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Foot and Ankle Ultrasound
Timothy W. Deyer, MD East River Medical Imaging
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Imaging Indications Tendon pathology Ligament assessment
Soft tissue masses Foreign bodies Dynamic evaluation Direct percutaneous intervention
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Normal Foot and Ankle Anatomy
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Technique Transducer Patient positioning
Linear transducer – 9-15 mHz Hockey stick Patient positioning Evaluate structures in longitudinal and transverse planes Anisotropy
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Peroneus Brevis Tendon
Probe not Perpindicular to Tendon Probe Perpindicular to Tendon
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Ankle Ultrasound Regions evaluated Anterior ankle Posterolateral ankle
Posteromedial ankle Posterior ankle
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Anterior Ankle Technique Structures evaluated Patient supine
Knee flexed 90°, plantar aspect of foot flat on table Structures evaluated Extensor tendons Retinaculum Anterior joint space Anterior ligaments
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Extensor Tendons Tibialis Anterior Extensor Hallucis Longus
Largest extensor tendon Most medial Only tendon sheath to start above the superior retinaculum Extensor Hallucis Longus ½ the size of TA Extensor Digitorum Longus Muscle belly may extend distal to the ankle joint
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Anterior Tendons EDL EHL ATT Talus
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Longitudinal Image - EHL
Extensor Hallucis Longus Tibia Talus
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Retinaculum Thin, hyperechoic band Superior and inferior components
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Extensor Retinaculum ATT EHL
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Anterior Joint Recess Best studied longitudinally
Small, < 3 mm, joint effusion is normal Anterior capsule Hyperechoic Cartilage Hypoechoic
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Anterior Capsule Talus Tibia Fat Pad Cartilage Tibia Joint Fluid Talus
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Anterior Ligaments Interosseous Anterior tibiofibular
Anterior talofibular
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Anterior Talofibular Ligament
Tibia
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Posteromedial Ankle Technique Structures evaluated
Patient in frog leg lateral position Structures evaluated Medial long flexor tendons Flexor retinaculum Deltoid ligament
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Flexor Tendons Examine supra-malleolar, malleolar, infra-malleolar
Examine transverse and longitudinal Posterior Tibial Largest of 3 tendons Tendon sheath may normally contain fluid Anisotropy proximal to navicular insertion due to oblique course Flexor Digitorum Longus Flexor Hallucis Longus Posterior to neurovascular bundle at the malleolus
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Tarsal Tunnel Flexor Neurovascular Bundle: Digitorum Posterior Tibial
Posterior Tibial Artery, Vein, Nerve Posterior Tibial Flexor Hallucis
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Longitudinal Image - PTT
Distal Anisotropy Posterior Tibial Tendon
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Deltoid Ligament Superficial and deep components
Plantar flex for anterior components and dorsiflex for posterior
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Deltoid Ligament Deltoid Ligament Tibia Talus Talus
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Posterolateral Ankle Technique Structures evaluated
Essentially the same as for evaluation of the anterior ankle Inverting the ankle aids in visualization Alternatively can have patient lie obliquely with the medial aspect of the foot on the table Structures evaluated Peroneal tendons Posterior ligaments
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Peroneal Tendons Continual adjustment necessary to stay transverse
Peroneal longus posterior to brevis at the malleolus Examine transverse and longitudinal Distally the tendons are separated by the peroneal tuberacle Distal to the tubercle the tendons have separate sheaths Can perform dynamic evaluation at the malleolus to look for subluxation
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Peroneal Tendons Peroneus Longus Peroneus Brevis Lateral Malleolus
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Posterolateral Ligaments
Posterior Tibiofibular Often poorly seen with ultrasound Posterior Talofibular Not successfully imaged with ultrasound Calcaneofibular Dorsiflex ankle to optimally image
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Calcaneofibular Ligament
Calcaneus
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Posterior Ankle Technique Structures evaluated Prone
Feet hanging off the table Structures evaluated Achilles tendon Retrocalcaneal bursa
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Achilles Tendon Achilles Retrocalcaneal Bursa Calcaneus
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Foot Ultrasound Structures evaluated Plantar fascia
Intermetatarsal space Plantar plate
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Plantar Fascia Technique Thickness < 4 mm Patient prone
Feet overhang the end of the bed Transverse and longitudinal planes Thickness < 4 mm
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Plantar Fascia Plantar Fascia
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Webspaces and Plantar Plates
Technique Dorsal and plantar Spread metatarsal heads Apply increasing pressure Normal appearance Homogeneous echogenic fat Plantar plate Triangular isoechoic structure at base of proximal phalanx
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MTP Joint and Webspace Normal Plantar Plate Phalanx Metatarsal Head
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Foot and Ankle Pathology
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Imaging Indications Tendon pathology Ligament assessment
Soft tissue masses Foreign bodies Dynamic evaluation Direct percutaneous intervention
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Common Tendon Pathology
Tenosynovitis Abnormal amount of fluid in the tendon sheath Tendinosis Enlarged tendon Increased hypoechogenicity between the echogenic fibrils Tendon tear Partial thickness – disruption of fascicular architecture Full thickness – gap Interstitial – tear parallels long axis
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Normal Amounts of Tendon Sheath Fluid
Site of Fluid Normal Fluid Measurement Posterior Tibial Tendon <4 mm Common Peroneal Tendon Sheath <3 mm FHL Undefined
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EDL Tenosynovitis Extensor Digitorum Tendon Sheath Fluid
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Thickened Achilles Tendon
Achilles Tendinosis Thickened Achilles Tendon Calcaneus
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Full Thickness Tear of the Achilles Tendon
Tendon Gap Filled with Fat Proximal Distal
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Full Thickness Tear of the EHL
Fluid in EHL Tear Calcaneus
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Interstitial Tendon Tear of the Peroneus Brevis Tendon
Peroneus Longus Peroneus Brevis Peroneus Longus Peroneus Brevis Peroneus Longus Peroneus Brevis
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Ligament Sprain Tear Thickened Heterogenous
Fluid insinuates into ligament
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Thickened Heterogenous ATFL
ATFL Sprain Thickened Heterogenous ATFL Fibula Talus
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Partial ATFL Tear Intact Fibers Fibula Fluid in the Tear Torn Fibers
Talus
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Plantar Fasciitis Findings Thickness > 4mm Heel pad edema
Partial thickness tears
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Thickened Plantar Fascia
Plantar Fasciitis Thickened Plantar Fascia 6mm Calcaneus
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Partial Tear of the Plantar Fascia
Intact Fibers Torn Fibers Calcaneus
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Morton’s Neuroma and Intermetatarsal Bursitis
Non-compressible Hypoechoic +/- entering/exiting nerve Bursitis Anechoic Compressible
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Morton’s Neuroma Compression Neuroma Bursitis No Compression
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Plantar Plate Findings Degeneration Tear Irregular contour
Heterogenous Tear Partial or full thickness Fluid extends into a tear
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Plantar Plate Degeneration
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Partial tear of the Plantar Plate
Plantar Plate Tear Partial tear of the Plantar Plate Intact Plantar Plate
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Foreign Body Complimentary to MRI, CT, X-ray
Can be used for real time localization
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Foreign Body - Splinter
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Soft Tissue Masses Complimentary to MRI, CT, X-ray Use
Sometimes diagnostic Ganglion Localize Identify involved tissues
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Anechoic Structure “Pointing” Toward Subtalar Joint
Ganglion Anechoic Structure “Pointing” Toward Subtalar Joint Fibula Talus
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Glomus Tumor Hypoechoic Mass Erosion Feeding Vessel Distal Phalanx
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Dynamic Evaluation Unique capability of Ultrasound Real time Utility
Tendon Subluxation Impingement
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Peroneal Brevis Subluxation
Peroneus Longus Anterior Posterior Peroneus Brevis Medial Malleolus
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Ultrasound Guided Injections and Aspirations
Sites Plantar fascia Neuroma Tendon sheath Ganglion Joint
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Plantar Fascia Injection
Techique Patient prone, foot over edge of bed Linear transducer 1.5” 25 gauge or 3.5” 22 gauge Posterior heel, superficial to plantar fascia Steroid/anesthetic 0.5 cc 1% lidocaine 0.5 cc 0.25% bupivicaine 1 cc Kenalog (40 mg/ml)
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Plantar Fascia Injection
Needle Steroid/Anesthetic Mixture Calcaneus
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Neuroma Injection Techique
Patient supine, knee flexed 90 degrees, foot flat on bed Hockey stick transducer 1.5” 25 gauge Webspace, tip in adjacent to neuroma Steroid/anesthetic – 0.75 cc of: 0.5 cc 1% lidocaine 0.5 cc 0.25% bupivicaine 1 cc Kenalog (40 mg/ml)
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Steroid/Anesthetic Mixture
Neuroma Injection Neuroma Steroid/Anesthetic Mixture Neuroma Needle
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Tendon Sheath Injection
Techique Position depends on tendon sheath Hockey stick transducer perpedicular to tendon 1.5” 25 gauge Needle into fluid in tendon sheath, if no fluid create effusion with lidocaine Steroid/anesthetic 0.5 cc 1% lidocaine 0.5 cc 0.25% bupivicaine 1 cc Kenalog (40 mg/ml)
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Tendon Sheath Injection
Steroid/Anesthetic Mixture Needle Interstitial Tears PTT
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Ganglion Aspiration Techique Position depends on location
Transducer depends on depth 1.5” gauge Attempt aspiration Inject lidocaine and re-attempt aspiration Lavage with steroid/anesthetic
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Ganglion Aspiration Needle Lidocaine Injection 5th TMT Ganglion
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Joint Injection Techique Position depends on joint
Transducer depends on joint Tibiotalar – Linear All others – Hockey stick 1.5” 25 gauge Parallel to transducer for tibiotalar Perpendicular for all other joints Variable amount of steroid/anesthetic mixture depending on joint size
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Steroid/Anesthetic Mixture
Joint Injection Steroid/Anesthetic Mixture Proximal Phalanx Metatarsal Needle Tip
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Summary Rigorous technique very important Must know normal anatomy
Diagnostic Use Tendinosis/Tenosynovitis Ligament sprain Soft tissue masses Dynamic evaluation Direct interventional procedures
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Thank You
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Questions
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