Diagnostic Ultrasound of the Ankle and Foot
Diagnostic Ultrasound of the Ankle and Foot
Diagnostic Ultrasound of the Ankle and Foot
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<strong>Diagnostic</strong><br />
<strong>Ultrasound</strong> <strong>of</strong> <strong>the</strong><br />
<strong>Ankle</strong> <strong>and</strong> <strong>Foot</strong><br />
Dr. Peter Resteghini<br />
Consultant Physio<strong>the</strong>rapist Musculoskeletal<br />
Medicine<br />
Musculoskeletal Sonographer<br />
Tel: 0208 510 5751<br />
E-mail: peter.resteghini@homerton.nhs.uk<br />
www.homerton.nhs.uk/sportsinjury
Aims<br />
• An overview <strong>of</strong> tendinopathy<br />
• Imaging <strong>of</strong> <strong>Ankle</strong> <strong>and</strong> <strong>Foot</strong>
Normal<br />
*<br />
• No thickening<br />
• Homogeneous echogenicity<br />
• No hypoechoic or hyperechoic foci<br />
• Nil neovascularisation (Levin, 2005)
Abnormal<br />
Diagnosed by 1 or more <strong>of</strong> <strong>the</strong><br />
following findings<br />
Thickened – ‘Spindle Shape’<br />
Neovascularization in <strong>the</strong> distal<br />
third <strong>of</strong> tendon<br />
1. Tendon thickening with<br />
heterogeneous echogenicity<br />
2. Hypoechoic foci representing<br />
intrasubstance tears (defined<br />
as linear hypoechoic foci<br />
associated with discontinuity<br />
<strong>of</strong> tendon fibres)<br />
3. Calcifications <strong>and</strong><br />
en<strong>the</strong>siophytes at <strong>the</strong> tendon<br />
attachment<br />
4. Neovascularization<br />
(Levin, 2005; Zanetti, 2003)
The <strong>Ankle</strong> &<br />
<strong>Foot</strong>
Superficial Peroneal N<br />
FHL<br />
Tib Ant<br />
Deep Peroneal N / Ant Tib A<br />
Superior Ext Ret<br />
Inf Ext Ret<br />
EDL<br />
Anatomy -<br />
Anterior
Anterior – US Transverse<br />
Med<br />
Lat<br />
EHL<br />
EDL<br />
TA ten & ms<br />
VAN
Anterior – US Long<br />
TA insert med cuneiform<br />
Tib<br />
*<br />
T Dome<br />
*<br />
T Head
Tibialis Anterior
Anterior – Mid Tarsal Jts & Ligs<br />
Talus<br />
Navicular<br />
Longitudinal
Practical –<br />
Anterior<br />
<strong>Ankle</strong>
Anatomy - Lateral<br />
Inf Tib<br />
Fib Lig<br />
ATFL<br />
Bifurcate Lig<br />
EDB<br />
CFL<br />
Dorsal C-C Lig
Lateral - ATFL<br />
ATFL<br />
Talus<br />
Fib
ATFL Complete rupture
Image clip <strong>of</strong> +ve sonographic draw<br />
ATFL rupture with +ve Sonographic Draw.avi
Lateral – CFL & Peroneal tendons<br />
PL<br />
PB<br />
Lat mall<br />
Calcaneus
Lateral – Peroneal tendons<br />
PL ten<br />
LM<br />
PL<br />
PB<br />
PB ms<br />
PB ten
Lateral – Peroneal tendons
Practical –<br />
Lateral <strong>Ankle</strong>
Anatomy - Medial<br />
TA<br />
TP<br />
Deltoid Lig<br />
FDL<br />
FHL<br />
AVN<br />
FDB
Medial - Transverse<br />
TP<br />
FDL<br />
A<br />
Med mall<br />
T n<br />
This way<br />
for FHL
Medial Artery Nerve FHL
• Medial ankle A N FHL.wmv
Tenosynovitis<br />
Tibialis Posterior<br />
• On <strong>the</strong> right fluid is noted within <strong>the</strong> tendon<br />
sheath <strong>of</strong> <strong>the</strong> tibialis posterior tendon. The<br />
tendon itself is <strong>of</strong> normal echotexture with<br />
no evidence <strong>of</strong> tendinopathy.<br />
• Tenosynovitis
Tibialis Posterior - Intrasubstance tear<br />
Longitudinal * marks tear<br />
Transverse – Tear seen as<br />
circumferential in nature<br />
*
Tibialis Posterior – tendinopathy / tenosynovitis
Tibialis Posterior injection
Medial - FHL<br />
MPTT<br />
FHL<br />
LPTT
Medial – Deltoid Lig<br />
TP<br />
Med mall<br />
talus<br />
Tibiotalar lig<br />
A – Posterior<br />
part<br />
TP<br />
mm<br />
tibionavicular<br />
talus<br />
cal<br />
B – Middle<br />
part
Practical –<br />
Medial <strong>Ankle</strong>
Anatomy – Posterior & Superficial<br />
Med Gastroc<br />
Lat Gastroc<br />
Soleus<br />
Aponeurosis <strong>of</strong> Gastroc<br />
TA
Anatomy – Posterior & Deep<br />
NAV<br />
Peroneals<br />
Med<br />
FHL<br />
Lat<br />
Retrocalcaneal bursa
Achilles Tendon - Normal<br />
Retrocal Bursa<br />
Kager’s<br />
cal<br />
Above Long<br />
Kager’s<br />
Right Transverse – ‘Bean shape –<br />
wider medially’
Achilles Tendon - abormal
The HVUSGI
Equipment
HVUSGI
Pre & 1/52 post
Achilles tendon – Soleus insertion<br />
TA<br />
Sol<br />
FHL
Medial Calf<br />
Gastroc<br />
Sol<br />
Above: Normal<br />
Right: Tear <strong>of</strong> gastroc from<br />
fascial attachment
TA - En<strong>the</strong>siopathy
TA – Complete tear
Retrocalcaneal Bursitis<br />
The Achilles tendon is intact but appears (slightly thickened). A<br />
large retrocalcaneal bursa is demonstrated. Injected short axis<br />
view.
Practical –<br />
Posterior<br />
<strong>Ankle</strong>
The foot
Plantar Fasciitis<br />
FDB<br />
cal<br />
cal
Plantar Fasciitis
Plantar Fasciitis – Injection
Stressing PF<br />
PF Stress test.wmv
Ruptured Plantar Fascia
Plantar Fibromatosis
Normal Plantar Fascia - Mid
Mortons Neuroma<br />
Transverse view: Hypoechoic focus between 3 rd <strong>and</strong> 4 th interspace.<br />
A +ve Mulder’s click was present
Mortons Neuroma<br />
Longitudinal view <strong>of</strong> neuroma<br />
between 3-4 th MT heads
Mortons Neuroma – Video Morton’s with<br />
+ve Mulder’s<br />
Morton's Neuroma.wmv
Aspiration / rupture ganglion foot
Practical –<br />
<strong>Foot</strong>