ULTRASOUND OF THE ANKLE - Normal

 

Note: Hover cursor over images for highlighted anatomy.

Lateral Ankle

  • Peroneus longus and brevis tendons.
  • Calcaneo-fibula ligament.
  • Anterior Talo-Fibula ligament
peroneus tendons scan plane> Peroneus longus and brevis tendons

Peroneus tendons scan plane

Peroneus longus and brevis tendons. Transverse at the medial malleolus.

 Scan plane for the peroneus brevis insertion to the base of the 5th MT Peroneus brevis insertion

Scan plane for the Peroneus Brevis insertion to the base of the 5th metatarsal.

Peroneus brevis insertion onto the base of the 5th metatarsal.

calcaneo fibula ligamentscan plane Calcaneo-fibular ligament

Calcaneo fibula ligament scan plane.

Calcaneo-fibular ligament.

ATAF scan plane Anterior Talo-fibula ligament

ATFL scan plane.

Anterior Talo-fibula ligament (ATFL).

 

Anterior Ankle

  • Tibio-fibula ligament
  • Extensor Digitorum tendon(s)
  • Extensor Hallucis Longus
  • Tibialis anterior
  • Extensor retinaculum
Tibio fibula ligament scan plane Tibio fibula ligament

Tibio fibula ligament scan plane.

Normal Tibio fibula ligament.

extensor digitorum scan plane extensor digitorum

Scan plane for the extensor digitorum tendon of the foot.

Extensor digitorum tendon. There is a common tendon until the level of the extensor retinaculum at the anterior ankle crease. After this, the tendon divides to the 4 lateral toes. (The big toe has it's own tendon - the extensor hallucis).

extensor hallucis scan plane Extensor hallucis tendon

Extensor hallucis scan plane

Longitudinal extensor hallucis longus tendon.

Tibialis anterior scan plane Tibialis anterior tendon

Tibialis Anterior scan plane.

Longitudinal Tibialis Anterior tendon.

 

Medial Ankle

  • Tibialis Posterior tendon
  • Flexor Digitorum tendon
  • Flexor Hallucis Longus tendon
  • Deltoid ligament
  • Posterior tibial nerve
TDH scan plane TDH

Scan plane to see Tibialis Posterior, Flexor Digitorum and Flexor Hallucis Longus (you may need to adjust the probe posteriorly to view the deeper FHL).

Tibialis posterior, flexor Digitorum and flexor Hallucis longus tendons (known as "Tom, Dick & Harry"). If including the neurovascular bundle - Tom Dick And Very Nervous Harry.

Deltoid ligament scan plane Deltoid ligament

Deltoid Ligament scan plane: Use plenty of gel and have the probe tip overlie the malleolar tip.

Because of it's obliquity, you cannot readily see all aspects of the ligament.

 

Ultrasound of a normal Tibialis Posterior tendon insertion.

Particular note is made of the accessory ossicle that should not be confused with an avulsed fragment.

Posterior Ankle

  • Achilles tendon
  • Retrocalcaneal (Kager's) fat-pad
 Scan plane for achilles ultrasound  Ultrasound of a normal Achilles tendon LS.
Scan plane for the Achilles tendon
Normal Achilles tendon longitudinal panorama.

 

 

 

For ankle pathology.

 

ULTRASOUND OF THE ANKLE PROTOCOL 

ROLE OF ULTRASOUND 

Ultrasound is essentially used for the external structures of the ankle. Ultrasound is a valuable diagnostic tool in assessing the following indications; Muscular, tendinous and ligamentous damage (chronic and acute) Bursitis Joint effusion Vascular pathology Haematomas Soft tissue masses such as ganglia, lipomas Classification of a mass eg solid, cystic, mixed Post surgical complications eg abscess, oedema Guidance of injection, aspiration or biopsy Relationship of normal anatomy and pathology to each other Some bony pathology.

LIMITATIONS

It is recognised that ultrasound cannot adequately assess the deltoid ligament, the ankle mortice and some inter-tarsal ligments.

EQUIPMENT SELECTION AND TECHNIQUE

Use of a high resolution, (8-15MHZ)small footprint probe , is essential when assessing the superficial structures of the ankle. Careful scanning technique to avoid anisotropy (and possible misdiagnosis) Beam steering or compounding can help to overcome anisotropy in linear structures such as tendons. Good colour / power / Doppler capabilities when assessing vessels or vascularity of a structure. Be prepared to change frequency output of probe (or probes) to adequately assess both superficial and deeper structures.

 

SCANNING TECHNIQUE

LATERAL ANKLE 

Patient sits on the side of a raised bed with foot resting on the Sonographers knee for support. Alternatively, the patient may sit or lie supine on bed with their foot flat.
Peroneus longus and brevis tendons: Begin in transverse, posterior to the lateral malleolus. The two tendons are easily seen with the peroneus brevis closest to the bone. Follow them proximally to the muscle and distally with particular attention to the insertion of the peroneus brevis tendon onto the base of the 5th metatarsal.

Calcaneo-fibular ligament: With the probe diagonally under the malleolus, angled from the fibula to the heel, you will see the peroneus tendons in transverse and the calcaneo-fibula ligament underlying them.

ANTERIOR ANKLE

Patient positioned as above.
Anterior talo-fibula ligament (ATFL): Place the heel of the probe on the anterior aspect of the distal fibula and rotate the toe of the probe towards the 2nd toe. The ligament should be readily visible as a 2cm long, 3mm thick tight fibrillar structure.
Tibio-Fibula ligament (TFL): From the ATAF, further rotate the toe of the probe until just above the horizontal. The TFL has a similar appearance to the ATAF.
Extensor tendons: In transverse across the anterior ankle crease, you will see, from lateral to medial, the extensor digitorum, extensor hallucis and tibialis anterior tendons. By independently mobilising each of the toes and watching the tendons glide, you can identify which is which and exclude tendon rupture The overlying extensor retinaculum should also be observed.

MEDIAL ANKLE 

Patient positioned as above.
Tibialis posterior, flexor digitorum and flexor hallucis longus tendons: Assess the tendons along their length in longitudinal and transverse. Pay particular attention to the insertion of the Tibialis Posterior tendon with caution not to mistake the often present accessory ossicle, for an avulsed fragment. Begin diagonally under the medial malleolus with the toe of the probe on the malleolus. You will see the tibialis posterior and flexor digitorum tendons in transverse. Slide the probe postero-inferiorly and you will see the flexor hallucis longus tendon deeper against the calcaneum.

The deltoid ligament: Is poorly assessed with ultrasound.

Posterior tibial nerve: The neurovascular bundle is easily seen posterior to the medial malleolus

POSTERIOR ANKLE 

Patient positioned prone with the feet off the end of the bed.
Achilles tendon: Perform a survey scan ,in transverse, from the calcaneum up to the musculo-tendinous junction (of both medial and lateral gastrocnemii). Rotate into longitudinal and examine for thickening and integrity. At the same time assess the retrocalcaneal (Kager's) fat pad.

The calf muscles and plantaris tendon should also be assessed as clinically indicated.

 

BASIC IMAGING 

An ankle series should include the following minimum images;

  • Peroneus tendons - long, trans + peroneus brevis insertion
  • Calcaneo-fibular ligament
  • Anterior talo-fibula ligament
  • Tibio-Fibula ligament
  • Extensor digitorum tendon
  • Extensor hallucis longus tendon
  • Tibialis anterior tendon
  • Tibialis posterior tendon
  • Flexor digitorum tendon
  • Flexor hallucis longus
  • Achilles tendon and retro calcaneal bursa
  • Document the normal anatomy. Any pathology found in 2 planes(ligament tears or thickening, synovial bulging/cysts, joint effusion, gross bony changes), including measurements and any vascularity.
 
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