Hypoechoic lesion below the fibula

[Xue Heng]

Hi, Steve!
There is one more case that I cannot solve, so I turn you to help.
This is a 37 year old female with multiple joint pain.
US found synovitis of MCP joint of 4th finger (Fig 1), MTP joint of big toe (Fig 2), peritendinitis of extensor tendon of 4th finger (Fig 3), synovitis of peroneal tendon sheath, peritendinitis of Achilles tendon.
There is also hypoechoic lesion below the fibula, with blurred margin and abundant color Doppler signal (Fig 4-6).
Is it synovitis? But it is superfical to the ATFL, so it is outside the ankle joint. I had no idea about that. Also, the patient had no history of ankle inversion injury, and she had intact ATFL.
Thank you, Steve!

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[Stephen Bird]

Off to the rheumatologist for this one.

You have multi locational synovial inflammatory disease which must have an underpinning rheumatological condition.

Good old fashioned rheumatoid arthritis is the most likely, but you can also consider other systemic conditions such as seronegative disease (was there any psoriasis? ) or gout.

I still think with these locations RA is going to be the answer.

All of these areas you have attached look like synovial proliferative synovitis. I can’t see any erosions or crystal deposition.
The ATFL is an interesting appearance, but I think it is still just a synovial proliferation process of the joint capsule.

Do a rheumatological workup and let me know what you discover.

Steve

[Xue Heng]

Thank you, Steve.
The patient was later proved to have RA as you diagnosed.
For hypoechoic lesion below the fibula, is it the synovial proliferation from the joint capsule of the ankle?

[Stephen Bird]

Yep, I think this area is simply a swollen joint capsule due to the RA.

It is a good lesson on why wyou should consider an underlying systemic cause for multi-locational disease,

Nice case mate,

Steve

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