Ultrasound-Guided Foot and Ankle Interventions Evan Peck, MD Section of Sports Health Department of Orthopaedic Surgery Cleveland Clinic Florida

Disclosures Financial disclosures: Neither I, Evan Peck, nor any family member(s), have any relevant financial relationships to be discussed, directly or indirectly, referred to or illustrated with or without recognition within the presentation. Off-label use disclosures: None.

Objectives Describe how to perform common ultrasound (US)-guided procedures in the foot and ankle region. Understand proper patient positioning for US-guided foot and ankle procedures. Be aware of potential pitfalls associated with each US-guided foot and ankle procedure.

Disclaimers Techniques will be described using common positioning and approaches, with influence from the presenter’s clinical experience. Alternative positioning and approaches may be necessary based on unique patient anatomy or other factors.

Ankle Joint Injection Patient position: Transducer position: Supine with knee flexed and foot flat on table. Transducer position: Sagittal plane between tibialis anterior and extensor hallucis longus tendons.

Ankle Joint Injection Needle orientation: Needle approach: Target: Long-axis to transducer. Needle approach: Anteroinferior. Target: Anterior ankle joint recess between distal tibia and talar dome. Avoid neurovascular structures.

Flexor Hallucis Longus (FHL) Tendon Sheath Injection Patient position: Prone with foot off table. Transducer position: Transverse plane over FHL tendon at level of posterior process of the talus.

Flexor Hallucis Longus (FHL) Tendon Sheath Injection Needle orientation: Long-axis to transducer. Needle approach: Lateral (deep to the Achilles tendon). Target: FHL tendon sheath. Avoid sural nerve and medial neurovascular structures.

Peroneal Tendon Sheath Injection Patient position: Lateral decubitus on contralateral side. Patient facing clinician. Transducer position: Transverse plane over peroneal tendons approximately 2-3 cm proximal to lateral malleolus.

Peroneal Tendon Sheath Injection Needle orientation: Long-axis to transducer. Needle approach: Anterolateral. Target: Peroneal tendon sheath. Utilize oblique standoff technique with sterile US gel.

Sinus Tarsi Injection Patient position: Transducer position: Lateral decubitus on contralateral side. Patient facing clinician. Transducer position: Oblique coronal plane over sinus tarsi.

Sinus Tarsi Injection Needle orientation: Needle approach: Target: Short-axis to transducer. Needle approach: Anterior. Target: Sinus tarsi. Advance needle until contact made with bottom of sinus tarsi.

Subtalar Joint (Posterior Facet) Injection Patient position: Lateral decubitus on contralateral side. Patient facing clinician. Transducer position: Oblique coronal plane over anterior margin of subtalar joint’s posterior facet, just anterior to lateral malleolus.

Subtalar Joint (Posterior Facet) Injection Needle orientation: Short-axis to transducer. Needle approach: Anterior. Target: Subtalar joint.

Retrocalcaneal Bursa Injection Patient position: Prone with foot off table. Transducer position: Transverse plane over retrocalcaneal bursa.

Retrocalcaneal Bursa Injection Needle orientation: Long-axis to transducer. Needle approach: Lateral. Target: Retrocalcaneal bursa between Achilles tendon and posterior calcaneus. Avoid sural nerve.

Retro-Achilles Bursa Injection Patient position: Prone with foot off table. Transducer position: Transverse plane over retro-Achilles bursa.

Retro-Achilles Bursa Injection Needle orientation: Long-axis to transducer. Needle approach: Lateral. Target: Retro-Achilles bursa superficial to Achilles tendon. Avoid sural nerve.

Percutaneous Needle Tenotomy of the Achilles Tendon Patient position: Prone with foot off table. Transducer position: Sagittal plane over Achilles tendon (mid-portion or insertion as applicable).

Percutaneous Needle Tenotomy of the Achilles Tendon Needle orientation: Long-axis to transducer. 18-20-gauge needle. Needle approach: Distal OR proximal. Target: Fenestrate tendon. Insertional: Fragment osteophytes and abrade periosteum.

High-Volume Injection with Percutaneous Needle Scraping of the Achilles Tendon Patient position: Prone with foot off table. Transducer position: Transverse plane over interface between mid-portion Achilles tendon and Kager fat pad.

High-Volume Injection with Percutaneous Needle Scraping of the Achilles Tendon Needle orientation: Long-axis to transducer. 18-20-gauge needle. Needle approach: Lateral. Target: Inject and repeatedly scrape along entire Achilles tendon-Kager fat pad interface.

Plantar Fascia Injection Patient position: Lateral decubitus on ipsilateral side. Transducer position: Coronal plane inferior to plantar fascia attachment to medial calcaneal tubercle.

Plantar Fascia Injection Needle orientation: Long-axis to transducer. Needle approach: Medial. Target: Superficial to plantar fascia. Avoid direct injection into plantar fascia.

Percutaneous Needle Fasciotomy of the Plantar Fascia Patient position: Prone with foot off table. Transducer position: Sagittal plane inferior to plantar fascia attachment to medial calcaneal tubercle.

Percutaneous Needle Fasciotomy of the Plantar Fascia Needle orientation: Long-axis to transducer. 18-20-gauge needle. Needle approach: Distal OR proximal. Target: Fenestrate fascia. Fragment osteophytes and abrade periosteum.

First Metatarsophalangeal (MTP) Joint Injection Patient position: Supine. Transducer position: Sagittal plane over dorsomedial aspect of first MTP joint.

First Metatarsophalangeal (MTP) Joint Injection Needle orientation: Short-axis to transducer. Needle approach: Medial. Target: Dorsomedial aspect of first MTP joint. Avoid medial hallucal nerve.

Interdigital Neuroma Injection Patient position: Supine. Transducer position: Sagittal plane inferior to intermetatarsal space on plantar aspect of the foot.

Interdigital Neuroma Injection Needle orientation: Long-axis to transducer. Needle approach: Distal to proximal. Target: Adjacent to or within neuroma. Avoid adjacent digital artery and vein.

Summary Proper patient, clinician, and US machine positioning are essential for optimizing performance of US-guided interventions. Pre-procedural scanning is important in order to plan transducer placement and needle approach during the procedure. Carefully look for neurovascular structures and other structures of interest to avoid procedural complications.

Thank You pecke@ccf.org