Our patient is a 55 year-old female runner with chronic ankle pain that did not present like classic Achilles tendinopathy. She reported a sharp pain only while running, and only on the lateral side of her ankle.
The patient had received multiple rounds of ESWT and PRP, but the pain persisted.
We used high-resolution diagnostic ultrasound to visualize the Achilles tendon, and found that her tendinopathy was at best mild to moderate. However, we discovered that the distal wall of the saphenous vein was dilated, with the sural nerve sandwiched between the vein and the artery. We also identified thickening of the lateral fascial plane.
We observed that the varicosity of the saphenous vein increased pulsatile pressure on the wall, causing compression of the sural nerve. We also observed friction where the nerve rubbed against the thickened fascial plane.
We referred the patient to a specialist for ablation of the saphenous vein – a minimally invasive procedure that closes off the faulty vein using heat or laser energy. However, when her pain persisted after the procedure, we used ultrasound-guided hydrodissection to treat the thickened fascial plane, which completely alleviated pressure on the nerve and eliminated her pain.
Our takeaway from this case: When confronted with any pathology, always examine the adjacent fascial planes for thickening or adhesions, and consider them as a factor in neurogenic pain.
Verified Expert Profiles
Dr. Lev Kalika is a world-recognized expert in musculoskeletal medicine. with 20+ years of clinical experience in diagnostic musculoskeletal ultrasonography, rehabilitative sports medicine and conservative orthopedics. In addition to operating his clinical practice in Manhattan, he regularly publishes peer-reviewed research on ultrasound-guided therapies and procedures. He serves as a peer reviewer for Springer Nature.
Dr. Kalika is an esteemed member of multiple professional organizations, including:
Below is a prime example of how ultrasound can take the guesswork out of diagnosis.
A bad physical therapy experience is one of the primary causes of unnecessary surgery
In this instance, an athlete was originally diagnosed with minor quadriceps muscle strain and was treated for four weeks, with unsatisfactory results. When he came to our clinic, the muscle was not healing, and the patients’ muscle tissue had already begun to atrophy.
Upon examination using MSUS, we discovered that he had a full muscle thickness tear that had been overlooked by his previous provider. To mitigate damage and promote healing, surgery should have been performed immediately after the injury occurred. Because of misdiagnosis and inappropriate treatment, the patient now has permanent damage that cannot be corrected.
The most important advantage of Ultrasound over MRI imaging is its ability to zero in on the symptomatic region and obtain imaging, with active participation and feedback from the patient. Using dynamic MSUS, we can see what happens when patients contract their muscles, something that cannot be done with MRI. From a diagnostic perspective, this interaction is invaluable.
Dynamic ultrasonography examination demonstrating
the full thickness tear and already occurring muscle atrophy
due to misdiagnosis and not referring the patient
to proper diagnostic workup
Demonstration of how very small muscle defect is made and revealed
to be a complete tear with muscle contraction
under diagnostic sonography (not possible with MRI)
Complete tear of rectus femoris
with large hematoma (blood)
Separation of muscle ends due to tear elicited
on dynamic sonography examination
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