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 Table of Contents  
Year : 2022  |  Volume : 3  |  Issue : 1  |  Page : 1-7

Current status of bone single-photon emission computed tomography combined with computed tomography in evaluation of foot and ankle pain

Department of Nuclear Medicine, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India

Date of Submission22-Oct-2021
Date of Acceptance06-Jan-2022
Date of Web Publication07-Jul-2022

Correspondence Address:
Vandana Kumar Dhingra
Department of Nuclear Medicine, All India Institute of Medical Sciences, Virbhadra Road, Rishikesh - 249 203, Uttarakhand
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jrmt.jrmt_25_21

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The complex anatomy of the foot and ankle makes it a clinical challenge to reach a final diagnosis in patients with foot and ankle pain. Conventional imaging modalities such as radiography, computed tomography (CT), and magnetic resonance imaging (MRI) play a vital role in making a diagnosis in patients with foot and ankle pain. MRI is considered to be the go-to modality for foot and ankle pathologies, but it has limitations in patients with metallic implants and claustrophobia. With wider availability and excellent imaging quality of new-age gamma cameras, bone single-photon emission computed tomography combined with CT (SPECT/CT) with technetium-99m (99mTc) labeled bisphosphonates has come into forefront for diagnosis of foot and ankle pathologies. SPECT is known to have high sensitivity to detect lesions but with low specificity. This low specificity was overcome by the introduction of SPECT/CT, a hybrid imaging modality that involves anatomical correlation of CT with the functional imaging of SPECT. SPECT/CT is extremely useful for evaluating the common but challenging causes of foot and ankle pain such as osteoarthritis, impingement syndrome, infection, inflammation for detecting optimal sites for intraarticular injection, and evaluation of diabetic foot. This review article aims to discuss various imaging modalities available for foot and ankle evaluation and the current status of SPECT/CT in diagnosing various foot and ankle pathologies.

Keywords: Ankle, bone scan, foot, technetium-99m 99mTc-methylene diphosphonate

How to cite this article:
Veerwal H, Meena A, Dhingra VK. Current status of bone single-photon emission computed tomography combined with computed tomography in evaluation of foot and ankle pain. J Radiat Med Trop 2022;3:1-7

How to cite this URL:
Veerwal H, Meena A, Dhingra VK. Current status of bone single-photon emission computed tomography combined with computed tomography in evaluation of foot and ankle pain. J Radiat Med Trop [serial online] 2022 [cited 2022 Dec 3];3:1-7. Available from: http://www.jrmt.org/text.asp?2022/3/1/1/350088

  Introduction Top

Due to the complex anatomy of the foot and ankle, it is a challenge for the clinician to make a diagnosis and localize the foot pathology. Currently available imaging modalities that are used to assess foot pathology are X-rays, ultrasound (US), computed tomography (CT), magnetic resonance imaging (MRI), and technetium-99 m (99mTc) bisphosphonate bone scan.

Bone scan is useful for functional localization of the foot and ankle pathologies but due to its low spatial resolution, localization of the lesion is difficult. This was overcome by the introduction of single-photon emission CT combined with CT (SPECT/CT) which combines the functional imaging using SPECT with the anatomical imaging of CT, thus overcoming the problem of accurate localization.[1],[2] The purpose of this review article is to discuss, the present role of 99mTc phosphates SPECT/CT in comparison to other modalities available.

  Imaging Modalities Top

Plain radiograph

Radiograph gives an overview of small bones of the foot and ankle and is the initial investigation for any foot pain, especially postacute trauma, and for detection of accessory bones before any other modality is utilized.[3] In fact, a plain radiograph finding may help select the next best modality for further detailed evaluation. But for chronic pathologies, it has a limited role, and thus, it is used in concordance with other imaging modalities. The most significant advantages of X-rays are easy availability, cost-effectiveness, and easy interpretation.


US is mainly used for soft-tissue assessment in patients with foot and ankle pathologies. The findings of the sonography can be directly correlated with the patient's clinical findings as well as comparative analysis with the contralateral normal limb is possible. It can be used to assess tendinosis, tenosynovitis, tears, subluxation, and dislocation as well as for ligament tear and nerve pathologies such as tarsal tunnel syndrome and lipomatosis of nerve.[4] US has limited use in patients with metallic implants due to hypoattenuation of echos, and hence, the structures below the implant are not visualized. Another limitation is it has high intraoperator variability, and thus, findings can differ if it is in an inexperienced hand.

Computed tomography

CT is the go-to imaging for visualization of the skeleton. A multidetector CT (MDCT) moves in a helical trajectory relative to the patient and acquires the data which can be viewed in sagittal, coronal, and axial views and can be constructed into a 3D image. With the advancement of medical sciences, MDCT allows viewing of scans with submillimeter resolution and thus aiding in identifying minor fractures, degenerative changes, and tendon and ligament pathologies up to an extent.[5] CT is also currently being used for preoperative planning of foot and ankle surgeries. However, it has only limited capabilities when it comes to assessing soft-tissue pathologies as compared to MRI or US.[6]

Magnetic resonance imaging

MRI is the most preferred imaging modality for soft-tissue pathologies. Its high signal-to-noise ratio and high-resolution images helps in detecting even the smallest of the lesion. It is mainly used for soft-tissue lesions such as ligament injury, synovial disorder, tarsal coalition, impingement syndrome, osteochondral lesion of the talar, and in certain bony pathologies such as accessory bone and stress fracture. MRI helps in the identification of bone marrow edema, which although being nonspecific points toward an underlying bony pathology.[7] The major disadvantage of MRI is claustrophobia experienced by the patient due to the design of the machinery. Furthermore, image distortion in high-field magnets is seen in patients with metal artifacts. Moreover, in patients with metal implants, MRI is contraindicated and in such scenarios, SPECT/CT can be the next viable option. Further problem arises in imaging limbs because the coils of MRI are not optimized for high-field imaging of extremities, thus rendering the use of MRI impractical.[8] Ha et al. compared the usefulness of SPECT/CT over MRI for the diagnosis of foot and ankle pathologies. Fifty patients were enrolled retrospectively in this study, and the specificity of the SPECT/CT(48%) was found to be significantly more than MRI (24%).[9]

  Bone Scan Top

Bone scan has been used for the diagnosis of foot and ankle pathologies for 3–4 decades now. Most commonly used tracers for bone scintigraphy are 99mTc-methylene diphosphonate (MDP), 99mTc-diphosphono -1,2-propanodicarboxylic acid (DPD), and 99mTc- hydroxymethylene diphosphonate (HDP). It is a highly sensitive imaging modality but with poor specificity, mainly attributed to the poor resolution when compared with CT or MRI.[10] The addition of SPECT to the bone scan for the patient with inconclusive planar imaging helps in further improving the diagnostic outcome. SPECT/CT is a comparatively newer modality that combines functional and anatomical imaging. [Table 1] list the recent studies on the utility and of SPECT/CT in patients of foot and ankle pathologies. These hybrid systems help in further increasing diagnostic accuracy.[1],[2]
Table 1: Utility of single-photon emission computed tomography combined with computed tomography in patient management

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  Most Relevant Application of Single-Photon Emission Computed Tomography Combined with Computed Tomography in Ankle and Foot Pain Top


History of trauma is one of the most common causes of osteoarthritis, especially in the younger age group.[11] Radiological changes seen in osteoarthritis are subchondral sclerosis, loss of joint space, subchondral cysts, and osteophytes.[12] With slow wear and tear of cartilage with age, there is a reduction of joint space and loss of chondral thickness. Subsequent loss of cartilage leads to the formation of subchondral cyst and sclerosis.[13] Thus, this increased level of osteoblastic activity leads to increased uptake of 99mTc phosphates at those sites. SPECT/CT when used in adjunction to the radiological findings helps in the delineation of the osteoarthritis, further improving the clinical outcomes [Figure 1].[14]
Figure 1: Osteoarthritis – A 31-year-old male with complaint of pain in his right ankle for the last 9 months. Coronal computed tomography, single-photon emission computed tomography, fused single-photon emission computed tomography combined with computed tomography (a-c) images showed an area of increased uptake in the right tibiotalar joint with computed tomography showing osteoarthritic changes

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Several studies have shown a superior outcome when SPECT/CT was part of the primary evaluation of foot and ankle diseases. In a study by Linke et al. on patients suffering from lower extremity pain, SPECT/CT led to revision of diagnosis of 23 out of 71 patients.[15] A similar study by Wuest et al. showed improved lesion localization using SPECT/CT in 8 of 11 patients (73%) and improvement in diagnostic accuracy in 4 of 11 patients (36%).[16] Pagenstert et al. reported that the mean intraobserver reliability for SPECT/CT was significantly higher for SPECT/CT than that for CT and bone scanning together, thus verifying the use of SPECT/CT in localizing active arthritis.[17] A similar study by Claassen et al. showed a higher interrater and intra-rater reliability for SPECT/CT compared with MRI alone for diagnosing complex foot and ankle pathologies.[18]

Paul et al. conducted a study to find a correlation between SPECT/CT imaging and histologic finding by increased osseous 99mTc-DPD uptake. Six patients were subjected to preoperative SPECT/CT and histomorphometric analyses were performed on postoperative tissue sections. It was found that subchondral bone tissues that show uptake in SPECT/CT histologically showed increased osteoblast-mediated bone formation and increased cellularity and collagen deposition in marrow tissues.[19]

  Valgus and Varus Deformity Top

The relationship between the alignment of the ankle and 99mTc-DPD uptake was investigated by Knupp et al. They took advantage of SPECT/CT for assessment of coronal plain hind deformity in a total of 21 patients. The varus and valgus malaligned ankles showed higher radioisotope uptake in the medial areas and lateral areas of SPECT/CT respectively, thus adding to the value of SPECT/CT in the assessment deformed ankle.[20]

  Intraarticular Injection Based on Single-Photon Emission Computed Tomography Combined with Computed Tomography Finding Top

CT has been used previously to decide the site to administer anesthetic injections. Recently, SPECT/CT has come into play for localization of the sites with increased osseous uptake. Sites of increased bone turnover are identified with the help of SPECT/CT and intraarticular injections are given at these sites which leads to significant improvement in the patient's symptoms. A relationship between pain and site of increased bone turnover has been established in several studies.[21]

In a prospective study by Parthipun et al., 203 patients underwent SPECT/CT of foot and ankle joint, out of which 52 patients were given intraarticular injection based on SPECT/CT findings. Forty-six percent of the patient showed improvement of >50% in the visual analog scale (VAS) and there was a change in management of 19 patients, thus demonstrating the high success rate with joint injection administered on the basis of SPECT/CT finding.[22] A similar study on 272 patients by Pountos et al. showed that SPECT/CT helped in changing the diagnosis of 55% of the patient. Improvement in the pain was seen in 86% of the patients who underwent joint injection based on the finding of SPECT/CT.[23]

  Soft-Tissue Pathologies Top

MRI currently is the preferred modality for the detection of soft-tissue pathologies with its ability to identify changes like edema and thickening of tendon and fascia. SPECT/CT has limited diagnostic value in the soft-tissue pathologies and is currently being used in the diagnosis of impingement syndrome, plantar fasciitis, and  Achilles tendinitis More Details [Figure 2] and [Figure 3].[1] Chicklore et al. did a study on 209 patients with ankle and foot pathology who have undergone SPECT/CT for soft-tissue pathologies and impingement syndrome. Forty-three patients were diagnosed out of a total of 209 for impingement syndrome, of which 24 were not clinically suspected. SPECT/CT thus can be used in conjunction with MRI for localization of soft-tissue pathologies.[24] Similarly, Zhang et al. selected 50 individuals with chronic ankle pain who underwent ankle SPECT/CT. They were enrolled retrospectively to correlate bone tracer uptake by ankle SPECT/CT with the lesion type and VAS pain score. The uptake grade of bone tracer was found to be significantly correlated to the lesion type of ankle impingement and VAS pain score.[25]
Figure 2: Graft evaluation and decreased perfusion – A 43-year-old male with history of chronic osteomyelitis of left distal tibia status post sequestrectomy and bone grafting. There is increased blood pooling (a) and increased tracer uptake in delayed images (b) in the distal end of left tibia along with decreased tracer pooling and tracer uptake in the contralateral limb. Coronal single-photon emission computed tomography combined with computed tomography (c) images showed an area of increased uptake in the distal end of the left tibia (site of bone grafting) along with decreased tracer uptake in the contralateral limb. A Doppler study of the right limb reveals a biphasic impaired flow of blood in the right dorsalis pedis artery

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Figure 3: Plantar Fasciitis – A 19-year-old male with complaint of pain in the right heel region for the last 8 months. Sagittal computed tomography, single-photon emission computed tomography, fused single-photon emission computed tomography combined with computed tomography (a-c) images showed an area of increased uptake on posterior aspect of the inferior surface of the right calcaneus at the site of plantar fascia origin

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  Osteochondral Lesion of Talus Top

Osteochondral lesion of talus (OLT) is one of the common sports injuries involving the articular cartilage and subchondral bone of talar dome. Usual presentation is that of pain in ankle region, associated with a history of trauma. Usual bone scan finding includes increased flow and blood pooling along with increased tracer activity at the dome of talus.[26] Leumann et al. conducted a study in which MRI and SPECT/CT of 25 patients of OLT were compared. There was a change in diagnosis of 12 patients with SPECT/CT alone and 13 patients with SPECT/CT and MRI combined.[27]

Another study was conducted by Wiewiorski et al. in which SPECT/CT was used for localization of pain site in patients with OLT. Intraarticular injection was given on sites with active tracer uptake to the patient followed by quantification of reduction in pain using VAS. Pain relief was accounted for all patients.[28] Meftah et al. conducted a study for assessing the role of SPECT/CT in the preoperative planning of OLT. Patients were given conservative and surgical treatment based on characteristics of lesions on SPECT/CT. The American Orthopedic Foot and Ankle Society (ASFOS) score was used to evaluate the prognosis of the patient and it was found that the ASFOS score was comparable in the surgical and nonsurgical groups.[29]

  Diabetic Foot Top

Diabetic foot is one of the most severe complications and early assessments in which demarcation of sites of involvement can help reduce the duration of treatment and improve the prognosis of the patient.[30] Limited studies have been done to assess the role of SPECT/CT in the diagnosis of infection in diabetic foot. Currently, available tracer used for infection imaging of diabetic foot includes 99mTc-labeled WBC and indium-111 (111In) hexamethylpropylene amine oxime (HMPAO) labeled (white blood cells) WBC. Filippi et al. conducted a study using 99mTc-labeled HMPAO leukocytes. The author reported a change in interpretation of 10 out of a total of 19 patients with diabetic foot.[31]

Lazaga et al. used 99mTc-labeled WBC SPECT/CT for assessing the treatment response of diabetic foot osteomyelitis. The sensitivity and specificity of SPECT/CT to determine osteomyelitis treatment remission were 90% and 56%, respectively.[32] A similar study by Vouillarmet et al. showed a sensitivity and specificity of 100% and 56% to predict remission in diabetic foot osteomyelitis.[33] Another pilot study by Przybylski et al. reported a sensitivity and specificity of 87⋅50% and 71⋅43% for 99mTc WBC-labeled SPECT/CT.[34]

Erdman et al. tried incorporating the parameter of SPECT/CT in a patient into a composite scoring system (CSI) for predicting the prognosis of patients with diabetic foot osteomyelitis. Composite scoring system of 0 had a 92% chance of favorable outcome, which fell progressively to 25% when it is >7.[35]

Heiba et al. used a dual-isotope SPECT/CT protocol with 99mTc-HDP and 111In labeled WBC. Dual isotope scanning showed better diagnostic accuracy than bone scan or leukocyte scanning alone.[36]

  Postoperative Foot and Ankle Pain Top

Postoperative pain affects almost 40% of the patients who undergo foot and ankle surgery. Bone-seeking agents like 99mTc-MDP help in localization of the foci causing pain in patients, thus it aids the operating surgeon in identifying the site for further intervention and surgical correction [Figure 4].[37] Gurbani et al. assess the utility of SPECT/CT in evaluating the pain in patients with total ankle replacement. SPECT/CT led to revision surgery in 29 out of 37 patients and showed high concordance with the surgical findings in 26 out of 28 cases.[38] Mason et al. retrospectively analyzed SPECT/CT in 14 patients with painful total ankle arthroplasty. SPECT/CT helped in identifying prosthetic loosening/failure of bony on growth in 10 of the 13 cases which showed no evidence of loosening on the plain radiograph.[39]
Figure 4: Postoperative complication – A 46-year-old male with a history of fracture of left calcaneus status post open reduction and internal fixation. The patient presented with complaints of pain and restricted movement in the left ankle for 7 months. Sagittal computed tomography, single-photon emission computed tomography, fused single-photon emission computed tomography combined with computed tomography (a-c) images showed the area of increased uptake on the talocalcaneal joint on basis of which correction surgery was performed

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On contrary, DeSutter et al. found that patients with ankle arthrodesis showed improvement in clinical/functional scores at 6 months postoperatively but with no changes in the intensity of the uptake. Thus, the author reported no association found between SPECT/CT findings and clinical improvement.[40]

  Stress Fracture Top

Stress fractures are associated with long-term insult to the bone, occurring commonly in lower extremities. Plain radiography has very poor sensitivity, while bone scan and MRI are known to have high sensitivity for the detection of stress fracture. MRI detects marrow edema associated with the stress fracture, which usually appears weeks before a fracture line is visible on radiological imaging. Bone scan usually shows the increased flow and blood pooling associated with increased tracer uptake in delayed imaging-denoting increased stress and bone remodeling at these sites [Figure 5].[2],[41]
Figure 5: Fracture – A 48-year-old male with a history of trauma over the left ankle. There is increased blood pooling in the left ankle region (a and b) indicating increased vascularity. Coronal computed tomography and fused single-photon emission computed tomography combined with computed tomography (c and d) images showed increased uptake seen in the medial malleolus of left foot corresponding to the site of fracture of computed tomography images

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  Painful Accessory Bone Top

Os trigonum and os naviculare are the most common accessory bone variants with a prevalence of 14%–25% and 4%–14%, respectively.[42] Usually, accessory bones are asymptomatic till degenerative changes set in. Bone scintigraphy shows increased uptake at the site of synchondrosis due to increased bone turnover. Thus, SPECT/CT can be used as a tool in identifying the site of degenerative changes in the accessory bone [Figure 6].[1],[2],[11]
Figure 6: Os Navicularum – A 64-year-old male with complaint of pain on the medial aspect of the left foot. Transaxial computed tomography and fused single-photon emission computed tomography combined with computed tomography (a and b) images showed uptake corresponding to syndesmosis between os navicularum and navicular bone

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  Tarsal Coalition Top

Tarsal coalition has a prevalence of <1% in the general population.[2] It is a fusion of two or more tarsal bones and can be osseous, fibrous, or cartilaginous in origin. The most common coalition involved are calcaneonavicular and talocalcaneal coalition. CT is usually diagnostic and SPECT/CT can be used to identify the site of the fusion as well as can help decide the site of intraarticular injection.[41],[43]

  Sickle Cell Disease Top

Sickle cell is a congenital heritable disease characterized by sickle-shaped RBCs which can cause painful crisis along with splenic infarct.[44] Due to a change in pain site due to recurrent pain site, it is difficult to recognize the cause of symptoms in such cases. Jafar et al. reported a case of a 21-year-old female with sickle cell anemia in which SPECT/CT incidentally revealed a Brodie's abscess in the left talus bone.[45] Brodie's abscess is a hidden cause of pain and it requires prompt identification and treatment, especially in patients with sickle cell disease. Thus, the utility of SPECT/CT in sickle cell disease needs further evaluation.

  Future Advances Top

With the introduction of PET/CT and PET/MR, the potential use of 18F NaF for the evaluation of foot and ankle pain patients is being explored. 18F NaF has a similar mechanism of action as 99mTc-labeled phosphates.[46] However, 18F NaF has better background clearance and less plasma protein binding in comparison to 99mTc-labeled phosphates. Thus, these characteristics allow earlier imaging along with better special resolution.[47] A prospective study was conducted on a total of 22 patients by Rauscher et al. to compare 18F NaF PET/CT with 18F NaF PET/MR. The author reported that the sensitivity of both the modalities was similar with PET/CT being more precise in localizing osteoarthritis and PET/MR being better at visualizing nondegenerative pathologies.[48] Jeon et al. did a study in 121 patients of a limited range of motion of ankle due to past trauma using 18F NaF PET/CT. The author reported increased tracer uptake in 113 out of 121 patients with a higher level of SUVmax and SUV mean for fracture group than nonfracture group. Increased tracer uptake correlated with reduced range of motion. The author concluded that 18F NaF PET/CT has a role in the evaluation of limited range of motion of the ankle joint, particularly in ankle group.[49] PET/CT and PET/MR use in foot and ankle pain patients is still in a nascent stage and would require more extensive research for the impact of these newer modalities on patient management.

In conclusion, bone SPECT/CT provides additional information complementary to conventional imaging modalities. This article highlights bone SPECT/CT in the evaluation of foot and ankle pain due to osseous or soft-tissue disorders caused by trauma (stress fractures, impingement syndrome) and infection (diabetic foot) or subtle structural anomalies like tarsal coalition, all of which causes foot pain and are challenging to diagnose. Thus, bone SPECT/CT must be considered to be of added advantage to conventional modalities such as radiographs, CT scan, USG, and MRI to aid the clinician in better management of patients with foot and ankle pain.[51]

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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]

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Imaging Modalities
Bone Scan
Most Relevant Ap...
Valgus and Varus...
Intraarticular I...
Soft-Tissue Path...
Osteochondral Le...
Diabetic Foot
Postoperative Fo...
Stress Fracture
Painful Accessor...
Tarsal Coalition
Sickle Cell Disease
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