sensitive for ankle fracture, and 2 indicators were 100% sensitive for midfoot fracture. 3
5. McLaughlin SA, Binder DS, Sklar DP. Ottawa ankle rules and the diabetic foot. Ann Emerg Med. 1998;32(4):518. Review/Other-Dx N/A Letter to editor commenting on the role of OAR in a diabetic woman. Diabetic patients with sensory neuropathy should be part of the exclusion criteria for use of OAR. 4
6. Stiell IG, Greenberg GH, McKnight RD, et al. Decision rules for the use of radiography in acute ankle injuries. Refinement and prospective validation. JAMA. 1993;269(9):1127-1132. Observational-Dx First stage 1,032 of 1,130 eligible patients: Second stage 453 of 530 eligible patients To validate and refine previously derived clinical decision rules that aid the efficient use of radiography in acute ankle injuries. Survey prospectively administered in two stages: validation and refinement of the original rules (first stage) and validation of the refined rules (second stage). OAR is 100% sensitive for fractures, reliable, and has the potential to allow physicians to safely reduce the number of radiographs ordered in patients with ankle injuries by one-third. 1
7. Bancroft LW, Kransdorf MJ, Adler R, et al. ACR Appropriateness Criteria Acute Trauma to the Foot. [Review]. J. Am. Coll. Radiol.. 12(6):575-81, 2015 Jun. Review/Other-Dx N/A Guidelines for acute trauma to the foot. No results stated in abstract. 4
8. De Smet AA, Doherty MP, Norris MA, Hollister MC, Smith DL. Are oblique views needed for trauma radiography of the distal extremities? AJR Am J Roentgenol.1999; 172(6):1561-1565. Observational-Dx 1,461 consecutive radiographic examinations To determine whether the oblique view uniquely revealed abnormalities or clarified findings when it was obtained along with routine frontal and lateral radiographs. The examinations included 421 with abnormal findings, 34 with equivocal findings, and 1,006 with normal findings. The addition of the oblique view changed the interpretation in 70 (4.8%) of the 1,461 examinations. Of these changed interpretations, 39 were changed from equivocal to either positive or negative, 3 from positive to negative, and 28 from negative to positive. Addition of the oblique view increased diagnostic confidence: The percentage of examinations scored as having probably normal, equivocal, and probably abnormal findings decreased from 13.9% with two views to 8.4% with 3 views (P<.0001). The oblique view was equally valuable in the ankle, foot, toe, wrist, hand, finger, and thumb. 3
9. Broomhead A, Stuart P. Validation of the Ottawa Ankle Rules in Australia. Emerg Med (Fremantle). 2003; 15(2):126-132. Observational-Dx 333 patients had 366 injuries; 43 fractures in 265 ankle injuries; 14 fractures in 101 foot injuries Prospective validation of the OAR in Australia following appropriate education in the use of the rules. OAR was applied to consecutive patients 18 years and over presenting with acute ankle and foot injuries. Sensitivity was 100% for ankle (95% CI: 92-100) and midfoot fractures (95% CI: 77-100). Specificity was 15.8% (95% CI: 11-21) for ankle fractures and 20.7% (95% CI: 13-31) for midfoot fractures. OAR had a sensitivity of 100% for ankle and midfoot fractures when used by both junior and senior physicians. 3
10. Leisey J. Prospective validation of the Ottawa Ankle Rules in a deployed military population. Mil Med. 2004; 169(10):804-806. Observational-Dx 45 consecutive patients Prospective validation of the OAR in a deployed military clinic. Patients presented with acute ankle trauma. Radiographs were read by a radiologist blinded to the study. 29 (64%) patients met the OAR criteria, 32 (71%) received radiographs, and 5 (11%) fractures were identified. All fractures were predicted by the OAR. Sensitivity of the OAR was 1.0 and specificity was 0.40. NPV was 1.0, PPV was 0.17, likelihood ratio positive value was 1.67, and likelihood ratio negative value was 0.0. The OAR correctly predicted all ankle fractures in the military population studied. 2
11. Hatch RL, Hacking S. Evaluation and management of toe fractures. Am Fam Physician. 2003; 68(12):2413-2418. Review/Other-Dx N/A Review article on evaluation and management of toe fractures. AP and oblique radiographs generally are most useful for identifying fractures, determining displacement, and evaluating adjacent phalanges and digits. 4
12. Schnaue-Constantouris EM, Birrer RB, Grisafi PJ, Dellacorte MP. Digital foot trauma: emergency diagnosis and treatment. J Emerg Med. 2002; 22(2):163-170. Review/Other-Dx N/A Review emergency diagnosis and treatment of foot trauma. Radiographs should be obtained in 3 views, AP, lateral, oblique. If the injury appears to be confined to the digits, focused images of the digits may be more helpful than views of the entire foot. CT, fluoroscopy, and technetium scanning also help in the diagnosis of difficult cases. Stress fractures are best diagnosed by bone scans. Surgical intervention may be required for an unstable or a displaced fracture, particularly of the first metatarsophalangeal joint. 4
13. Canagasabey MD, Callaghan MJ, Carley S. The sonographic Ottawa Foot and Ankle Rules study (the SOFAR study). Emerg Med J. 28(10):838-40, 2011 Oct. Observational-Dx 110 subjects To examine if US could detect acute bony foot and ankle injuries. 110 subjects were recruited. 11 had significant radiological fractures, and 10 were seen on US. The single missed fracture arose due to the operator not scanning proximally enough on the fibula. On rescanning following radiograph review, the fracture was clearly seen. The sensitivity of US is 90.9% (95% CI, 65.7 to 98.3), and the specificity is 90.9% (95% CI, 88.1 to 91.7). The PPV is 0.526 (95% CI, 0.380 to 0.569). The NPV is 0.989 (95% CI, 0.959 to 0.998). The positive likelihood ratio is 10.00 (95% CI, 5.526 to 11.901), and the negative likelihood ratio is 0.100 (95% CI, 0.018 to 0.389). 3
14. Sconfienza LM, Albano D, Allen G, et al. Clinical indications for musculoskeletal ultrasound updated in 2017 by European Society of Musculoskeletal Radiology (ESSR) consensus. [Review]. Eur Radiol. 28(12):5338-5351, 2018 Dec. Review/Other-Dx 123 papers To update the 2012 European Society of Musculoskeletal Radiology (ESSR) clinical consensus guidelines for musculoskeletal ultrasound referral in Europe. A total of 123 new papers were reviewed. No evidence change was found regarding the shoulder. There were no new relevant articles for the shoulder, 10 new articles for the elbow, 28 for the hand/wrist, 3 for the hip, 7 for the knee, and 4 for the ankle/foot. Four new evidence levels of A were determined, one for the hip (gluteal tendons tears), one for the knee (meniscal cysts), one for the ankle (ankle joint instability), and one for the foot (plantar plate tear). There was no level A evidence for elastography, although for Achilles tendinopathy and lateral epicondylitis evidence level was B with grade 3 indication. 4
15. Zhang T, Chen W, Su Y, Wang H, Zhang Y. Does axial view still play an important role in dealing with calcaneal fractures?. BMC surg.. 15:19, 2015 Mar 08. Observational-Dx 140 patients To analyze the role of axial view in different phases of treatment and demonstrate whether axial view is still useful in evaluating the calcaneal fractures. According to the two assessments, without axial view, specificity value will be significantly lower in diagnosing calcaneal fractures (p = 0.024) and sensitivity value will be significantly lower in distinguishing intra-articular fractures (p < 0.001). The normal threshold of angle Z was estimated from 98.06° to 100.64° (p <0.001). Liner regression shows that the lateral hindfoot pain will obviously aggravate along with the increasing of angle Z value (p <0.001). 2
16. Rankine JJ, Nicholas CM, Wells G, Barron DA. The diagnostic accuracy of radiographs in Lisfranc injury and the potential value of a craniocaudal projection. AJR Am J Roentgenol. 198(4):W365-9, 2012 Apr. Observational-Dx 60 patients To determine the diagnostic accuracy of radiographs in the diagnosis of Lisfranc injury. The radiographs correctly identified 31 of the 45 cases (68.9%) of Lisfranc injury, with a PPV of 84.4%, a NPV of 53.3%, a sensitivity of 84.4%, and a specificity of 53.3%. Twenty degrees of craniocaudal angulation best showed the second tarsal-metatarsal joint of the phantom, and this correlated with a 20 degrees angle measured by CT. The mean (+/- SD) angle of the joint in the patients was 28.9 degrees +/- 5.7 degrees. 2
17. Shapiro MS, Wascher DC, Finerman GA. Rupture of Lisfranc's ligament in athletes. Am J Sports Med. 1994; 22(5):687-691. Review/Other-Dx 9 injuries To describe rupture of Lisfranc ligament in athletes. History and physical findings are important for evaluating injury, but confirmation can best be obtained by comparison weight-bearing radiographs; the space between the first and second metatarsal bases may be widened 2 to 5 mm. 4
18. Kalia V, Fishman EK, Carrino JA, Fayad LM. Epidemiology, imaging, and treatment of Lisfranc fracture-dislocations revisited. Skeletal Radiol. 2012; 41(2):129-136. Review/Other-Dx N/A To discuss the features of Lisfranc injuries and identify their typical imaging findings on radiographs, CT, and MRI. The most common radiographic findings include diastasis of the base of the first and second metatarsals and the "fleck" sign, though neither is necessarily present in every Lisfranc fracture-dislocation. Owing to their often subtle radiographic presentation, clinically suspected Lisfranc injuries warrant imaging with a more sensitive test for the detection of osseous and ligamentous Lisfranc injuries. 3D CT imaging provides a comprehensive evaluation of the injury for optimal treatment planning, with resultant decreased long-term patient morbidity. Furthermore, 3D volume-rendered CT and CT MPRs provide osseous and neurovascular anatomic detail that may be a considerable help with surgical planning for operative cases of Lisfranc injuries. Also, with 3D CT and MPRs, other occult fractures, which are common in patients with high-energy injury and multiple trauma, may become evident. 4
19. Nunley JA, Vertullo CJ. Classification, investigation, and management of midfoot sprains: Lisfranc injuries in the athlete. Am J Sports Med. 30(6):871-8, 2002 Nov-Dec. Observational-Tx 15 athletes To report the outcome of treatment in athletes with Lisfranc injuries classified according to our system. We achieved an excellent outcome in 93% of 15 athletes with midfoot sprains at an average follow-up of 27 months(range, 9 to 72). 1
20. Siddiqui NA, Galizia MS, Almusa E, Omar IM. Evaluation of the tarsometatarsal joint using conventional radiography, CT, and MR imaging. Radiographics. 34(2):514-31, 2014 Mar-Apr. Review/Other-Dx N/A To discuss the the Lisfrancjoint complex, common mechanisms of tarsometatarsal joint complex injuries, and image findings of injuries to the Lisfranc joint complex. No results stated in article. 4
21. Haapamaki VV, Kiuru MJ, Koskinen SK. Ankle and foot injuries: analysis of MDCT findings. AJR Am J Roentgenol. 183(3):615-22, 2004 Sep. Observational-Dx 388 patients Retrospective study to assess MDCT findings and the advantages of MDCT compared with radiography in patients referred to a level 1 trauma center for diagnostic evaluation of acute ankle and foot trauma. 344 (89%) of the 388 patients had one or more fractures in the ankle or foot. Calcaneus was the most commonly fractured bone, and the sensitivity of radiography in the detection of calcaneal fractures was 87%. The sensitivity of radiography in the detection of talar fractures was 78%, whereas it was only 25%-33% in the detection of midfoot fractures. A Lisfranc fracture-dislocation was not detected on primary radiography in 5 (24%) of 21 cases. The 3 main injury mechanisms were falling from a height (164 patients [48%]), a simple fall (68 patients [20%]), and a traffic accident (47 patients [14%]). In patients with injuries from high-energy polytrauma and in those with complex ankle and foot fractures, the sensitivity of radiography is only moderate to poor; in these cases, MDCT is recommended as the primary imaging technique. 3
22. Watura R, Cobby M, Taylor J. Multislice CT in imaging of trauma of the spine, pelvis and complex foot injuries. [Review] [32 refs]. Br J Radiol. 77 Spec No 1:S46-63, 2004. Review/Other-Dx N/A Review general principles of scanning for musculoskeletal trauma and describe multislice CT of the traumatized spine, pelvis and foot. The advantages of volume imaging, such as MPR with near isotropic viewing, 3D imaging and thick slice (wedge) MPR (mimicking conventional radiographs), enable more accurate assessment of complex anatomical areas such as the spine, pelvis and foot. 4
23. Atilla OD, Yesilaras M, Kilic TY, et al. The accuracy of bedside ultrasonography as a diagnostic tool for fractures in the ankle and foot. Acad Emerg Med. 21(9):1058-61, 2014 Sep. Observational-Dx 246 patients To determine the diagnostic accuracy of US for fractures in patients presenting to the ED with foot and/or ankle sprain and positive Ottawa foot and ankle rules. A total of 246 patients were included in the study. In 76 (30.9%) of the patients, a total of 79 fractures were detected by radiography. Ten false-negative and nine false-positive results were obtained by US examination. Only one patient, whose US showed a fracture but whose radiographs were normal, had a fracture detected by computed tomography (CT). The sensitivity and specificity of US scanning in detecting fractures were 87.3% (95% confidence interval [CI] = 77.5% to 93.4%) and 96.4% (95% CI = 93.1% to 98.2%), respectively. 2
24. Friedman DI, Forti RJ, Wall SP, Crain EF. The utility of bedside ultrasound and patient perception in detecting soft tissue foreign bodies in children. Pediatric Emergency Care. 21(8):487-92, 2005 Aug.Pediatr Emerg Care. 21(8):487-92, 2005 Aug. Observational-Dx 105 patients To determine if bedside US and perception of wound FBs are useful screening tools for detecting wound FBs in children. 131 wounds were studied in 105 patients. FBs were identified in 12 wounds (9.2%). A subanalysis was performed on patients able to answer questions regarding their perception of wound FBs. There were no significant differences in the test performance characteristics of bedside US alone compared with radiography for detecting wound FBs. Except for specificity, there were no significant differences in the test performance characteristics of bedside US combined with perception compared with radiography for detecting wound FBs. 2
25. Manthey DE, Storrow AB, Milbourn JM, Wagner BJ. Ultrasound versus radiography in the detection of soft-tissue foreign bodies. Ann Emerg Med. 1996;28(1):7-9. Observational-Dx 120 chicken thighs Randomized, blinded, descriptive study to determine the usefulness of US and radiography in detecting FBs in soft-tissue models closely duplicating puncture-wound trauma and hand anatomy. Sensitivity of US in detecting gravel was 40%, for metal was 45%, for glass was 50%, for cactus spine was 30%, for wood was 50%, and for plastic was 40%. Overall sensitivity, specificity, and false-negative and false-positive rates for US were 43%, 70%, 50%, and 30%, respectively. Radiography detected FBs generally considered radiopaque (gravel, glass, metal) 98% of the time, but it never detected bodies considered radiolucent (wood, plastic, cactus spine). The false-negative and false-positive rates for radiography were 50% and 1.6%, respectively. Data suggest US is not reliable in ruling out the possibility of a retained FBs in the distal extremities. 1
26. Pugmire BS, Shailam R, Sagar P, et al. Initial Clinical Experience With Extremity Cone-Beam CT of the Foot and Ankle in Pediatric Patients. AJR Am J Roentgenol. 206(2):431-5, 2016 Feb. Observational-Dx 34 patients To review an initial clinical experience with cone-beam CT (CBCT) of the foot and ankle in pediatric patients. Thirty-four CBCT examinations were performed. The mean effective dose was 0.013 ± 0.003 mSv compared with 0.023 ± 0.020 mSv for MDCT of age-matched control subjects (p < 0.005). The mean numbers of foot or ankle CT examinations per month were 3.4 in the 18 months before and 3.8 in the 18 months after installation of the CBCT scanner (p = 0.28). The mean number of foot or ankle MDCT examinations per month decreased significantly (3.4 vs 1.9, p = 0.03) over the same period. In 56% of patients, CBCT revealed important findings that were not visible on contemporaneous radiographs. In 68% of patients, the CBCT findings affected clinical management. 3
27. Jacobson JA, Powell A, Craig JG, Bouffard JA, van Holsbeeck MT. Wooden foreign bodies in soft tissue: detection at US. Radiology. 1998;206(1):45-48. Observational-Dx 10 FBs were 2.5 x 1.0 mm (length x diameter); 10 were 5.0 x 1.0 mm To evaluate the use of US for detection of wooden FBs implanted in cadaveric specimens. Wooden FBs were randomly placed in the plantar soft-tissues of three cadaver feet by using 5-mm-long incisions. Three musculoskeletal Radiologists independently performed US in blinded fashion. Sensitivity and specificity for detection of 2.5-mm-long FBs were 86.7% and 96.7%, respectively. Sensitivity and specificity for detection of 5.0-mm-long FBs were 93.3% and 96.7%, respectively. Overall sensitivity was 90.0%, with specificity of 96.7%, accuracy of 92.3%, PPV of 98.0%, and NPV of 83.0%. US can be used effectively to locate wooden FBs as small as 2.5 mm in length. 2
28. Peterson JJ, Bancroft LW, Kransdorf MJ. Wooden foreign bodies: imaging appearance. AJR. American Journal of Roentgenology. 178(3):557-62, 2002 Mar.AJR Am J Roentgenol. 178(3):557-62, 2002 Mar. Review/Other-Dx 12 patients Retrospectively review patients with surgically confirmed wooden FBs to identify the characteristic imaging features of wooden FBs. Radiographs failed to reveal the retained FBs in all patients. With MRI, wooden FBs displayed a variable signal intensity that was equal to or less than that of skeletal muscle on both T1- and T2-weighted images. MRI showed the surrounding inflammatory response in all patients. CT showed the retained wood as linear cylindric foci of increased attenuation. Wood was highly echogenic and revealed pronounced acoustic shadowing on US. Arthrography in one patient showed an associated reactive synovitis. US is frequently underused but proved most useful for the evaluation of retained wooden FBs. 4
29. McCormick JJ, Anderson RB. Turf toe: anatomy, diagnosis, and treatment. Sports Health. 2010;2(6):487-494. Review/Other-Dx N/A To review the anatomy, diagnosis, and treatment algorithm for turf toe injury by reviewing relevant studies and presenting information useful to clinicians, therapists, and athletic trainers. Grade I injury is a sprain or attenuation of the plantar capsular ligamentous complex of the hallux MTP joint; athletes are typically able to return to play as tolerated. Grade II injury is a partial rupture of the plantar soft tissue structures of the hallux MTP joint, typically requiring about 2 weeks to recover. Grade III injury is a complete rupture of the plantar structures of the hallux MTP joint, requiring at least 10 to 16 weeks to recover. Some complete ruptures require surgical repair. 4
30. Klein EE, Weil L Jr, Weil LS Sr, Knight J. The underlying osseous deformity in plantar plate tears: a radiographic analysis. Foot ankle spec.. 6(2):108-18, 2013 Apr. Observational-Dx 106 feet, 88 patients To correlate common radiographic findings with observed intraoperative pathology in patients with plantar plate pathology. Of 106 feet, 97 had intra-operative plantar plate tears. The radiographs of patients with plantar plate tears had an increased amount of digital splay on the anteroposterior radiograph compared to patients without pathology. For patients with unilateral plantar plate pathology, the metatarsal parabola of the symptomatic foot was compared with that of the asymptomatic foot. A significantly increased second metatarsal protrusion distance as measured by 2 different methods was noted in the symptomatic foot. Odds ratios revealed that patients with an intermetatarsal angle >12, medial deviation of the second toe, and splaying of the digits were more likely to be diagnosed with a plantar plate tear intraoperatively. 3
31. Klein EE, Weil L Jr, Weil LS Sr, Bowen M, Fleischer AE. Positive drawer test combined with radiographic deviation of the third metatarsophalangeal joint suggests high grade tear of the second metatarsophalangeal joint plantar plate. Foot ankle spec.. 7(6):466-70, 2014 Dec. Observational-Dx 98 patients To examine the combined value of using clinical and radiographic findings to diagnose high grade tears (> 50% disruption) within the second metatarsophalangeal(MTP) joint. A positive drawer sign was the most informative individual test for differentiating high from low grade tears (odds ratio [OR] = 2.9; 95% confidence interval [CI], 0.92-9.5; sensitivity 91.5%; specificity 22%). Patients with longstanding forefoot symptoms (> 2 years) tended to be more likely to have low grade tears only (OR = 2.1; 95% CI, 0.98-4.5; sensitivity 61.7%; specificity 58.1%). Most radiographic measurements did little to distinguish high from low grade tears; however, the addition of ipsilateral third MTP joint transverse deviation angle showed a trend toward improving upon the diagnostic accuracy of strategies that used clinical findings alone (area under the curve [AUC] improved from 0.63 to 0.67; P = .11). A third MTP joint deviation angle greater than 15o in either direction combined with drawer testing and duration of symptoms achieved the highest specificities of any combination of variables examined in the study (specificities 82.4% [95% CI, 73.7%-91.1%] and 89.1 [95% CI, 82.1- 96.3], respectively). 2
32. Linklater JM.. Imaging of sports injuries in the foot. [Review][Erratum appears in AJR Am J Roentgenol. 2012 Oct;199(4):944]. AJR Am J Roentgenol. 199(3):500-8, 2012 Sep. Review/Other-Dx N/A To selectively review several areas in which imaging can play a major role in the diagnosis and treatment of sports injuries of the foot. Diagnostic imaging provides useful evaluation of capsuloligamentous sports injuries and Morton neuroma in the foot and facilitates appropriate treatment. An understanding of the relevant anatomy, normal imaging appearance, and the spectrum of imaging findings in the setting of injury is important for the practicing radiologist. 4
33. Preidler KW, Peicha G, Lajtai G, et al. Conventional radiography, CT, and MR imaging in patients with hyperflexion injuries of the foot: diagnostic accuracy in the detection of bony and ligamentous changes. AJR Am J Roentgenol. 1999; 173(6):1673-1677. Observational-Dx 49 patients with hyperflexion injuries of the foot (22 women and 27 men) Prospective study to compare the capabilities of conventional radiography, CT, and MRI in revealing ligamentous and bony changes in patients after hyperflexion injuries. Conventional radiographs revealed 33 metatarsal and 20 tarsal fractures for all 49 patients. CT showed 41 tarsal fractures and 53 metatarsal fractures. MRI revealed 41 metatarsal fractures and 18 metatarsal bone bruises. Conventional radiographs including weight-bearing images are not sufficient for routine diagnostic workup of patients with acute hyperflexion injuries of the foot. CT should serve as the primary imaging technique for such patients. 2
34. Freund W, Weber F, Billich C, Schuetz UH. The foot in multistage ultra-marathon runners: experience in a cohort study of 22 participants of the Trans Europe Footrace Project with mobile MRI. BMJ Open. 2012; 2(3). Observational-Dx 22 patients To determine prospectively if sustained maximal load during an ultra-marathon leads to damage to the foot. The 22 study participants did not differ significantly from the total of the 67 TEFR09 runners regarding height, weight and age. The AT diameter increased significantly from 6.8 to 7.8 mm as did intraosseous signal, bone lesions and subcutaneous oedema. However, finishers differed only regarding plantar aponeurosis and subcutaneous oedema from participants aborting the TEFR09. Inter-rater reliability was 0.88-0.98. 2
35. Sormaala MJ, Ruohola JP, Mattila VM, Koskinen SK, Pihlajamaki HK. Comparison of 1.5T and 3T MRI scanners in evaluation of acute bone stress in the foot. BMC Musculoskelet Disord. 12:128, 2011 Jun 06. Observational-Dx 10 patients To investigate the ability of radiographs, 1.5T and 3T MRI to identify acute bone marrow changes in the foot. Of the 63 acute bone stress changes seen on 3T images, 61 were also seen on 1.5T images. The sensitivity of 1.5T MRI was 97% (95% CI: 89%-99%) compared with 3T. The 3T MRI images where, therefore, at least equally sensitive to 1.5T scanners in detection of bone marrow edema. On T1-weighted sequences, 3T images were slightly superior to 1.5T images in visualizing the demarcation of the edema and bone trabeculae. The kappa-value for inter-observer variability was 0.86 in the MRI indicating substantial interobserver agreement. 3
36. Gerling MC, Pfirrmann CW, Farooki S, et al. Posterior tibialis tendon tears: comparison of the diagnostic efficacy of magnetic resonance imaging and ultrasonography for the detection of surgically created longitudinal tears in cadavers. Invest Radiol. 2003; 38(1):51-56. Observational-Dx 16 fresh cadaveric foot and ankle specimens (3 men, 13 women; average age at death 83.9 years; age range 71-96 years) Prospective blinded study to compare diagnostic efficacy of MRI and US for the detection of surgically created longitudinal tears in cadavers. Sensitivity, specificity, and accuracy of MRI in the diagnosis of PTT tears were 73%, 69%, and 72%, respectively. Dynamic US interpretation yielded values of 69% sensitivity, 81% specificity, and 72% accuracy. Static US interpretation was less reliable than dynamic interpretation, and the only significance of static imaging was a high specificity (94%) for detection of longitudinal tears. PPV for MRI and US was 88% and 92% respectively, and the NPV was 46% for both MRI and US. Results suggest that US and MRI perform at the same level for the detection of surgically created longitudinal PTT tears in a cadaveric model. US has a higher specificity compared with MRI. 1
37. Kuwada GT. Surgical correlation of preoperative MRI findings of trauma to tendons and ligaments of the foot and ankle. J Am Podiatr Med Assoc. 2008; 98(5):370-373. Observational-Dx 28 patients Retrospective study to determine whether MRI findings are accurate and can be confirmed surgically. Surgical correlation of preoperative MRI findings of trauma to tendons and ligaments of the foot and ankle were examined in patients who had undergone surgical repair for tears of the Achilles tendon, posterior tibial tendon, peroneal tendons, collateral ligaments, and other pathology. MRI findings are confirmed surgically 83% of the time for tears of tendons and ligaments of the foot and ankle. Larger tendons (Achilles, PTT) have 94% sensitivity and 6% specificity, respectively. Collateral ligament and high ankle sprains have 73% sensitivity. There is a lower sensitivity of 57% for peroneus brevis and longus ruptures. Study revealed that peroneal trauma can be an isolated event and in some cases can occur with other traumatic pathology such as collateral ligament tears. 3
38. Macmahon PJ, Dheer S, Raikin SM, et al. MRI of injuries to the first interosseous cuneometatarsal (Lisfranc) ligament. Skeletal Radiol. 38(3):255-60, 2009 Mar. Review/Other-Dx 15 patients (16 feet) To assess the value of MRI in diagnosing injury to the first interosseous cuneometatarsal (Lisfranc) ligament and to additionally determine the associated patterns of traumatic soft-tissue and osseous injury. Surgical reports used as the reference standard. 7/10 cases of grade 3 Lisfranc ligament injuries at surgery were correctly graded at MRI. No cases of surgically proven complete Lisfranc ligament tears (grade 3) were interpreted as normal at MRI. All Lisfranc ligament sprains (grade 2 or 3) at surgery were detected at MRI. 2/6 cases reported as grade 1 injuries at MRI was normal at surgery. No cases of surgically proven normal or sprained Lisfranc ligaments were interpreted as grade 3 tears on MRI. 4/6 of our cases of normal or sprained Lisfranc ligaments demonstrated fractures; while the minority of complete Lisfranc ligament tears (3/10) contained fractures. MRI is reasonably accurate at detecting traumatic injury to the Lisfranc ligament. 4
39. Klauser AS, Tagliafico A, Allen GM, et al. Clinical indications for musculoskeletal ultrasound: a Delphi-based consensus paper of the European Society of MusculoSkeletal Radiology. Eur Radiol. 2012; 22(5):1140-1148. Review/Other-Dx 16 musculoskeletal Radiologists from 7 European countries To develop clinical guidelines for musculoskeletal US referral in Europe. On expert consensus, the use of musculoskeletal US is indicated to detect joint synovitis, fluid and septic effusion for potential aspiration, and poorly indicated to detect loose bodies. Recommendations for most appropriate use of musculoskeletal US are reported in six areas relevant to musculoskeletal US: hand/wrist, elbow, shoulder, hip, knee and ankle/foot. 4
40. Nallamshetty L, Nazarian LN, Schweitzer ME, et al. Evaluation of posterior tibial pathology: comparison of sonography and MR imaging. Skeletal Radiol. 2005;34(7):375-380. Observational-Dx 18 women; 22 ankles evaluated with US and MRI To compare the results of US and MRI in detecting pathology of the PTT in patients with PTT dysfunction. Based on a commonly accepted staging system for PTT dysfunction, 6 ankles were classified as stage I, 11 ankles as stage II, and 5 ankles as stage III. All stage I ankles were interpreted as having an intact PTT by both MR imaging and US. In the stage II and III tendons, MR imaging demonstrated PTT tears in 12 of 22 examinations, including 11 partial tears and 1 complete tear. US demonstrated PTT tears in 8 of 22 examinations, including 8 partial tears and no complete tears. The findings of US and MR imaging were consistent in 17 of 22 cases (77%). The five inconsistencies were as follows: in 4 cases, US reported tendinosis when MR imaging interpreted partial tears (no change in management); in one case, US diagnosed a partial tear when MR reported a complete tear of the PTT (no change in management because the clinical findings were more consistent with a partial tear). In this study, US and MR imaging of the PTT were concordant in the majority of cases. US was slightly less sensitive than MR imaging for PTT pathology, but these discrepancies did not affect clinical management. 3
41. Castro M, Melao L, Canella C, et al. Lisfranc joint ligamentous complex: MRI with anatomic correlation in cadavers. AJR Am J Roentgenol. 2010; 195(6):W447-455. Review/Other-Dx 10 cadaveric specimens To clarify the ligamentous anatomy of the Lisfranc joint complex and show the diagnostic capability of MRI in the assessment of the Lisfranc joint complex with detailed anatomic correlation in cadavers. By clearly defining the normal ligaments that contribute to the stability of the Lisfranc joint, MRI allows a more precise and correct diagnosis of the origin of the Lisfranc joint instability, perhaps permitting a more specific surgical management. MRI also allows a better understanding of the normal imaging anatomy of the different ligamentous components of the Lisfranc joint, mainly of the Lisfranc and plantar Lisfranc ligaments. 4
42. Melao L, Canella C, Weber M, Negrao P, Trudell D, Resnick D. Ligaments of the transverse tarsal joint complex: MRI-anatomic correlation in cadavers. AJR Am J Roentgenol. 2009; 193(3):662-671. Observational-Dx 10 cadaveric specimens To clarify the detailed anatomy of the transverse tarsal joint ligamentous complex and evaluate the diagnostic capability of MRI in the assessment of the tarsal joint complex with detailed anatomic correlation in cadavers. In all 10 cadaveric specimens, the various ligamentous elements, their different configurations, imaging characteristics, and contributions to the overall stability of the transverse tarsal joint complex were identified. By clearly defining the normal ligaments that contribute to the stability of the calcaneocuboid joint, MRI allows a more precise and correct diagnosis of the etiology of the calcaneocuboid instability, perhaps permitting a more specific surgical management. MRI also allows a better understanding of the normal imaging anatomy of the different components of the ligamentous structures of the talocalcaneonavicular joint, particularly of the spring ligament complex. 3
43. Potter HG, Deland JT, Gusmer PB, Carson E, Warren RF. Magnetic resonance imaging of the Lisfranc ligament of the foot. Foot Ankle Int. 1998; 19(7):438-446. Review/Other-Dx 23 patients Patients (mean age, 25.4 years) with a history of midfoot trauma with both radiographs and MRI were studied. MRI revealed 2 intact ligaments, 3 complete tears, and 18 partial tears. MRI was found to be useful in identifying Lisfranc ligament tears. If there is clear diastasis on weight-bearing radiographs, MRI is not indicated. Whereas radiographic findings may be equivocal, however, MRI may accurately disclose the degree of ligament disruption. 4
44. Raikin SM, Elias I, Dheer S, Besser MP, Morrison WB, Zoga AC. Prediction of midfoot instability in the subtle Lisfranc injury. Comparison of magnetic resonance imaging with intraoperative findings. J Bone Joint Surg Am. 2009; 91(4):892-899. Observational-Dx 20 patients: 10 women and 10 men (21 feet) To assess the utility of MRI for the diagnosis of an injury to the Lisfranc and adjacent ligaments and to determine whether conventional MRI is a reliable diagnostic tool, with manual stress radiographic evaluation with the patient under anesthesia and surgical findings being used as a reference standard. Radiographic observations were compared with intraoperative findings. 17 unstable and 4 stable Lisfranc joints were identified intraoperatively. The strongest predictor of instability was disruption of the plantar ligament between the first cuneiform and the bases of the second and third metatarsals (the pC1-M2M3 ligament), with a sensitivity, specificity, and PPV of 94%, 75%, and 94%, respectively. 19 (90%) of the 21 Lisfranc joint complexes were correctly classified on MRI. MRI is accurate for detecting traumatic injury of the Lisfranc ligament and for predicting Lisfranc joint complex instability when the plantar Lisfranc ligament bundle is used as a predictor. 3
45. Ulbrich EJ, Zubler V, Sutter R, Espinosa N, Pfirrmann CW, Zanetti M. Ligaments of the Lisfranc joint in MRI: 3D-SPACE (sampling perfection with application optimized contrasts using different flip-angle evolution) sequence compared to three orthogonal proton-density fat-saturated (PD fs) sequences. Skeletal Radiol. 42(3):399-409, 2013 Mar. Observational-Dx 31 asymptomatic feet and 15 patients To compare the detection rate and visibility of the ligaments in the Lisfranc joint with a single 3D-SPACE MR sequence and 3 orthogonal proton-density fat-saturated sequences. In asymptomatic feet, 692 ligaments were detected with the SPACE sequence, 90.6% exhibited normal signal, and most (96.9%) were completely visible on one single image. A total of 659 ligaments were detected with the proton-density fat-saturated sequence, 86.6% yielded normal signal, and 28.5% were completely visible on one single image. In patients, 327 ligaments were detected with SPACE, 50.6 % appeared completely visible with high signal. On proton-density fat-saturated, 308 ligaments were detected, 42.2% of the ligaments had high signals. 2
46. Ting AY, Morrison WB, Kavanagh EC. MR imaging of midfoot injury. [Review] [26 refs]. Magn Reson Imaging Clin N Am. 16(1):105-15, vi, 2008 Feb. Review/Other-Dx N/A To discuss other traumatic entities affecting the midfoot region, which in the case of tendon pathology often goes hand in hand with degenerative and metabolic conditions. MRI is the imaging modality of choice for the evaluation of acute and chronic injuries of the midfoot. The complex anatomy of this region demands the multiplanar capabilities of this modality, and because injuries of this region most commonly involve the tendon, ligament, and muscular supports of the foot and ankle, MR offers superior soft tissue resolution. MRI has the added advantage of accurate osseous injury characterization in most instances; however, CT may also be required because the two modalities are complementary for demonstrating pathology of bone. 4
47. Ballard DH, Campbell KJ, Blanton LE, et al. Tendon entrapments and dislocations in ankle and hindfoot fractures: evaluation with multidetector computed tomography. EMERG. RADIOL.. 23(4):357-63, 2016 Aug. Review/Other-Dx 398 patients To assess the incidence of tendon entrapments and tendon dislocations associated with ankle and hindfoot fractures in patients studied by multidetector computed tomography (MDCT). There were 30 (46.9 %) patients with 40 tendon entrapments, 31 (48.4 %) patients with 59 tendon dislocations, and three (4.7 %) patients with both tendon entrapment and dislocation. All patients with tendon entrapments were seen with either pilon fractures and/or a combination of posterior, medial, or lateral malleolar fractures. The most frequently entrapped tendon was the posterior tibialis tendon (PTT) in 27 patients (27/30, 90.0 %). The peroneal tendons were the most frequently dislocated, representing 27 (87.1 %) of patients with tendon dislocation; all resulted from a talar or calcaneal fracture or subluxation. 4
48. Golshani A, Zhu L, Cai C, Beckmann NM. Incidence and Association of CT Findings of Ankle Tendon Injuries in Patients Presenting With Ankle and Hindfoot Fractures. AJR. American Journal of Roentgenology. 208(2):373-379, 2017 Feb. Review/Other-Dx 410 patients To identify the incidence and associations of tendon injuries in ankle CT examinations performed for fractures. Tendon injuries were common, seen in 25% of all ankle CT examinations. Tendon subluxation-dislocation accounted for most of the tendon injuries (77 of 196 total injuries). Pilon fractures carried 2.2 times increased risk of tibialis posterior tendon injury (p = 0.0094). Calcaneus fractures carried 11.86 times increased risk of peroneus brevis tendon and 10.71 times increased risk of peroneus longus tendon injury (p < 0.0001). Calcaneus fractures also carried 5.21 times increased risk of flexor hallucis longus tendon injury (p = 0.0024). Talus fracture was associated with injury to all flexor compartment tendons. Talus fractures carried 3.43 times increased risk of tibialis posterior tendon injury (p < 0.0001), 4.51 times increased risk of flexor digitorum longus tendon injury (p = 0.0005), and 6.97 times increased risk of flexor hallucis longus tendon injury (p < 0.0001). 4
49. Ohashi K, Restrepo JM, El-Khoury GY, Berbaum KS. Peroneal tendon subluxation and dislocation: detection on volume-rendered images--initial experience. Radiology. 242(1):252-7, 2007 Jan. Observational-Dx 32 patients (24 men, 8 women; mean age, 41 years; age range, 18-75 years); 37 images; 2 readers To retrospectively assess the time efficiency of 3D volume-rendered images obtained from MDCT data for the diagnosis of peroneal tendon subluxation or dislocation by using the consensus interpretation of MPR images as the reference standard. Average time required for diagnosis was significantly shorter with volume-rendered images than with MPR images (reader 1: 42 vs 78 seconds, P<.001; reader 2: 50 vs 69 seconds, P<.01). 2
50. Rosenfeld P. Acute and chronic peroneal tendon dislocations. Foot Ankle Clin. 2007; 12(4):643-657, vii. Review/Other-Dx N/A To review acute and chronic peroneal tendon dislocations. Peroneal tendon dislocation is an infrequent sports injury and can be difficult to diagnose. Posterior fibula tenderness and pain with eversion are useful signs to discriminate this from an ankle sprain. In the acute setting, a direct repair provides good results but may need to be augmented with additional soft tissue or bony restraints. For chronic injuries, there are several methods of reconstruction, all with acceptable outcomes, although bone block procedures have the highest rate of secondary procedures. 4
51. Baker JC, Hoover EG, Hillen TJ, Smith MV, Wright RW, Rubin DA. Subradiographic Foot and Ankle Fractures and Bone Contusions Detected by MRI in Elite Ice Hockey Players. Am J Sports Med. 44(5):1317-23, 2016 May. Observational-Dx 27 participants To study foot and ankle bone injuries detected with magnetic resonance imaging (MRI) that occurred in elite hockey players. The observers identified at least 1 bone injury in 27 of the 31 MRI examinations, including 10 with radiographically occultfractures. Agreement among the 3 observers for injury categorization was substantial (k = 0.76). Seventeen injuries were causedby a direct blow (15 from a moving puck, 2 from an uncertain source), resulting in 6 fractures and 6 high-grade bone contusions,with 14 of the 17 involving a medial bone (medial malleolus, navicular, or first metatarsal base). Compared with other mechanisms,direct impaction was statistically more likely to result in a severe bone injury and to involve the medial foot and ankle. In 20 injurieswhere return-to-play information was available, players with severe bone injuries missed a mean of 10.6 games compared with2.4 games for other players (P = .05). 2
52. Walter WR, Hirschmann A, Alaia EF, Garwood ER, Rosenberg ZS. JOURNAL CLUB: MRI Evaluation of Midtarsal (Chopart) Sprain in the Setting of Acute Ankle Injury. AJR 2018;210:386-95. Observational-Dx 47 patients with ankle injury and 16 control To determine the frequency and MRI appearance of osseous and ligamentous injuries in midtarsal (Chopart) sprains and their association with ankle sprainsafter acute ankle injuries. MR images of control subjects (n = 16) and patients with ankle injury (n = 47) were reviewed. The normal dorsal calcaneocuboid and calcaneocuboid component of bifurcate ligaments were variably visualized; the remaining normal ligaments were always seen. Eleven patients (23%) had midtarsal ligamentous and osseous injury consistent with midtarsal sprain (eight acute or subacute, one probable, and two old). Six (75%) of eight acute or subacute cases had coexisting lateral collateral ligament injury. Eighty-nine percent of osseous injuries were reported prospectively, but 83% of ligamentous injuries were missed. Substantial interobserver agreement was achieved regarding diagnosis of midtarsal sprain. 3
53. Hirschmann A, Walter WR, Alaia EF, Garwood E, Amsler F, Rosenberg ZS. Acute Fracture of the Anterior Process of Calcaneus: Does It Herald a More Advanced Injury to Chopart Joint?. AJR. American Journal of Roentgenology. 210(5):1123-1130, 2018 May. Observational-Dx 21 patients To assess the coexistence of injuries at the calcaneocuboid and talonavicular joint using radiography and MRI and to correlate our findings with radiologic and clinical diagnoses. Radiographic and MRI rates of detection of injuries across the Chopart joint were statistically different. Calcaneocuboid avulsion fractures were evident on 48% of radiographs and 100% of MR images (p = 0.001). Talonavicular joint injuries were evident on 38% of radiographs and 76% of MR images (p = 0.008). Concomitant injury at both joints was evident on 14% of radiographs and 76% of MR images (p < 0.0001). Interrater agreement was 0.488–0.637 and 0.286–0.364 for talonavicular and 0.144–0.538 and 0.976–1 for calcaneocuboid injuries on radiography and MRI, respectively. Sixty percent of calcaneocuboid fractureswere prospectively missed on radiography (none on MRI), whereas 38% and 25% of talonavicular findings were missed on radiography and MRI, respectively. Sixty percent of injuries were clinically misdiagnosed as ankle sprains. Chopart joint injury was never mentioned in prospective clinical or imaging diagnoses. 3
54. Torriani M, Thomas BJ, Bredella MA, Ouellette H. MRI of metatarsal head subchondral fractures in patients with forefoot pain. AJR Am J Roentgenol. 2008; 190(3):570-575. Observational-Dx 131 wounds in 105 patients To determine if bedside US and perception of wound FBs are useful screening tools for detecting wound FBs in a prospective consecutive sample of children aged 18 years or younger. Utilities of US and US with FB perception were compared with radiography for screening for wound FBs. FBs were identified in 12 wounds (9.2%). Bedside US is comparable to the performance of radiography interpreted by an attending pediatric radiologist. Bedside US alone or combined with patient perception may be an adequate initial screening tool for detecting wound FBs. 3
55. Arbona N, Jedrzynski M, Frankfather R, et al. Is glass visible on plain radiographs? A cadaver study. J Foot Ankle Surg. 38(4):264-70, 1999 Jul-Aug. Observational-Dx 18 randomly selected pieces of nonleaded glass from a collection of 30 pieces from broken bottles of 4 known color types To determine if regular glass is visible on plain radiographs and whether color, location, or volume of these fragments had any effect on the detection of nonleaded glass. Five examiners read radiographs. Overall sensitivity for all of the examiners was 90%; overall false-positive rate was 10%. Intraobserver and interobserver Pearson’s correlation coefficients showed reliability between the first and second readings and between observers. Authors conclude that regular nonleaded glass is radiographically visible. 4
56. Nery C, Umans H, Baumfeld D. Etiology, Clinical Assessment, and Surgical Repair of Plantar Plate Tears. [Review]. Semin Musculoskelet Radiol. 20(2):205-13, 2016 Apr. Observational-Dx N/A To review etiology, clinical assessment and surgical repair of plantar plate tears. No results stated in abstract. 4
57. Jamadar DA, Jacobson JA, Caoili EM, et al. Musculoskeletal sonography technique: focused versus comprehensive evaluation. AJR Am J Roentgenol. 2008; 190(1):5-9. Observational-Dx 602 patients To evaluate the utility of performing a focused musculoskeletal US examination on the basis of patients' presenting complaints. 83% of the 602 patients had a sonographically detectable abnormality, 2.2% of whom had an abnormality not detectable by routine protocol-based scanning. The more peripheral the body part, the more likely that abnormalities detected by US correlated with focal symptoms: 81% in the wrist and hand and 73% in the ankle and foot, compared with the more central body parts of 15% in the shoulder and 31% in the hip. Chi-square analysis showed a significant association between the body part scanned and a detectable abnormality (P<0.0001). 3
58. Slater HK. Acute peroneal tendon tears. Foot Ankle Clin. 2007;12(4):659-674, vii. Review/Other-Dx N/A To review acute peroneal tendon tears. No results stated in abstract. 4
59. Woodward S, Jacobson JA, Femino JE, Morag Y, Fessell DP, Dong Q. Sonographic evaluation of Lisfranc ligament injuries. J Ultrasound Med. 28(3):351-7, 2009 Mar. Review/Other-Dx 10 patients Study role of US in Lisfranc injuries. Sonography reports (2000-2007) were searched for “Lisfranc,” and US images of affected and asymptomatic contralateral feet were reviewed, recording the thickness of the dorsal ligament between the first (medial) cuneiform and second metatarsal) ligaments, distance between cuneiform and second metatarsal ligament, and change in this distance with weight bearing, hyperemia, and fractures. Nonvisualization of the dorsal cuneiform and second metatarsal ligament and a cuneiform and second metatarsal ligament distance of 2.5 mm or greater were indirect signs of a Lisfranc ligament tear. Dynamic evaluation with weight bearing showed widening of the space between cuneiform and second metatarsal ligament. 4
60. Kaicker J, Zajac M, Shergill R, Choudur HN. Ultrasound appearance of the normal Lisfranc ligament. EMERG. RADIOL.. 23(6):609-614, 2016 Dec. Observational-Dx 50 patients To prospectively evaluate the ultrasound appearance of the normal Lisfranc’s ligament in 50 patients (100 ft) with no prior or current ligament injury. The mean right- and left-sided ligament (RT) thickness were 0.096 (0.021) and 0.104 (0.023), respectively. The mean right- and left-sided ligament RT length was 0.54 (0.11) and 0.57 (0.11), respectively. The appearance of the ligament was similar in all patients with a central thin band of hypoechogenicity lined by hyperechoic lines on either side. 3
61. Marshall JJ, Graves NC, Rettedal DD, Frush K, Vardaxis V. Ultrasound assessment of bilateral symmetry in dorsal Lisfranc ligament. J Foot Ankle Surg. 52(3):319-23, 2013 May-Jun. Observational-Dx 50 subjects To investigate whether bilateral symmetry exists in the human dorsal Lisfranc ligament (dLL) under different loads and positions using readily available ultrasoundtechnology. The bilateral pooled dLL length was 7.01 +- 1.38 mm and showed a moderate correlation with the foot length and width. No bilateral differences were found in the dLL length under any of the stress loads in the abducted position or under the medium and high stress load in the rectus position. However, the low stress load rectus position demonstrated a significant bilateral difference in the dLL length (p = .005). The smallest bilateral difference was observed at the 15 degrees abducted position under medium stress (measurement error mean -0.062 mm). 2
62. Ryba D, Ibrahim N, Choi J, Vardaxis V. Evaluation of dorsal Lisfranc ligament deformation with load using ultrasound imaging. FOOT. 26:30-5, 2016 Mar. Observational-Dx 50 participants To assess the deformation characteristics of the asymptomatic dorsal Lisfranc ligament (dLL) using physiologically relevant stress/loads in a clinical setting and to discern normative dLL parameters. The average dLL elongation, as percent resting length change, was 8.76% between seated and single leg standing positions. Most of the dLL elongation (6.26%) occurred between seated and bilateral standing. 3
63. Khoury V, Guillin R, Dhanju J, Cardinal E. Ultrasound of ankle and foot: overuse and sports injuries. [Review] [119 refs]. Semin Musculoskelet Radiol. 11(2):149-61, 2007 Jun. Review/Other-Dx N/A To review the use of US for ankle disorders related to sports or overuse that affect tendons, including tendinosis, tenosynovitis, paratendinitis, rupture, dislocation, and ligaments that are commonly torn. No results stated in abstract. 4
64. Gregg J, Silberstein M, Schneider T, Marks P. Sonographic and MRI evaluation of the plantar plate: A prospective study. Eur Radiol. 2006; 16(12):2661-2669. Observational-Dx 160 asymptomatic and 160 symptomatic plantar plates To establish the accuracy of US in the examination of the plantar plate by comparing it with MRI, or if available, surgical findings. US detected 75/160 and 139/160 plantar plates torn in the asymptomatic and symptomatic groups, respectively. MRI detected 56/160 and 142/160 tears in the symptomatic and asymptomatic groups, respectively. The sensitivity of MRI and US with surgical correlation was calculated to be 87 and 96%, respectively, with poor specificity. US correlates moderately with MRI in the evaluation of the plantar plate. Surgical correlations, although limited (n=10), indicate US is superior to MRI with more accurate detection of tears. 3
65. Grant TH, Kelikian AS, Jereb SE, McCarthy RJ. Ultrasound diagnosis of peroneal tendon tears. A surgical correlation. J Bone Joint Surg Am. 2005;87(8):1788-1794. Observational-Dx 58 patients Prospectively evaluate patients to determine whether US is effective for evaluating peroneal tendon injuries, with surgical findings used as the standard of reference. Of 60 tendons evaluated operatively, 25 were torn. The sensitivity, specificity, and accuracy of US were 100%, 85%, and 90%, respectively. Dynamic US should be considered a first-line diagnostic tool. The use of dynamic US is effective for determining the presence or absence of a peroneal tendon tear and should be considered a first-line diagnostic tool. 3
66. Pattamapaspong N, Srisuwan T, Sivasomboon C, et al. Accuracy of radiography, computed tomography and magnetic resonance imaging in diagnosing foreign bodies in the foot. Radiol Med (Torino). 118(2):303-10, 2013 Mar. Experimental-Dx 160 FBs (cadaver feet) To determine the accuracy of conventional radiography, CT and MRI in detecting FBs by using cadaver feet. Overall sensitivity and specificity for FB detection was 29% and 100% for radiographs, 63% and 98% for CT and 58% and 100% for MRI. The sensitivity of radiography was lower in the forefoot. CT and MRI detection rates depended on the attenuation values of the FBs and on the susceptibility artifact, respectively. CT was superior to MRI in identifying water-rich fresh wood. 2
67. American College of Radiology. ACR Appropriateness Criteria® Radiation Dose Assessment Introduction. Available at: https://www.acr.org/-/media/ACR/Files/Appropriateness-Criteria/RadiationDoseAssessmentIntro.pdf. Review/Other-Dx N/A To provide evidence-based guidelines on exposure of patients to ionizing radiation. No abstract available. 4
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