Diagnostic

Ultrasound of the

Ankle and Foot

Dr. Peter Resteghini Consultant Physiotherapist Musculoskeletal Medicine Musculoskeletal Sonographer Tel: 0208 510 5751 E-mail: peter.resteghini@homerton.nhs.uk www.homerton.nhs.uk/sportsinjury

Aims

An overview of tendinopathy

Imaging of Ankle and Foot

Normal

No thickening

Homogeneous echogenicity

No hypoechoic or hyperechoic foci

Nil neovascularisation (Levin, 2005)

*

Abnormal

Neovascularization in the distal

third of tendon

Thickened – ‘Spindle Shape’

Diagnosed by 1 or more of the

following findings

1. Tendon thickening with

heterogeneous echogenicity

2. Hypoechoic foci representing

intrasubstance tears (defined

as linear hypoechoic foci

associated with discontinuity

of tendon fibres)

3. Calcifications and

enthesiophytes at the tendon

attachment

4. Neovascularization

(Levin, 2005; Zanetti, 2003)

The Ankle &

Foot

Anatomy -

Anterior

FHL Inf Ext Ret

Deep Peroneal N / Ant Tib A

EDL

Tib Ant

Superior Ext Ret

Superficial Peroneal N

Anterior – US Transverse

Med Lat

TA ten & ms

EHL EDL

VAN

Anterior – US Long

TA insert med cuneiform

Tib T Dome

T Head

*

*

Tibialis Anterior

Anterior – Mid Tarsal Jts & Ligs

Longitudinal

Navicular

Talus

Practical –

Anterior

Ankle

Anatomy - Lateral

ATFL

CFL

Bifurcate Lig

Inf Tib

Fib Lig

Dorsal C-C Lig

EDB

Lateral - ATFL

Fib Talus

ATFL

ATFL Complete rupture

ATFL rupture with +ve Sonographic Draw.avi

Image clip of +ve sonographic draw

Lateral – CFL & Peroneal tendons

Lat mall

Calcaneus

PL

PB

Lateral – Peroneal tendons

PB ms

LM

PB ten

PL ten

PB PL

Lateral – Peroneal tendons

Practical –

Lateral Ankle

Anatomy - Medial

TA TP

FDL

FHL

FDB

AVN

Deltoid Lig

Medial - Transverse

Med mall

TP

FDL A

This way

for FHL

T n

Medial Artery Nerve FHL

Medial ankle A N FHL.wmv

Tenosynovitis

Tibialis Posterior

On the right fluid is noted within the tendon

sheath of the tibialis posterior tendon. The

tendon itself is of normal echotexture with

no evidence of tendinopathy.

Tenosynovitis

Tibialis Posterior - Intrasubstance tear

*

Longitudinal * marks tear

Transverse – Tear seen as

circumferential in nature

Tibialis Posterior – tendinopathy / tenosynovitis

Tibialis Posterior injection

Medial - FHL

FHL MPTT

LPTT

Medial – Deltoid Lig

A – Posterior

part

B – Middle

part

Med mall

talus

TP

Tibiotalar lig

mm

talus

cal

TP

tibionavicular

Practical –

Medial Ankle

Anatomy – Posterior & Superficial

Soleus

Med Gastroc Lat Gastroc

Aponeurosis of Gastroc

TA

Anatomy – Posterior & Deep

Lat Med

Peroneals

FHL

NAV

Retrocalcaneal bursa

Achilles Tendon - Normal

Above Long

Right Transverse – ‘Bean shape –

wider medially’

cal Kager’s

Retrocal Bursa

Kager’s

Achilles Tendon - abormal

The HVUSGI

Equipment

HVUSGI

Pre & 1/52 post

Achilles tendon – Soleus insertion

Sol

FHL

TA

Medial Calf

Above: Normal

Right: Tear of gastroc from

fascial attachment

Sol

Gastroc

TA - Enthesiopathy

TA – Complete tear

*

Retrocalcaneal Bursitis

The Achilles tendon is intact but appears (slightly thickened). A

large retrocalcaneal bursa is demonstrated. Injected short axis

view.

Practical –

Posterior

Ankle

The foot

Plantar Fasciitis

cal

cal

FDB

Plantar Fasciitis

Plantar Fasciitis – Injection

Stressing PF

PF Stress test.wmv

Ruptured Plantar Fascia

Plantar Fibromatosis

Normal Plantar Fascia - Mid

Mortons Neuroma

Transverse view: Hypoechoic focus between 3rd and 4th interspace.

A +ve Mulder’s click was present

Mortons Neuroma Longitudinal view of neuroma

between 3-4th MT heads

Mortons Neuroma – Video Morton’s with

+ve Mulder’s

Morton's Neuroma.wmv

Aspiration / rupture ganglion foot

Practical –

Foot