Musculoskeletal Ultrasound Technical Guidelines VI. Ankle

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AnkleNoteThe systematic scanning technique described below is only theoretical, considering thefact that the examination of the ankle is, for the most, focused to one (or a few) aspect(s)only of the joint based on clinical findings.1 Patient seated on the examination bed with the knee flexed 45° sothat the plantar surface of the foot lies flat on the table. Alternatively,the patient may lie supine with the foot free to allow manipulation bythe examiner during scanning. Place the transducer in the axial planeand sweep it up and down over the dorsum of the ankle to examinethe tibialis anterior, extensor hallucis longus and extensor digitorumlongus. These tendons must be examined in their full length startingfrom the myotendinous junction. Look at the tibialis anterior arteryand the adjacent deep peroneal nerve.taehledlvaehlTalusBe sure to examine the superior extensor retinaculum and the insertion of the tibialis anteriortendon, which lies distally and medially. Follow the tibialis anterior tendon up to reachits insertion onto the first cuneiform.Cuneiform 1Legend: a, anterior tibial artery;edl, extensor digitorumlongus tendon; ehl, extensorhallucis longus tendon;ta, tibialis anterior tendon;void arrows, distal tibialisanterior tendon; v, anteriortibial vein; void arrowheads,superior extensor retinaculum;white arrowhead, deepperoneal nerve1
2AnklePlace the transducer in themid longitudinal plane overthe dorsum of the ankle toexamine the anterior recessof the tibiotalar joint.Fluid may be shifted awayfrom this recess using excessiveplantar flexion.60%-70% of the talar domecan be easily assessed bymoving the probe mediallyand laterally.3!T* *TalusLegend: asterisks, anterior fat pad; arrows, anterior recess of the tibiotalarjoint; T, tibia; TD, talar dome; TH, talar headFrom the position described at point-1, roll the forefoot slightly internally (inversion) tostretch the lateral ligaments. A small pillow under the medial malleolus may help to improvethe contact between transducer and skin over the lateral ankle. Place the transducerparallel to the examination bed placing its posterior edge over the distal lateral malleolusto image the anterior talofibular ligament.TDTHLMTalusWhen distinguishing a partial from acomplete tear is difficult, perform a sonographicanterior drawer test by placingthe patient prone with the foothanging over the edge of the examinationtable while pulling the forefootanteriorly when in plantar flexion andinversion. When the ligament is torn,the anterior shift of the talus againstthe tibia will open the gap in the substanceof the ligament.Legend: Anterior drawer test in patient with anterior talofibularligament tear. asterisks, ligament stumps; arrow, talar shift; 1,talar landmark; 2, fibular landmarkLegend: LM, lateral malleolus; void arrowheads,anterior talofibular ligament1* *1* *222
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Musculoskeletal Ultrasound Technical Guidelines VI. Ankle

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