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Sonography of the Foot and Ankle
Evan Peck, MD Section of Sports Health Department of Orthopaedic Surgery Cleveland Clinic Florida
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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.
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Objectives Understand the proper technique for performance of the diagnostic foot and ankle ultrasound (US) examination. Be familiar with the structures required for complete diagnostic US evaluation of each region of the ankle and selected structures relevant to sonographic examination of the foot. Recognize the sonographic appearance of normal foot and ankle structures and common pathology.
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Before You Start High-frequency (>10 MHz) linear-array transducer.
Bone is your friend. Beware of anisotropy.
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General Considerations
Patient supine (anterior), lateral decubitus (medial, lateral), or prone (posterior; possibly medial, lateral). Pillow or towel roll useful for ankle positioning, particularly for decreasing anisotropy of ligaments. Utilize generous gel stacking for concave and convex contours of the foot and ankle. Be mindful of transducer pressure, which can displace (and hide) abnormal fluid collections.
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What to Scan? AIUM Practice Guideline for the Performance of a Musculoskeletal Ultrasound Examination and AIUM Diagnostic Musculoskeletal Case Submission Requirements. May select one quadrant of the ankle for “complete” US evaluation (anterior, medial, lateral, posterior) based on clinical presentation. Foot US evaluation usually focused on specific structure(s) of primary clinical interest.
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Anterior Ankle: Checklist
Tibialis anterior tendon (long and short axis). Extensor hallucis longus tendon (long and short axis). Extensor digitorum longus tendon (long and short axis). Anterior joint recess. Anterior inferior tibiofibular ligament (oblique axial images). AIUM.org
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Anterior Ankle: Short Axis
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Tibialis Anterior Tendon: Long Axis
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Extensor Hallucis Longus Tendon: Long Axis
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Extensor Digitorum Longus Tendon: Long Axis
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Anterior Ankle Joint Recess
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Anterior Ankle Joint Effusion
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Anterior Inferior Tibiofibular Ligament
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Medial Ankle: Checklist
Posterior tibial tendon (long and short axis). Flexor digitorum longus tendon (long and short axis). Flexor hallucis longus tendon (long and short axis). Tibial nerve. Deltoid ligament (long axis). AIUM.org
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Medial Ankle (Tarsal Tunnel): Short Axis
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Posterior Tibial Tendon: Long Axis
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Flexor Digitorum Longus Tendon: Long Axis
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Flexor Hallucis Longus Tendon: Long Axis
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Tibial Nerve: Long Axis
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Deltoid Ligament - Three components of deltoid ligament (A-P): Tibionavicular, tibiocalcanear, tibiotalar.
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Lateral Ankle: Checklist
Peroneus brevis tendon (long and short axis). Peroneus longus tendon (long and short axis). Calcaneofibular ligament. Anterior talofibular ligament. Dynamic imaging as indicated. AIUM.org
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Peroneal Tendons (Short Axis)
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Peroneus Brevis (Long Axis)
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Peroneus Longus (Long Axis)
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Peroneus Longus Tenosynovitis (Short Axis)
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Calcaneofibular Ligament
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Anterior Talofibular Ligament
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Anterior Talofibular Ligament Tear
- Sensitivity/specificity of US detecting ATFL tear: 98.9%/96.2%. - Sensitivity/specificity of US detecting CFL tear: 93.8%/90.9%. Cheng 2014
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Posterior Ankle: Checklist
Achilles tendon. Plantaris tendon (may be absent in 20% of population). Retrocalcaneal bursa (typically visible without pathology). Retro-Achilles bursa (typically not visible without pathology). Plantar fascia. AIUM.org, Delgado 2002
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Achilles Tendon (Long Axis)
- Retrocalcaneal bursa: Up to 2.5 mm AP stripe of anechoic fluid may be normal. Nazarian 1995
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Achilles Tendon (Short Axis)
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Mid-Portion Achilles Tendinosis (Long Axis)
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Insertional Achilles Tendinosis (Long Axis)
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Mid-Portion Achilles Tendinosis (Long Axis, Extended FOV)
Picture courtesy Jay Smith, MD
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Achilles Tendon Full-Thickness Tear (Long Axis)
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Plantar Fascia (Long Axis)
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Plantar Fascia (Short Axis)
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Plantar Fasciosis (Long Axis)
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Plantar Fasciosis with Partial-Thickness Tear (Long Axis)
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Plantar Fasciosis with Partial-Thickness Tear (Short Axis)
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Foot: As Indicated Metatarsophalangeal joints (if inflammatory arthritis suspected). Proximal interphalangeal joints (if inflammatory arthritis suspected). Interdigital nerves. Interdigital bursae. AIUM.org
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First Metatarsophalangeal Joint Effusion
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Interdigital Neuroma in First Intermetatarsal Space (Short Axis)
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Picture courtesy Mederic Hall, MD
Foot Foreign Body Picture courtesy Mederic Hall, MD
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Summary Use a systematic approach.
Patient positioning and use of bony landmarks key for optimizing visualization of foot and ankle structures, particularly ligaments. Be aware of anisotropy, particularly with tendons that change direction about the ankle. Utilize dynamic imaging as indicated.
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References AIUM.org. AIUM Practice Guideline for the Performance of a Musculoskeletal Ultrasound Examination. AIUM.org. Diagnostic Musculoskeletal Case Submission Requirements. Cheng Y et al. Value of ultrasonography for detecting chronic injury of the lateral ligaments of the ankle joint compared with arthroscopy findings. Br J Radiol Jan;87(1033): Delgado GJ et al. Tennis leg: Clinical US study of 141 patients and anatomic investigation of four cadavers with MR imaging and US. Radiology Jul;224(1): Nazarian LN et al. Synovial fluid in the hindfoot and ankle: detection of amount and distribution with US. Radiology Oct;197(1):275-8.
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Thank You
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