AGNES KAWEME FOOT ULTRASOUND
•
•
•
•
•
•
•
•
•
•
•
•
•
Student:
Student Number:
Email Address:
School:
Workplace:
Lecturer:
Due Date:
Agnes Kaweme
17324438
Agnes.kaweme@postgrad.curtin.edu.au
Science and Engineering
My Radiology Centre (MRC) Perth
Le-Anne Grimshaw
26/05/2014
I declare that this assignment is my own work and has not been
submitted in any form for another unit, degree or diploma at any
university or other institute of tertiary education. Information derived
from the published or unpublished work of others has been
acknowledged in the text and a list of references is given. I warrant that
any disks and or computer files submitted as part of this assignment have
been checked for viruses and reported clean.
Student Signature: akaweme
Date: 30/05/2014
INTRODUCTION
Ultrasound is effective in diagnosis of various disorders of the foot. Throughout
the semester theoretical and practical knowledge has been gained to assist in
developing and improving my technique in foot ultrasound. This portfolio
presents a case study from one of the cases I came across which has been
beneficial in further developing my skills.
NORMAL BONE ANATOMY
Structures of the hind foot


•
•
•
•
•
•
•
Calcaneus – Lies posteriorly forms the heel and lever for the muscles of
the calf. Cuboid in shape with 6 articular surfaces- superiorly it supports a
fat pad for the Achilles tendon-the posterior surface articulates with the
talus- the anterior surface articulates with the cuboid bone, other surfaces
serve as attachments for ligaments of the foot of the foot. -It’s the largest
bone of the foot- transmits the weight of the body to the ground
Talus- second largest tarsal bone in the foot, irregularly shaped- the head
of the talus articulates with the navicular, The neck serves as an
attachment for ligaments of the foot and the body supports the leg
through articulations with the medial and lateral malleolus –rests on the
calcaneus
Mid foot- 5 Tarsal bones
Cuboid- found on the lateral aspect of the foot – pyramid shaped and
gives shape to the transverse arch of the foot-articulates with the
calcaneus, cuneiform, the 4th and 5th metatarsals and the navicular bone
Navicular- found medially
3Cuneiforms – lateral –mid –medial
Forefoot - 5 metatarsals-5 proximal phalanges- 5 middle phalanges
4 distal phalanges
Joints- Talo-calcaneal joint. -Talo-navicular joint medially, - Calcaneocuboid joint lateral aspect, Transverse tarsal metatarsal joints- 1-5
Metatarsophalangeal joints
1-5 proximal inter- phalangeal joints – 1-4 –distal interphalangeal joints.
(Bianchi and Martinoli 2007).
TENDONS AND MUSCLES
DORSAL ASPECT
•
Extensor digitorum brevis its an intrinsic wide thin muscle of the dorsum
of the foot- originates from the dorsal and lateral surface of the calcaneus-
•
•
inserting on the lateral sides of the extensor digitorum longus tendons of
digits 2-4- main action is to extend digits 2-4
Tibialis anterior – originates from the lateral condyle and proximal lateral
shaft of the tibia, inserts on the base of the metatarsal 1 and medial
cuneiform innervated by the deep Peroneal nerve, its main action is to
dorsiflex and inverse the foot
Extensor hallucis brevis- originates from the dorsal portion of the
calcaneus, inserting on the dorsal surface of the base of the proximal
phalanx of digit 1 or the great toe
PLANTAR ASPECT
FIRST LAYER OF MUSCLES
• Flexor digitorum brevis-first layer intrinsic muscle of the plantar surface
of the foot-acts on digits 2-5 – originates from the medial process of the
calcaneal tuberosity, plantar aponeurosis- inserts on the lateral surfaces
of the middle phalanx of digits 2-5- main action is to flex digits 2-5. The
muscle is innervated by the medial plantar nerve
• Flexor hallucis longus-originates from the inferior two thirds of the
posterior fibula and the inferior interosseous membrane –inserting on the
inferior surface of the first distal phalanx - main action is to flex the distal
phalanx, is innervated by the medial plantar nerve
• Abductors hallucis- originates from the flexor retinaculum, medial
process of the calcaneal tuberosity, plantar aponeurosis –its an intrinsic
muscle of the first layer of medial side of the plantar surface of the footmain action is to abduct digit 1 Innervated by the medial plantar nerve
• Abductor digiti minimi-originates from the lateral process of the calcaneal
tuberosity and the plantar aponeurosis – inserts on the lateral side of the
proximal phalanx of the 5th digit- main action is to abduct and flex the 5th
digit (Human anatomy atlas 2014)
•
SECONDD LAYER OF MUSCLES



Quadratus plantae- has two heads originates from the medial and lateral
sides of the calcaneus, Insertion - the two portions join and end in a
flattened band at the tendon of the flexor digitorum longus, innervated by
the medial and the lateral plantar branches.
Flexor digitorum longus – originates from the posterior surface of the
tibia, insertion is on the inferior surfaces of the distal phalanges 2-5,
innervated by the deep Peroneal branch of the tibial nerve, main action is
to flex the phalanges of the distal joints 2-5, inversion and plantar flexion
of the foot.
Lumbricals- originates from the tendons of flexor digitorum longus.
Insertion s on the dorsal surface of the proximal phalanges 2-4,
innervated by the terminal divisions of the tibial nerve. The first
lumbrical innervated by the medial plantar nerve. Second, third and
fourth lumbricals by the lateral plantar nerve, main action is to flex the
metatarsophalangeal joints.
THIRD LAYER OF MUSCLES
 Flexor hallucis brevis- originates from the plantar surface of the lateral
cuneiform and cuboid bones- splits into two parts as it approaches its
insertion - to the proximal phalanx of the great toe, innervated by the
medial plantar nerve.
 Adductor hallucis oblique head- originates from the second, third and
fourth metatarsals and the tendon sheath of peroneus longus, inserts on
the base of the proximal phalanx of the great toe (hallux), innervated by
the lateral plantar nerve. The trans verse originates from the plantar
metatarsophalangeal ligaments of the third, fourth and fifth digit joints
and inserts on the lateral side of the great toe, innervation is by the lateral
plantar nerve, main action is to adduct the great toe.
 Flexor digiti minimi-originates from the base of the fifth metatarsal bone,
inserting on the lateral side of the base of the fifth toe, innervated by the
superficial branch of the lateral plantar nerve, main action is to flex the
metatarsophalangeal joint of the fifth toe (small toe).
FOURTH LAYER OF MUSCLES
 There are three bipennate plantar interossei a combined with the four
dorsal interossei – originates from the bases and medial sides of the
metatarsals of the third, fourth and fifth digits, inserting on the bases of
the proximal phalanx of the third, fourth and fifth digits, innervated by the
lateral plantar nerve, main action is to adduct the third, fourth and fifth
digits flexing the metatarsophalangeal joints (MTPs) extending the
proximal interphalangeal (PIP) joints and distal interphalangeal (DIP)
joints
LIGAMENTS





Plantar fascia- this is a thick hypoechoic, fibrillar band with similar
appearance to tendons plantar becomes thin towards the mid and fore
foot– originates from the medial tubercle of the calcaneal tuberosity,
splits distally inserting on the metatarsal heads.
Plantar plates are the main platform for weight bearing; the metatarsal
heads provide stability of the metatarsophalangeal joints by resisting
dorsiflexion of the foot.
Long plantar and plantar calcane0cuboid ligaments arise from the
calcaneus to the cuboid.
Lateral ligaments -posterior talofibular ligament, posterior tibiofibular
ligament, anterior tibiofibular ligament, anteriortalofibular ligament
Medial ligaments – posterior tibiofibular part, tibiocalcaneal part, anterior
tibiotalar part, tibionavicular part
VASCULAR CIRCULATION
According to Bianchi and Martinoli (2007,841), The main vascular supply
to the foot is by the dorsalis pedis artery. A continuation of the anterior
tibial artery (ATA) branches to supply oxygenated blood to the dorsal
surface of the foot. A network of superficial veins in the foot form the
dorsal venous arch which carry de-oxygenated blood and drains into the
great and small saphenous veins through dorsalis pedis vein. The deep
plantar venous network from distal to proximal forms the deep venous
arch located in the plantar surface of the foot- connects with dorsal
metatarsals. The medial and lateral plantar veins navigate posteriorly
from the deep plantar arch uniting near the calcaneal region to form the
posterior tibial vein.
NERVES
The foot is innervated by the deep tibial nerve, which divides into the
medial and lateral planter nerves:
The medial planter nerve further branches into the abductor hallucis
nerve, flexor digitorum brevis nerve, 1st lumbrical, medial proper plantar
nerve and digital nerves to the 3 1/2 toes
The lateral plantar nerve branches into Quadratus plantae nerve,
abductor hallucis nerve, interosseous nerve, two to fourth lumbricals and
digital nerves to lateral one and half toes (Ebrahaem 2013).
The sural nerve is composed of two branches – one from the tibial nerve
and the other from the common peroneal nerve. Its distal continuation
supplies sensation to the lower lateral leg, lateral heel, ankle and dorsal
foot.
The deep fibular nerve innervates the extensor digitorum brevis and the
first 2 interosseous muscles.
INDICATIONS FOR EXAMINATION OF THE FOOT
Below are some of the indications for examination of the foot:
•
•
•
•
•
•
•
•
•
•
•
•
Sports injuries
Chronic pain in the foot- could be hind for plantar fascia, mid or forefoot
Muscular, ligament and tendon tears
Vascular pathology
Lumps and bumps in the foot
Arthritis
Suspected bony spur
Ganglia, lipomas
Foot swelling
Foot pain- suspected Morton’s neuroma
Ultrasound guided joint injections and aspiration
Bursitis (Grimshaw 2014)
Morton’s Neuroma
Morton’s neuroma is a benign growth of the nerve tissue, which develops in the
foot, commonly between the third and the fourth toes. It is also known as an
intermetatarsal neuroma. It is the thickening of the nerve tissue and located in
the ball of the foot. It is caused by compression and irritation of the nerve, which
becomes fibrous as a result of acute foot arch, flat feet and wearing high heeled
or narrow shoes (Betts et al 2003). Patient history is taken into consideration
when diagnosing Morton’s neuroma. Kaminski et al (1997,37) states that
ultrasound is helpful in confirming the presence of an enlarged neuroma.
CASE STUDY
A 29 years old lady presented at our imaging department with a request form for
ultrasound of both feet.
Clinical findings- Pain on the tarsometatarsal joints, with bony growth on the
dorsum of the left foot.
The patient was asked questions concerning the on set of symptoms, medical
history and current medication she was taking. She confirmed pain had
developed in both feet over a period of six months on and off having been on
analgesics and anti-inflammatory medication. She described her pain as burning,
sometimes numbness in the foot as well as tingling and pricking felt from time to
time. She also acknowledged the fact that she used to wear high-heeled shoes
prior to her pain starting, found relief in wearing padded shoes.
SCANNING TECHNIQUE:
Right forefoot
The patient was scanned in a sitting position with both plantar aspects of the feet
on the couch. The right forefoot was scanned first, from the dorsum aspect
starting at the 1st metatarsal phalangeal joint (MTPJ) in longitudinal through to
the 5th MTPJ assessing each joint space and extensor tendons. Then the
tarsometatarsal joints were assessed from 1st-5th joint spaces, they all appeared
normal (refer to images 1-5)
The plantar aspect of the foot was scanned with right leg extended and the foot is
flexed at the ankle joint to allow easy access to the webspaces 1-2, 2-3 and 3-4.
Complex webspaces were demonstrated and compression was applied, 2nd -3rd
right webspace was non compressible suggestive of possible presence of a
neuroma. The other webspaces were compressible; the complex appearances
were possible bursitis (refer to images 6 and 8)
Left foot
The plantar aspect of the foot was placed on the couch scanning in longitudinal
plane from the 1- 5 MTPJ assessing joint spaces and the extensor tendons, which
appeared normal. With the leg extended the plantar aspect of the foot was
scanned, assessing the web spaces 1-2, 2-3, and 3-4. The 2-3 webspace was
pathological in that it was non compressible, possibly due to the presence of a
Morton’s neuroma. The 1-2 and 3-4 webspaces appeared hypoechoic but were
compressible this could be due to bursal complexes (bursitis) though colour
Doppler images is not displayed to show hyperemia.
The plantar aspect of both feet were assessed for fibromas and other pathology
such as plantar warts
RIGHT PLANTA PLATES
Image 1 Right foot. Shows 1st MTPJ
Image 2 Right foot shows 2nd MTPJ
Image 3 Right foot shows 3rd MTPJ
Image 4 Right foot shows 4th MTPJ
Image 5 Right foot shows 5th MTPJ
Image 6 Right foot shows 1st -2nd webspaces
Image 7 Right foot- shows 2-3rd webspaces
Image 8 Right foot –shows 3-4th webspace
Image 10 Right foot – shows 1st TMTJ
Image 11 Right foot shows 2nd TMTJ
Image 12 Right foot- shows 3rd TMTJ
Image 13 Right foot –shows 4th TMTJ
Image 14 Right foot –shows 5th TMTJ
IMAGES OF THE LEFT FOOT
PLANTA PLATES
Image 15 Left foot –shows normal 1st MTPJ
Image 16 left foot- shows normal 2nd MTPJ
Image 17 left foot –shows 3rd MTPJ
Image 18-Left foot shows -4th MTPJ
Image 19 Left foot – shows normal 5th MTPJ
Image 20-Left foot shows 1-2 webspace
Image 21-Left foot shows 2nd to 3rd webspace
Image 22-Left foot shows 3rd to 4th webspace
Image 23 shows 4th webspace
Image 24 shows 1st TMTJ
REFERENCE
Beggs Ian Stefano, Bianchi Michel Cohen, Michel Court-Payen, Andrew Grainger,
Franz Kainberger, Andrea Klauser, Carlo Martinoli, Eugene McNally,
Philip J. O’Connor, Monique Reijnierse Philip and Remplik Enzo
Silvestri.2010. “Musculoskeletal Ultrasound: Technical Guidelines”
Insights into Imaging 1:99-141.
Bianchi, S., and C. Martinoli. 2007. Ultrasound of the Musculoskeletal
System: New York: Springer
http://www.curtin.eblib.com.au.dbgw.lis.curtin.edu.au/patron
/SearchResults.aspx?
q=Bianchi%2CS.%2C+and+C.+Martinoli.+
2007+ultrasound+of+the+musculoskeletal+system%3ASpring
er&t=quick
Grimshaw, Le-Anne.2014 “Module seven- ankle and foot.” Lecture
notes. https://lms.curtin.edu.au/bbcswebdav/pid1076942-dtcontent-rid-7331507_1/courses/310697- FacSciEng1717724458/module%20seven%20msk%20%20ankle%20and%20foot%202013.pdf
Ultrasound of the foot pathology.2014. Ultrasoundpaedia.
http://www.ultrasoundpaedia.com/pathology-foot.