Case 6. Chronic lateral ankle pain

38 y/o female 18 months post repair partial tear peroneus brevis tear with tenodesis to peroneus longus. 8 months post re-exploration and lysis of adhesions in the synovial sheath for persistant pain. She returns with ongoing pain unrelieved by the usual conservative measures. We performed an anesthetic peroneal tenogram followed by high resolution CT.

Fluoroscopic tenogram Radiographic tenogram

Sag CT 2

Notice how you can follow the p. longus (left, below) and p. brevis (right, below).

Sag CT 1Sag CT 3

This is a case of stenosing tenosynovitis. The CT clearly shows the pathology.

How many of you still do tenography? Most of the cases for which we used tenography in the past are nowimaged with MR. However, when we do these procedures, we usually perform them in conjunction with local anesthetic to elicit pain response, the imaging often secondary, other than confirmation of position. All of my previous cases of “CT Tenography” have been incidental filling of the peroneal tendon sheaths during subtalar injections under CT guidance. I noticed that the detail on the tendon within the sheath was quite good, and when this case came along I decided to try the CT imaging. The MR was apparently not particularly helpful in this case (outside referral). Does anyone else use this technique? Do we have enough combined cases to write this procedure up for publication or for an SSR presentation?

Comments (2)

Chris Beaulieu, M.D. Mar 17, 2007 01:16 PM

Yes, we have a robust tenography service. Since 1994, 357 total cases, represented by 113 peroneal, 66 post tibial, 168 FHL, 7 ant tibial, 3 achilles.

As with John, the goal of the test is therapeutic and imaging, with marcaine injection and decadron into the sheath after contrast shows correct placement.

We have not done CT post tenography, but have done a few MRI’s and US cases in conjunction. In keeping with our loss leading practice, most of the MRI’s are performed elsewhere, and we get the 50 bucks for the tenogram which may take 1 hr.

Having said this, I believe it is a very useful test for both the surgeon and the patient, and we’re currently putting together our FHL experience.

Rajeev Varma, M.D. Mar 17, 2007 01:21 PM

I have only rarely ever done tenography with contrast but have have ultrasound to be much simpler to inject marcaine/steroids into tendon sheaths, I just use a little filling with xylocaine to ensure needle is not in the tendon.