The Foot 21 (2011) 149153

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The Foot
journal homepage: www.elsevier.com/locate/foot

Review

The role of diagnostic imaging in the evaluation of suspected osteomyelitis in the

foot: A critical review
James L. Harmer a, , James Pickard b , Simon J. Stinchcombe c
a
b
c

Nottingham County Health Primary Care Trust, Park House Health Centre, 61 Burton Road, Carlton, Nottingham, UK
Hudderseld School of Podiatry, University of Hudderseld, Consultant Podiatric Surgeon, Mid Yorkshire Hospital Trust, West Yorkshire, UK
Sherwood Forest Hospitals NHS Foundation Trust, UK

a r t i c l e

i n f o

Article history:
Received 17 September 2010
Received in revised form 4 November 2010
Accepted 5 November 2010
Keywords:
Osteomyelitis
Diagnostic imaging
Radiographs
Ultrasound
Computer Tomography
Radionuclide Imaging Tests
Magnetic Resonance Imaging

a b s t r a c t
The early diagnosis of osteomyelitis in the foot from its clinical presentation alone can be difcult particularly in cases when the early signs are subtle. Early diagnosis and subsequent early intervention are
imperative to reduce the risk of chronic infection, associated early lytic changes to bone and potential
long term structural complications caused by subsequent deformity and lost anatomy.
Diagnostic imaging has a major role to play in the early assessment and diagnosis of bone infection,
yet the choice of approach can be controversial.
Several imaging modalities have been advocated, imaging of the infected foot is complex and no single
test is ideal for every situation. The clinician needs to be aware of the strengths and weaknesses of
each imaging modality so that the most appropriate test is selected for the individual case. Factors such
as site of infection in the foot, the aggressive nature of the organism, the time since onset, previous
associated surgery and co-morbidity may all play apart in the clinicians decision making process to
determine the best approach in detecting the sometimes subtle changes which may be seen in some
cases of osteomyelitis.
This review considers the literature and highlights the advantages and disadvantages of the main
imaging techniques used for the evaluation of the foot when osteomyelitis is suspected. An evidence
based algorithm for the selection of appropriate imaging techniques is suggested to aid clinicians in
there decision making process.
2011 Elsevier Ltd. All rights reserved.

Contents
1.
2.
3.
4.
5.
6.

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Radiography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Computer Tomography (CT) and ultrasound . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Radionuclide (RI) Imaging Tests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Magnetic Resonance Imaging (MRI) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Competing interests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1. Introduction
The term osteomyelitis is generally applied to infections of
bone whether cortex, marrow or periosteum is involved [1].

Corresponding author. Tel.: +44 0115 9617616

E-mail addresses: james.harmer@nottinghamcountyhealth.nhs.uk (J.L. Harmer),
j.m.pickard@hud.ac.uk, james.pickard@midyorks.nhs.uk (J. Pickard).

149
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It is characterised by acute inammation, vascular engorgement, oedema, cellular inltration and often, but not in every case,
abscess formation. Osteomyelitis develops as a consequence of bacterial contamination of bone by either direct implantation, such
as from a puncture wound or dirty surgery, haematogenous from
organisms via the circulation, or from a contiguous source such as a
local soft tissue infection site [2]. In the adult foot most cases are as
a consequence of either direct implantation or from a contiguous
source [1].

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J.L. Harmer et al. / The Foot 21 (2011) 149153

Bone infection can be classied as acute or chronic and clinical

presentation varies depending on the organism, location and host
factors. Predisposing factors include immune deciency, diabetes
mellitus, chronic steroid therapy, malignancy, extremes of age and
renal or liver failure.
The importance of taking an accurate history of the presenting
complaint and undertaking a comprehensive clinical assessment to
assist in the diagnosis of osteomyelitis cannot be over emphasised.
This includes the collection of data relating to demographic, medical and medication details, presenting signs and symptoms and
wound evaluation if present. From initial assessment the source of
infection should be identied and investigated using appropriate
modalities including microbiology, histopathology and diagnostic
imaging.
Osteomyelitis can be a difcult disease to diagnose and treat in
the foot. Early diagnosis is imperative to avoid chronic infection and
potential complications caused by bone necrosis and destruction.
Diagnostic imaging has a major role to play in early assessment
and diagnosis of bone infection, yet the choice of approach can be
controversial [3,4].
The aim of this review is to critically evaluate these imaging
modalities and then suggest an evidenced based imaging pathway
that clinicians could follow.

2. Radiography
X-rays are a relatively inexpensive, safe and readily available
mode of imaging to clinician holding IRMER certication. Radiographs are reported to be the initial imaging procedure of choice in
all patients suspected of having osteomyelitis [46].
The earliest radiographic changes may develop as quickly as two
to three days after the onset of infection and manifest as soft tissue swelling and loss of fat planes adjacent to the affected bone.
However the clinician should remember that plain lms are an
inherently insensitive test. Radiological changes may not be reliably present especially in the early stages and observer error may
compound the issue resulting in subtle changes being missed rendering the examination even more insensitive [7]. They do however
provide an appropriate base line examination for later comparison
as the disease progress.
It can take as many as 14 days before bony changes become evident on a radiograph as osteolysis or bone loss will not be apparent
until 3060% of bone is destroyed [8]. Thus, the accuracy for early
diagnosis is only about 5060% with sensitivity around 60% and
specicity around 80% [9]. Sensitivity is the proportion of patients
with disease who have a positive test (true positive/(true positive + false negative)) and specicity is the proportion of patients
without the disease who have a negative result (true negative/(true
negative + false positive)) [10].
Other investigations maybe appropriate when early signs of
osteomyelitis are unclear. These may include blood tests to establish raised white cell count and increased CRP. When signs of
osteomyelitis are unclear, a second radiograph should be requested
after a further two weeks. If infection is present characteristic
progressive changes maybe seen within the bone, these include
osteolysis, periosteal reaction and cortical erosions (Fig. 1). The
formation of sequestra, involucrum and cloaca may also be seen
however these are more chronic bony changes and as such are seen
less frequently in practice [1,2,4,6].
A reliance on radiographs alone may delay therapy while the
infection process continues to destroy osseous tissue as bone
changes may lag behind clinical and laboratory ndings. Early diagnosis and treatment may lead to complete resolution before bone
changes develop. In cases where there is moderate to high suspicion of infection and radiographs are inconclusive it is prudent

Fig. 1. Plain radiograph oblique view showing osteomyelitis and septic arthritis of
the 2nd MTPJ. Severe osteolysis and periosteal reactions can be clearly seen around
the head of the 2nd metatarsal and base of the proximal phalanx.

to order additional advanced imaging tests to rene the diagnostic

process. The main strength of plain lms is in their availability, cost
and relative specicity. Where bony changes are present in uncomplicated bone the clinician may not require any further imaging to
conrm the diagnosis [11]. Unfortunately radiography has poor soft
tissue contrast and radiographic ndings of osteomyelitis can on
occasion, if taken in isolation resemble malignancy, fractures and
neuroarthropathy reducing the sensitivity and specicity further.
Boutin et al. reported that radiographs were diagnostic in as few as
35% of culture-positive cases of complicated osteomyelitis [12].
3. Computer Tomography (CT) and ultrasound
Computer tomography and ultrasonography are also used to
evaluate acute osteomyelitis, but have been cited as being an inferior approach to magnetic resonance imaging (MRI) and for that
reason they may not be routinely used in services where MRI is
readily available [4].
With CT, features of acute osteomyelitis show up earlier, more
clearly and in more detail than on radiographs. CT can detect subtle
marrow and cortical abnormalities as well as small gas collections.
Findings specic to infection such as sequestra, involucrum and
cloacae can also be seen in good detail [1,2,6]. Despite this CT has
been largely replaced by MRI as the imagining test of choice for
suspected osteomyelitis when radiographs fail to provide a clear
diagnosis MRI has better soft tissue contrast and the patient is not
exposed to high levels of ionising radiation. However CT still offers
an option in patients who are contra-indicated for MRI as it shows
excellent bony detail.
Ultrasound may show features of osteomyelitis several days
earlier than radiographs [13]. Juxtacortical soft tissue swelling
together with early periosteal thickening is the earliest sign of acute
osteomyelitis on ultrasound (Fig. 2). This is followed by increase
periosteal thickening, subperiosteal exudate and abscess formation [14]. Sensitivity and specicity of ultrasound evaluation of
osteomyelitis has not been determined yet but it is not likely to
be as high as MRI or radionuclide studies as visualisation is limited
to outer cortical and juxtacortical tissues.
Advantages of ultrasound are that it is readily available, cheap,
quick to perform and does not use ionising radiation. Ultrasound is
useful in postoperative evaluation of suspected infection in regions
complicated by orthopaedic metal work, which used to adversely
affect both MRI and CT images although this is now less of a problem
with newer generation CT and MRI scanners with the development
of metallic artefact reducing software. Ultrasound is also being used
more frequently in guided aspiration to help conrm the presence
of osteomyelitis [13].

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J.L. Harmer et al. / The Foot 21 (2011) 149153

151

Fig. 2. Ultrasound of the 1st metatarsal following a bone graft showing soft tissue
swelling and periosteal reaction consistent with osteomyelitis, however this is not
conclusive and additional imaging would be required for conrmation.

Disadvantages of ultrasound are that it is operator-dependent

and there is high risk of false-positives and false-negatives. Ultrasound cannot image past the cortex of the bone and so in early
osteomyelitis which has not produced a sub-periosteal reaction,
the diagnosis can be missed. Finally the complex anatomical structure of the foot makes bone infection difcult to evaluate with
ultrasound [4].

4. Radionuclide (RI) Imaging Tests

Radionuclide bone scintigraphy has been extensively used and
found effective to aid the early diagnosis of suspected osteomyelitis
[36].
Bone scintigraphy also known as a bone scan, generally uses
the radioisotope technetium. The radioisotope is injected into the
vascular system and distributed around the body where the technetium is bound to phosphate. This complex has an increased
uptake at the site of new bone formation which shows as a hot
spot when imaged. In cases of osteomyelitis there is greater new
bone formation than normal with a consequential increased focal
uptake of radioisotope at the site of pathology [15]. Radioisotope
uptake is dependent on blood ow and the rate of new bone formation thus its effectiveness will be affected by conditions that cause
ischemia or hyperaemia.
When used for suspected osteomyelitis, a three or four phase
bone scan should be used to distinguish between cellulitis and
osteomyelitis [36,16]. The three-phase bone scan consists rstly
of a blood ow phase of scanning performed immediately after
tracer injection showing the relative arterial supply of the area
under examination. The second phase or the blood pool phase is
obtained 510 min after injection. This phase quanties the relative hyperaemia or ischemia present and is reective of soft tissue
inammation. The third phase is obtained 24 h after injection and
demonstrates osseous uptake only [2].
The classic scan appearance of osteomyelitis shows focal
hyperperfusion, focal hyperaemia and focal bone uptake (Fig. 3).
Osteomyelitis is characterised by abnormal accumulation of the
radioisotope in all three-phases while cellulites shows accumulation only in the rst two-phases [16]. Three-phase bone
scintigraphy is reported to be the radionuclide test of choice for
diagnosing acute osteomyelitis in bones not affected by underlying conditions despite the fact they use a high radiation dose [3].
Bone scans are widely available, relatively inexpensive, easily performed and rapidly completed. The test is extremely sensitive with
an accuracy of more than 90% in uncomplicated bone and they can

Fig. 3. Bone scan: a single focus of increased radiopharmaceutical activity is identied on all three phases within the distal right 4th metatarsal.

detect increase radionuclide uptake hot spots as early as 12 days

after onset of infection [17].
However specicity is reported to be lower than plain radiography Oloff and Schulhofer reported a mean of 27.3%, other diseases
of bone involve osteoblastic activity in general and not infection
specically [2]. Pathologies such as fractures, neuroarthropathy,
malignancy and previous surgery can result in a positive scan in
the absence of infection. Further more compared to radiography,
CT and MRI a bone scan has poor anatomical detail and may remain
positive for months after successful therapy making it impossible
to conrm an active infectious disease process [9].
The three-phase bone scan combined with labelled white blood
cells increases the specicity of the scan to infection and is
the radionuclide test of choice for complicated bony pathology
when distinguishing between neuroarthropathy and osteomyelitis
[6,16,18]. This combination improves the sensitivity and specicity
signicantly [18]. This test does have some signicant draw backs
as it is not readily available, it is complicated to perform, requires
additional hospital stay and it is more expensive than MRI [15].
The latest development in imagining for bone infections is Fuorodeoxyglucose positron emission tomography or (PET scan).
PET evaluates cellular glucose metabolism to identify increased use
by certain leukocytes. The sensitivity and specicity are higher than
either MRI or combined bone scans [6]. The advantage of PET is its
ability to differentiate between neuroarthropathy and osteomyelitis and it is particularly good at imaging around surgical implants
where MRI and CT are weak. PET is relatively new, it is not readily
available, it is expensive and there is still not enough evidence to
support it being used as a mainstream imaging modality for diagnosing osteomyelitis but it should be kept in mind when trying
to diagnose complicated osteomyelitis in the presence of metal
implants.
5. Magnetic Resonance Imaging (MRI)
The Infectious Disease Society of America names MRI as the preferred advanced imaging test for suspected osteomyelitis but still

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152

J.L. Harmer et al. / The Foot 21 (2011) 149153

Fig. 4. (a) Axial foot T1 weighted MRI showing abnormal bone marrow oedema of decreased intensity around the 3rd and 4th metatarsal heads and base of the proximal
phalanges with adjacent soft tissue swelling indicating Osteomyelitis and septic arthritis of the 3rd and 4th MTPJs. (b) Axial foot PD SPIR MRI of the same foot conrming
the diagnosis by showing increased signal intensity from the bone marrow around the 3rd and 4th MTPJs, bony destruction and soft tissue swelling.

recommends performing plain radiography before ordering MRI

[5]. MRI is a sensitive imaging technique that provides excellent
bone and soft tissue contrast and images can be obtained in multiple
plains.
The earliest nding of osteomyelitis on MRI is an alteration of
the normal marrow signal intensity, which can be seen as early as
12 days after the onset of infection. The abnormal marrow oedema
shows up as reduced signal intensity on T1 and increased intensity
on T2 weighted sequences (Fig. 4). Periosteal reaction and adjacent
soft-tissue oedema subsequently develop and are apparent earlier
and in more detail than on radiographs [6]. The literature nds
MRI to be equal to or superior to combined bone scans in diagnosing complicated osteomyelitis, although there are aws in the
published literature as few studies prospectively followed cohorts

up, imaging was not blinded and few veried the diagnosis with a
biopsy [5].
The advantages of MRI over other imaging modalities are undeniable it is readily available, cost effective, does not use ionising
radiation and is quick to perform. The scan provides precise
anatomical detail showing adjacent abscess formation, sinus tracts
and the extent of osseous involvement, which can be used for surgical planning if necessary [1,46]. These qualities have meant that
MRI has largely replaced other imaging modalities such as CT and
bone scans, as the imaging test of choice when radiographs are
inconclusive.
MRI has almost 100% negative predictive value for excluding
osteomyelitis, if the marrow is completely normal infection can be
reliably excluded. The positive predictive value that is its ability

Suspected Bone
Infection

Weak suspicion of
OM

Request plain films

Request Lab
investigations

Second X-ray at 14 days

Diagnosis
Confirmed

Diagnosis
Confirmed

Strong suspicion of OM,Plain films in conclusive

request MRI & Labtests

Diagnosis
not proven

MRI indicated

MRI Contraindicated

Diagnosis
Rejected

Consider further imaging

Bone Scan
MRI with Contrast
CT

MRI

Labelled Bone Scan

Ultrasound

PET
Guided Bone Biopsy

Diagnosis
Confirmed

Diagnosis
Rejected

Diagnosis
Rejected

Diagnosis
Confirmed

Diagnosis not
proven

Fig. 5. Suggested algorithm for imaging suspected osteomyelitis in the foot.

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Diagnosis
Rejected

Diagnosis
Confirmed

J.L. Harmer et al. / The Foot 21 (2011) 149153

to differentiate osteomyelitis from other causes of abnormal marrow signal intensity such as neuroarthropathy and reactive marrow
oedema is not as high ranging from 70% to 80% [19].
Reactive bone marrow oedema is non-infectious oedema that
occurs in bone marrow, following trauma, prior surgery or adjacent
to a site of soft tissue infection. MRI is unable to reliably distinguish between reactive marrow oedema and osteomyelitis, which
explains its lower specicity.
Other limitations with MRI include its inherent dependability on practitioner interpretation and although most orthopaedic
implants are now non-ferromagnetic meaning MRI is not contraindicated local metal work can still distort the image, making
evaluation of bone and adjacent soft tissue difcult. In these circumstances other imaging tests such as radiographs, ultrasound
and specialist bone scans should be considered if new generation
scanners with metallic artefact reducing software are unavailable
[1].
MRI with intravenous gadolinium contrast has been reported
to improve the detection of soft tissue pathology thus increasing
specicity and reducing false-positives. In uncomplicated cases this
is not routinely needed but in cases where neuroarthropathy or
prior surgery are present highlighting soft tissue disease may help
diagnosis, although like bone scans the vascular status of some
patients may compromise the effectiveness of MRI with contrast
as it may not reach the affected areas.
6. Conclusion
Diagnostic imagining modalities have an important role in the
diagnostic process of osteomyelitis in the foot. They are also extensively used to monitor the progression of the disease following
treatment. Imagining of the infected foot is complex and no single
test is optimal for every situation. Such interventions need to be
undertaken in a timely manner, the clinician needs to be aware of
the strengths and weaknesses of each imaging test so that the most
appropriate test is chosen for each patient at a specic time to give
the best opportunity of detecting the sometimes subtle changes
seen in osteomyelitis. Diagnostic imaging should not be used in isolation, accuracy is improved when it is used in combination with
good patient assessment and other clinical investigations to establish the presence of infection and possibly identify the infective
organism itself [20].
After critically reviewing the literature an evidence-based
algorithm has been designed to demonstrate the decision making process for imaging modalities in diagnosing suspected
osteomyelitis in the foot (Fig. 5).

153

Competing interests
The authors declare that they have no competing interests.
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