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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>

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