presentation1.pptx. ultrasound examination of the ankle joint
TRANSCRIPT
Ultrasound examination of the ankle joint
Dr ABD ALLAH NAZEER MD
ULTRASOUND OF THE ANKLE ndash NormalLateral AnklePeroneus longus and brevis tendonsCalcaneo-fibula ligamentAnterior Talo-Fibula ligament
Peroneus tendons scan planePeroneus longus and brevis tendons Transverse at the medial malleolus
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 ligament scan plane Calcaneo-fibular ligament
ATFL scan plane Anterior Talo-fibula ligament (ATFL)
Ultrasound of the Peroneus Longus tendon insertion The insertion is to the lateral edge of the 1st cuneiform with some fibers extending to the base of the 1st metatarsal
Anterior AnkleTibio-fibula ligamentExtensor Digitorum tendon(s)Extensor Hallucis LongusTibialis anteriorExtensor retinaculum
Tibio fibula ligament scan plane Normal Tibio fibula ligament
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 its own tendon - the extensor hallucis)
Extensor hallucis scan plane Longitudinal extensor hallucis longus tendon
Tibialis Anterior scan plane Longitudinal Tibialis Anterior tendon
Medial AnkleTibialis Posterior tendonFlexor Digitorum tendonFlexor Hallucis Longus tendonDeltoid ligamentPosterior tibial nerve
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 amp Harry) If including the neurovascular bundle - Tom Dick And Very Nervous Harry
Deltoid Ligament scan plane Use plenty of gel and have the probe tip overlie the malleolar tip
Because of its obliquity you cannotreadily see all aspects of the ligament
Posterior AnkleAchilles tendonRetrocalcaneal (Kagers) fat-pad
Scan plane for the Achilles tendon Normal Achilles tendon longitudinal panorama
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 edema Guidance of injection aspiration or biopsy Relationship of normal anatomy and pathology to each other Some bony pathologyLIMITATIONSIt is recognised that ultrasound cannot adequately assess the deltoid ligament the ankle mortice and some inter-tarsal ligamentsEQUIPMENT SELECTION AND TECHNIQUEUse 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 TECHNIQUELATERAL 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 ANKLEPatient 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 mobilizing 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 calcaneumThe deltoid ligament Is poorly assessed with ultrasoundPosterior tibial nerve The neurovascular bundle is easily seen posterior to the medial malleolusPOSTERIOR 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 (Kagers) fat padThe calf muscles and plantaris tendon should also be assessed as clinically indicated
An ankle series should include the following minimum imagesPeroneus tendons - long trans + peroneus brevis insertionCalcaneo-fibular ligamentAnterior talo-fibula ligamentTibio-Fibula ligamentExtensor digitorum tendonExtensor hallucis longus tendonTibialis anterior tendonTibialis posterior tendonFlexor digitorum tendonFlexor hallucis longusAchilles tendon and retro calcaneal bursaDocument the normal anatomy Any pathology found in 2 planes(ligament tears or thickening synovial bulgingcysts joint effusion gross bony changes) including measurements and any vascularity
MAIN INDICATIONS OFTHE ANKLE ULTRASONOGRAPHIC STUDY
Tendon pathology of the different compartments
of the ankle
bull Evaluation of ligament injuries
bull Bone and joint disorders (synovitis chondral
and osteochondral lesions occult fractures)
bull Retroachilles and preachilles bursitis
bull Characterization of tumors (accessory muscles ganglia
neurogenic tumours soft tissue abscesses etc)
bull Localization of foreign bodies
ABNORMALITIES OF TENDONS
Tendon injuries include tenosynovitis tendinosis
rupture and instability
POSTERIOR COMPARTMENTACHILLES TENDINOPATHY
Can be classified as tendinosis and paratendinitis The isolated
paratendinitis shows intratendinous normal structure exist paratendinitis
spill shown irregularities in the edges of the tendon adhesions and
scarring associated paratendon and a heterogeneous aspect preachilles
fat pad In the tendinosis there is in swelling of the tendon usually
bilateral and textural heterogeneity intratendinous focal hypoechoic areas
TEAR OF ACHILLESThe rupture site is located generally between the 2 and 6 cm from the insertion into the calcaneous in the called critical zone of relative hypovascularityIn ultrasound complete rupture of the Achilles tendon is seen as a focal defect
between the broken ends of the tendon In the acute phase ends are contiguous but the defect may be filled by the anechoic or hypoechoic hematoma In most cases paratendon remains intact as a envelope straight echogenic contouring breakage As a sign associated can exist distortion of the fibrillar configuration and loss of parallelism of the tendon fibers Other signs are indicative fat herniation into the defect better visualization of the plantar tendon and the existence of a posterior acoustic shadowing at the site of the tear (useful sign to differentiate partial thickness tears)
Complete rupture of the Achilles tendon with focal defect between
the ends of the tendon and posterior acoustic shadowing at the
site of the tear useful sign to differentiate partial thickness tears
Patient with psoriasis which identifies tendinosis and Achilles tendon swelling
bilateral and textural heterogeneity with intratendinous focal hypoechoic areas
Ultrasound and radiological correlation calcified Achilles
enthesitis Calcaneal spur as associated finding
Discreetly thickened right Achilles tendon at its insertion combining linear hyperechoic
and hypoechoic areas on small breaks intrasubstance and calcifications of the enthesis
Fat herniation into the defect by complete tear of the Achilles tendon
Complete tear of the Achilles tendon with retraction
of ends and integrity thin plantaris tendon
Tendinosis versus partial tear of Achilles tendon
bullPREACHILLES AND RETROACHILLES BURSITIS
Although bursitis can occur in isolation often are
related and systemic inflammatory diseases
In the ultrasound examination the distended
retrocalcaneal and preachilles appears are a
hypoechoic structure shaped coma interposed
between the Achilles tendon and the posterosuperior
aspect of the calcaneous Care must be taken not to
confuse it with the fatty space Kager containing oval
lobules of hyperechoic fat When bursitis is a
manifestation of synovitis is appreciated
hypervascular area with Doppler ultrasound
In the retroachilles bursitis exists thickening and
collection of fluid in the subcutaneous tissue
superficial to the tendon retrocalcaneal portion
Bursitis preachilles with typical morphology appreciating accumulation of fluid
in a coma between the anterior portion of the Achilles tendon and the calcaneous
Bursitis preachiacutelea that associated synovitis showing hyperemia with increased Doppler flow
Rheumatoid arthritis with retrocalcaneal bursitis (1) and calcaneal erosions (2)
ACCESSORY NAVICULAR BONEIn the distal insertion site may exist TP 2 types of bones
accessories
Accessory navicular bone type I (os tibiale externum) size
between the 2 and 6 mm can be contained within the TP and
being positioned immediately proximal posteromedial to the
navicular bone It generally produces symptoms and should
not be confused with a tendon calcification or avulsion
fracture
Type II accessory navicular bone is an accessory
ossification centre of the navicular bone with size between
9 and 12 mm triangular shaped and articulated through a
synchondrosis of the posterior and medial navicular bone
It insertion site of some fibers of TP and is associated with a
syndrome of pain and increased incidence of tendon rupture
caused by abnormal overloads Osteoarthritic changes may
underlie this synchondrosis which mimic tendon pathology
Accessory navicular bone within the posterior tibial tendon as anatomical variant
ANTERIOR COMPARTMENTThe tendons of the anterior ankle compared
with the rest of the ankle tendons are rarely
affected by disease The anterior tibial tendon
is the most prone to abnormalities like
tendinopathy tenosynovitis and its place
between the most frequent rupture is extensor
retinaculum and insertion into the first
cuneiform and the base of the first metatarsal
Sometimes the retracted tendon stump causes
a nodule on the anteromedial aspect of the
distal portion of the leg making clinically
confused with a tumour or cyst
Distal insertion tendinopathy of the anterior tibial tendon with increased vascularity
Tenosynovitis of the anterior tibial tendon with effusion
Anterior tibial tendon tenosynovitis with intratendinous ruptures
Anterior tibial tendon rupture with retraction of the tendon
Tenosynovitis of the extensor digitorum tendons with a synovial effusion
Tenosynovitis of the extensor digitorum tendon with hypervascularized thickened tendon and synovium and synovial fluid
Rheumatoid arthritis with tenosynovitis of the extensor digitorum and peroneal tendons
Thickening of the extensor hallucis longus tendon caused by osteosynthesis material
Multicystic non vascularized intramuscular mass in the extensor digitorum brevis muscle
LATERAL COMPARTMENTTENOSYNOVITIS OF THE PERONEAL TENDONSThe main sign of ultrasound is the presence of liquid inside the
common synovial sheath whereas usually tendinous
morphology is preserved We must differentiate tenosynovitis of
a spill within the common peroneal sheath secondary to a tear of
calcaneofibular ligament (PCL) The ultrasound diagnosis is the detection of the tendons in a lateral plane relative to the distal portion of the lateral malleolus instead of behind it The dynamic exploration foot dorsiflexion as both eversion may help identify cases of intermittent subluxation In long-standing disease can be observed fusiform thickening
of the peroneal tendons at the tip of the malleolus The complete tears of the peroneus brevis tendon (PC) and peroneus longus (PL) are rare occurring in the area of the lateral malleolus or midfoot Seen in patients with ankle sprains or history of chronic instability especially if they suffer widespread diseases (RA DM) or treated with corticosteroids The peroneal tendon ruptures causing the inability to eversion of the foot and cavus foot varus
Important thickening of both peroneal tendons (longus and brevis) associated
with moderate amount of fluid and thickening of the synovial sheath
Discreet amount of fluid in the common sheath of the peroneal tendons
associated with disorganization and a heterogeneous appearance
peroneus brevis tendon related to longitudinal rupture
Peroneal tenosynovitis and osteosynthesis
Tenosynovitis of the peroneal tendons and an intratendinous rupture of the short peroneal tendon
Intratendinous rupture and cyst in the peroneus brevis tendon
Peroneus quartus with an accessory muscle next to the peroneus longus and brevis tendons
Tumor next to the peroneal tendons that proved to be a benign fibrous mass
MEDIAL COMPARTMENT
ANOMALIES POSTERIOR TIBIAL TENDON (TP)
It is the most frequently injured in this compartment with ruptures
in asymptomatic middle-aged obese women as a result of
widespread disease (RA seronegative Spondyloarthropathy) or
associated with bone fractures It causes a gradual collapse of the
medial longitudinal arch with hindfoot valgus deformity and
excessive forefoot pronation
The presence of small vessels in inflammatory diseases
intratendinosis can simulate a fissuration tendon confusion can be ignored using colour Doppler Another possible diagnostic difficulty is when the undamaged tendon flexor digitorum longus (FLD) moves back and simulates the TP unbroken but it is smaller and in this case we only see in the groove retromalleolar 1 only tendon
Ultrasound has also proven to be an effective resource for identifying alterations associated tendon tenosynovitis serosa and hypertrophicSubluxation and dislocation anteriorly and medial TP relative to internal
malleolus is rare and valued sonographically placing the foot in dorsiflexion with forced supination
Thickening moderate amount of fluid surrounding calcifications and
hyperemia affecting the sheath and the posterior tibial tendon related
to chronic tenosynovitis in patient affects rheumatoid arthritis
Thickening moderate amount of surrounding fluid and calcifications (arrow) affecting the
posterior tibial tendon related to chronic tenosynovitis in patient affects rheumatoid arthritis
Tenosynovitis of the posterior tibial tendon caused by a bony ridge at the insertion of the retinaculum The retinaculum is thickened and the tendon subluxates
Psoriatic arthritis Ankle Grayscale examination Posterior tibial tendon on longitudinal (a) and transverse (b) scan Marked tendon sheath widening with homogeneous anechoic aspect (asterisks) of the content indicating an exudative tenosynovitis Note as the normal fibrillar echotexture is conserved Hand Flexor tendons of second finger The volar longitudinal (c) and transverse scan (d) shows a tendon sheath widening with signs of synovial proliferation presence of intense power Doppler signal surrounding the tendon and micro interruption of the margin (arrow) e Wrist Extensor carpi ulnaris tendon (sixth compartment of the extensor tendons ecu) on lateral longitudinal (e) and transverse (f) scan Chronic tenosynovitis with clear areas of low of echogenicity and loss of the continuity of tendon fibrils indicative of partial tendon tear (arrows) Moreover note the presence of power Doppler signal within the interruption indicating still activity of the inflammatory process g Dactylitis Volar longitudinal scan using the ldquoextended viewrdquo technique showing proliferative tenosynovitis of the finger flexor tendon (circle) exudative synovitis of both proximal and distal interphalangeal joint (white asterisks) and edema of the peritendinous tissue (black asterisks) TP posterior tibial tendon mm medial malleolus DP distal phalanx mp middle phalanx cu cubital bone ft flexor tendons
Tenosynovitis of the posterior tibial (1) and flexor digitorum longus tendon (2)
Tibialis Posterior Tendon rupture
Tenosynovitis of the posterior tibial tendon the flexor digitorum tendon and flexor hallucis longus tendon
Tenosynovitis of the tendons on the medial side in the left ankle
bullLIGAMENT INJURIESThe ligament partial tear ligament shows a hypoechoic
areas swollen with internal focal or diffuse In the complete
ruptures within the substance of the divided ligament rift is
observed corresponding to the hematoma hypoechoic and
the free ends of the divided ligament can be and retracted
appreciated corrugated in contrast with normal
appearance straight
Grade I Mild stretching of the ligament without breakage
or instability
Grade II Partial tearing of the ligament
Grade III Complete tearing
Degrees depending on the severity of the injury and the
place of employment
LATERAL COMPARTMENTThese injuries occur secondary to inversion sprains with internal rotation of
the foot combined with ankle plantar flexion
The anterior talar fibular ligament tears (ATFL) usually occur as isolated
involvement (70) or associated with calcaneal fibular ligament (CFL) (20-40)
but the posterior talar fibular ligament (PTFL) affects only major trauma
involving ankle dislocation
ATFL breaks is associated with breakage of the joint capsule and synovial fluid
extravasation into the anterolateral soft ankle whereas the complete tearing of
CFL can communicate the ankle joint and synovial sheath peroneal tendons
Rupture of CFL is rarely associated with superior peroneal retinaculum tear
The CFL is tensioned during dorsiflexion pulling on peroneal tendons laterally
so that absence of its displacement is sign of a complete tear
Within a damaged ligament can also observe calcifications that often
correspond to fragments of avulsion bone
During the ultrasound can be performed forced maneuvers to detect to joint
laxity and ligament injuries The anterior drawer test is performed with the feet
hanging over the edge of the examination table while the forefoot is pulled
anteriorly when the foot is in plantar flexion and inversion This maneuver
helps differentiate partial tears (grade II) of the ATFL to complete (grade III)
where the anterior displacement of the talus on the tibia open a crack in the
substance becoming more visible the ligament injury
The sindesmosys sprains are up to 10 of ankle
injuries happening in eversion and pronation
movements (like the deltoid ligament injury) and
primarily affect the anterior tibiofibular ligament (ATFL)
the failure is frequently associated with fracture of the
fibula
According to the place of employment are 4 degrees
useful for prognostic evaluation and therapeutic strategy
choice
Grade I stretch or partial tear of the ATFL
Grade II complete tearing but only the ATFL
Grade III complete tear of the ATFL and partial CFL
Grade IV complete tear of the ATFL and CFL
The grade I and II injuries usually scarred without any
significant instability whereas grade III and IV injuries
can cause chronic pain and require surgical treatment
Thickened but continued ATFL right in relation to the partial rupture
Grade 111 sprain of right ATFL
Thickened anterior talofibular ligament with calcifications and a partial rupture
Thickened tibiofibular ligament after trauma
Anterior Talofibular Ligament Partial Tear and Elastography
Tibio fibular ligament rupture with bony avulsion
Complete rupture of right ATFL
Bony avulsion with radiographic evidence as visible calcification in a grade III sprain ATFL
Moderately thickened and hypoechoic ATFL
Discontinuity of the ATFL with fluid surrounding the torn ends (arrow)
Thickening and hypoechogenicity of the fibular end of the ligament seen here passing over the subtalar joint which contains a small of fluid
Complete disruption to the tibiofibular ligament with bony irregularity of particularly the tibial margin and fluid in the gap
MEDIAL COMPARTMENTBecause of the low incidence of eversion ankle
sprains and the thickness of the deltoid ligament
is rarely injured in isolation and when the injury
does not usually full thickness Usually
accompanied by lesions of the medial malleolus
and lateral displacement of the talus with
consequent widening of the ankle mortise
Ultrasound is useful for differentiating ligament
injury of the posterior tibial tendon injury
(TP) adjacent they have similar symptoms
The inability to visualize the deltoid ligament may
indicate tear but this is not considered a reliable
sign as its full ultrasound is not always possible
Partial medial ligament rupture
Thickened heterogeneous abnormal deltoid demonstrating hyperemia
Ultrasonogram showing a disrupted deltoid ligament with the probe in the coronal plane The white arrow indicates the medial malleolus the blue arrow indicates the talus and the red arrows indicate the disrupted deltoid ligament (A) Radiograph showing the same injury (B)
bullJOINT AND BONE DISORDERSUltrasound reliably detect spills mild (gt 2 ml) inside
of the ankle joint by exploring the front and rear
recess as well as areas of synovial proliferation and
may even display using the colour Doppler
hyperemic areas in arthritis patients
The intraarticular joints are displayed surrounded
fluid in one of the recesses of the ankle or subtalar
joint Sonographically diagnosed when changing position to perform flexion and extension Fracture of the lateral process of the talus is overlooked up to 50 of cases with plain radiography Ultrasound may suspect the presence of focal cortical disruption helping further to exclude concomitant ligament injury
Rheumatoid arthritis with synovial thickening (1) and erosion of the tibia (2)
Infectious arthritis with a pus filled anterior recess of the ankle
Arthritis and tenosynovitis of the ankle in a patient with rheumatoid arthritis
bullTUMOURSUltrasound can differentiate between a mass complex
and solid and a cystic in addition to verifying the
existence of accessory muscles (peroneus fourth
accessory flexor digitorum longus and accessory
soleus) As in any other location can be found
neoformative soft tissue tumors inflammatory
infectious etc
Ganglions of this location are more often symptomatic
and larger with multiple partitions
branched and lobed edges Differential diagnosis must
be made with tenosynovitis abscesses seromas and
varicosities
Neurogenic tumours are described as pathognomonic
homogeneous hypoechoic oval mass in continuity with
a nerve of origin
Ganglion cysts are non-malignant cystic masses that occur in association with musculoskeletal structures They are sometimes also simply referred to as ganglia or a ganglion but should not be confused with the anatomical term ganglion UltrasoundThe vast majority are anechoic to hypoechoic on ultrasound and have well defined margins Many demonstrate internal septations as well as acoustic enhancement A synovial cyst is a small fluid-filled sac or pouch that can develop over a tendon or joint creating a mass under the skin Synovial cyst is rare in ankle joint A synovial cyst may or may not be painful depending on their size and location
Ganglion cyst in the foot with bony erosion between navicular and cuneiform bones
Tarsal synovial cyst
Anechoic ganglion situated in the sinus tarsi fat between the talus and calcaneous
Plantar fasciitis (PF) refers to inflammation of the
plantar fascia of the foot It is considered the most common cause of heel pain
Clinical presentation Pain on the undersurface of the heel on weight bearing is the principal complaint It can be worse when weight is borne after a period of rest (eg in the morning) and eases with walking Passive dorsiflexion of the toes may exacerbates discomfort
UltrasoundOften the initial imaging modality of choice Ultrasound typically shows increased thickness of the fascia and a hypoechoic fascia
Thickened hypoechoic origin of the plantar fascia which has a convex superior margin
Complete avulsion of the plantar fascia from the calcaneal tubercle
Plantar fasciitis
bull LOCATING FOREIGN BODIES AND FRACTURES
As in any other location the ankle
area is also subsidiary host foreign
whose classification location and
existence can be defined perfectly by
ultrasound Being a focused study to
the area of interest and with great
resolution for surface structures can
be considered more resolute
examination to screen these cases
Osseous diseases and fractures | Sonography discovered Medial Malleolus Fracture
Ultrasound examination of left ankle A Longitudinal sonogram left ankle demonstrates a wooden foreign body B Transverse view left ankle Note the hypervascularity in the inflamed area C Corresponding X-ray of left ankle Note the swelling on the lateral aspect No foreign body is visible
Thank You
ULTRASOUND OF THE ANKLE ndash NormalLateral AnklePeroneus longus and brevis tendonsCalcaneo-fibula ligamentAnterior Talo-Fibula ligament
Peroneus tendons scan planePeroneus longus and brevis tendons Transverse at the medial malleolus
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 ligament scan plane Calcaneo-fibular ligament
ATFL scan plane Anterior Talo-fibula ligament (ATFL)
Ultrasound of the Peroneus Longus tendon insertion The insertion is to the lateral edge of the 1st cuneiform with some fibers extending to the base of the 1st metatarsal
Anterior AnkleTibio-fibula ligamentExtensor Digitorum tendon(s)Extensor Hallucis LongusTibialis anteriorExtensor retinaculum
Tibio fibula ligament scan plane Normal Tibio fibula ligament
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 its own tendon - the extensor hallucis)
Extensor hallucis scan plane Longitudinal extensor hallucis longus tendon
Tibialis Anterior scan plane Longitudinal Tibialis Anterior tendon
Medial AnkleTibialis Posterior tendonFlexor Digitorum tendonFlexor Hallucis Longus tendonDeltoid ligamentPosterior tibial nerve
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 amp Harry) If including the neurovascular bundle - Tom Dick And Very Nervous Harry
Deltoid Ligament scan plane Use plenty of gel and have the probe tip overlie the malleolar tip
Because of its obliquity you cannotreadily see all aspects of the ligament
Posterior AnkleAchilles tendonRetrocalcaneal (Kagers) fat-pad
Scan plane for the Achilles tendon Normal Achilles tendon longitudinal panorama
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 edema Guidance of injection aspiration or biopsy Relationship of normal anatomy and pathology to each other Some bony pathologyLIMITATIONSIt is recognised that ultrasound cannot adequately assess the deltoid ligament the ankle mortice and some inter-tarsal ligamentsEQUIPMENT SELECTION AND TECHNIQUEUse 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 TECHNIQUELATERAL 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 ANKLEPatient 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 mobilizing 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 calcaneumThe deltoid ligament Is poorly assessed with ultrasoundPosterior tibial nerve The neurovascular bundle is easily seen posterior to the medial malleolusPOSTERIOR 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 (Kagers) fat padThe calf muscles and plantaris tendon should also be assessed as clinically indicated
An ankle series should include the following minimum imagesPeroneus tendons - long trans + peroneus brevis insertionCalcaneo-fibular ligamentAnterior talo-fibula ligamentTibio-Fibula ligamentExtensor digitorum tendonExtensor hallucis longus tendonTibialis anterior tendonTibialis posterior tendonFlexor digitorum tendonFlexor hallucis longusAchilles tendon and retro calcaneal bursaDocument the normal anatomy Any pathology found in 2 planes(ligament tears or thickening synovial bulgingcysts joint effusion gross bony changes) including measurements and any vascularity
MAIN INDICATIONS OFTHE ANKLE ULTRASONOGRAPHIC STUDY
Tendon pathology of the different compartments
of the ankle
bull Evaluation of ligament injuries
bull Bone and joint disorders (synovitis chondral
and osteochondral lesions occult fractures)
bull Retroachilles and preachilles bursitis
bull Characterization of tumors (accessory muscles ganglia
neurogenic tumours soft tissue abscesses etc)
bull Localization of foreign bodies
ABNORMALITIES OF TENDONS
Tendon injuries include tenosynovitis tendinosis
rupture and instability
POSTERIOR COMPARTMENTACHILLES TENDINOPATHY
Can be classified as tendinosis and paratendinitis The isolated
paratendinitis shows intratendinous normal structure exist paratendinitis
spill shown irregularities in the edges of the tendon adhesions and
scarring associated paratendon and a heterogeneous aspect preachilles
fat pad In the tendinosis there is in swelling of the tendon usually
bilateral and textural heterogeneity intratendinous focal hypoechoic areas
TEAR OF ACHILLESThe rupture site is located generally between the 2 and 6 cm from the insertion into the calcaneous in the called critical zone of relative hypovascularityIn ultrasound complete rupture of the Achilles tendon is seen as a focal defect
between the broken ends of the tendon In the acute phase ends are contiguous but the defect may be filled by the anechoic or hypoechoic hematoma In most cases paratendon remains intact as a envelope straight echogenic contouring breakage As a sign associated can exist distortion of the fibrillar configuration and loss of parallelism of the tendon fibers Other signs are indicative fat herniation into the defect better visualization of the plantar tendon and the existence of a posterior acoustic shadowing at the site of the tear (useful sign to differentiate partial thickness tears)
Complete rupture of the Achilles tendon with focal defect between
the ends of the tendon and posterior acoustic shadowing at the
site of the tear useful sign to differentiate partial thickness tears
Patient with psoriasis which identifies tendinosis and Achilles tendon swelling
bilateral and textural heterogeneity with intratendinous focal hypoechoic areas
Ultrasound and radiological correlation calcified Achilles
enthesitis Calcaneal spur as associated finding
Discreetly thickened right Achilles tendon at its insertion combining linear hyperechoic
and hypoechoic areas on small breaks intrasubstance and calcifications of the enthesis
Fat herniation into the defect by complete tear of the Achilles tendon
Complete tear of the Achilles tendon with retraction
of ends and integrity thin plantaris tendon
Tendinosis versus partial tear of Achilles tendon
bullPREACHILLES AND RETROACHILLES BURSITIS
Although bursitis can occur in isolation often are
related and systemic inflammatory diseases
In the ultrasound examination the distended
retrocalcaneal and preachilles appears are a
hypoechoic structure shaped coma interposed
between the Achilles tendon and the posterosuperior
aspect of the calcaneous Care must be taken not to
confuse it with the fatty space Kager containing oval
lobules of hyperechoic fat When bursitis is a
manifestation of synovitis is appreciated
hypervascular area with Doppler ultrasound
In the retroachilles bursitis exists thickening and
collection of fluid in the subcutaneous tissue
superficial to the tendon retrocalcaneal portion
Bursitis preachilles with typical morphology appreciating accumulation of fluid
in a coma between the anterior portion of the Achilles tendon and the calcaneous
Bursitis preachiacutelea that associated synovitis showing hyperemia with increased Doppler flow
Rheumatoid arthritis with retrocalcaneal bursitis (1) and calcaneal erosions (2)
ACCESSORY NAVICULAR BONEIn the distal insertion site may exist TP 2 types of bones
accessories
Accessory navicular bone type I (os tibiale externum) size
between the 2 and 6 mm can be contained within the TP and
being positioned immediately proximal posteromedial to the
navicular bone It generally produces symptoms and should
not be confused with a tendon calcification or avulsion
fracture
Type II accessory navicular bone is an accessory
ossification centre of the navicular bone with size between
9 and 12 mm triangular shaped and articulated through a
synchondrosis of the posterior and medial navicular bone
It insertion site of some fibers of TP and is associated with a
syndrome of pain and increased incidence of tendon rupture
caused by abnormal overloads Osteoarthritic changes may
underlie this synchondrosis which mimic tendon pathology
Accessory navicular bone within the posterior tibial tendon as anatomical variant
ANTERIOR COMPARTMENTThe tendons of the anterior ankle compared
with the rest of the ankle tendons are rarely
affected by disease The anterior tibial tendon
is the most prone to abnormalities like
tendinopathy tenosynovitis and its place
between the most frequent rupture is extensor
retinaculum and insertion into the first
cuneiform and the base of the first metatarsal
Sometimes the retracted tendon stump causes
a nodule on the anteromedial aspect of the
distal portion of the leg making clinically
confused with a tumour or cyst
Distal insertion tendinopathy of the anterior tibial tendon with increased vascularity
Tenosynovitis of the anterior tibial tendon with effusion
Anterior tibial tendon tenosynovitis with intratendinous ruptures
Anterior tibial tendon rupture with retraction of the tendon
Tenosynovitis of the extensor digitorum tendons with a synovial effusion
Tenosynovitis of the extensor digitorum tendon with hypervascularized thickened tendon and synovium and synovial fluid
Rheumatoid arthritis with tenosynovitis of the extensor digitorum and peroneal tendons
Thickening of the extensor hallucis longus tendon caused by osteosynthesis material
Multicystic non vascularized intramuscular mass in the extensor digitorum brevis muscle
LATERAL COMPARTMENTTENOSYNOVITIS OF THE PERONEAL TENDONSThe main sign of ultrasound is the presence of liquid inside the
common synovial sheath whereas usually tendinous
morphology is preserved We must differentiate tenosynovitis of
a spill within the common peroneal sheath secondary to a tear of
calcaneofibular ligament (PCL) The ultrasound diagnosis is the detection of the tendons in a lateral plane relative to the distal portion of the lateral malleolus instead of behind it The dynamic exploration foot dorsiflexion as both eversion may help identify cases of intermittent subluxation In long-standing disease can be observed fusiform thickening
of the peroneal tendons at the tip of the malleolus The complete tears of the peroneus brevis tendon (PC) and peroneus longus (PL) are rare occurring in the area of the lateral malleolus or midfoot Seen in patients with ankle sprains or history of chronic instability especially if they suffer widespread diseases (RA DM) or treated with corticosteroids The peroneal tendon ruptures causing the inability to eversion of the foot and cavus foot varus
Important thickening of both peroneal tendons (longus and brevis) associated
with moderate amount of fluid and thickening of the synovial sheath
Discreet amount of fluid in the common sheath of the peroneal tendons
associated with disorganization and a heterogeneous appearance
peroneus brevis tendon related to longitudinal rupture
Peroneal tenosynovitis and osteosynthesis
Tenosynovitis of the peroneal tendons and an intratendinous rupture of the short peroneal tendon
Intratendinous rupture and cyst in the peroneus brevis tendon
Peroneus quartus with an accessory muscle next to the peroneus longus and brevis tendons
Tumor next to the peroneal tendons that proved to be a benign fibrous mass
MEDIAL COMPARTMENT
ANOMALIES POSTERIOR TIBIAL TENDON (TP)
It is the most frequently injured in this compartment with ruptures
in asymptomatic middle-aged obese women as a result of
widespread disease (RA seronegative Spondyloarthropathy) or
associated with bone fractures It causes a gradual collapse of the
medial longitudinal arch with hindfoot valgus deformity and
excessive forefoot pronation
The presence of small vessels in inflammatory diseases
intratendinosis can simulate a fissuration tendon confusion can be ignored using colour Doppler Another possible diagnostic difficulty is when the undamaged tendon flexor digitorum longus (FLD) moves back and simulates the TP unbroken but it is smaller and in this case we only see in the groove retromalleolar 1 only tendon
Ultrasound has also proven to be an effective resource for identifying alterations associated tendon tenosynovitis serosa and hypertrophicSubluxation and dislocation anteriorly and medial TP relative to internal
malleolus is rare and valued sonographically placing the foot in dorsiflexion with forced supination
Thickening moderate amount of fluid surrounding calcifications and
hyperemia affecting the sheath and the posterior tibial tendon related
to chronic tenosynovitis in patient affects rheumatoid arthritis
Thickening moderate amount of surrounding fluid and calcifications (arrow) affecting the
posterior tibial tendon related to chronic tenosynovitis in patient affects rheumatoid arthritis
Tenosynovitis of the posterior tibial tendon caused by a bony ridge at the insertion of the retinaculum The retinaculum is thickened and the tendon subluxates
Psoriatic arthritis Ankle Grayscale examination Posterior tibial tendon on longitudinal (a) and transverse (b) scan Marked tendon sheath widening with homogeneous anechoic aspect (asterisks) of the content indicating an exudative tenosynovitis Note as the normal fibrillar echotexture is conserved Hand Flexor tendons of second finger The volar longitudinal (c) and transverse scan (d) shows a tendon sheath widening with signs of synovial proliferation presence of intense power Doppler signal surrounding the tendon and micro interruption of the margin (arrow) e Wrist Extensor carpi ulnaris tendon (sixth compartment of the extensor tendons ecu) on lateral longitudinal (e) and transverse (f) scan Chronic tenosynovitis with clear areas of low of echogenicity and loss of the continuity of tendon fibrils indicative of partial tendon tear (arrows) Moreover note the presence of power Doppler signal within the interruption indicating still activity of the inflammatory process g Dactylitis Volar longitudinal scan using the ldquoextended viewrdquo technique showing proliferative tenosynovitis of the finger flexor tendon (circle) exudative synovitis of both proximal and distal interphalangeal joint (white asterisks) and edema of the peritendinous tissue (black asterisks) TP posterior tibial tendon mm medial malleolus DP distal phalanx mp middle phalanx cu cubital bone ft flexor tendons
Tenosynovitis of the posterior tibial (1) and flexor digitorum longus tendon (2)
Tibialis Posterior Tendon rupture
Tenosynovitis of the posterior tibial tendon the flexor digitorum tendon and flexor hallucis longus tendon
Tenosynovitis of the tendons on the medial side in the left ankle
bullLIGAMENT INJURIESThe ligament partial tear ligament shows a hypoechoic
areas swollen with internal focal or diffuse In the complete
ruptures within the substance of the divided ligament rift is
observed corresponding to the hematoma hypoechoic and
the free ends of the divided ligament can be and retracted
appreciated corrugated in contrast with normal
appearance straight
Grade I Mild stretching of the ligament without breakage
or instability
Grade II Partial tearing of the ligament
Grade III Complete tearing
Degrees depending on the severity of the injury and the
place of employment
LATERAL COMPARTMENTThese injuries occur secondary to inversion sprains with internal rotation of
the foot combined with ankle plantar flexion
The anterior talar fibular ligament tears (ATFL) usually occur as isolated
involvement (70) or associated with calcaneal fibular ligament (CFL) (20-40)
but the posterior talar fibular ligament (PTFL) affects only major trauma
involving ankle dislocation
ATFL breaks is associated with breakage of the joint capsule and synovial fluid
extravasation into the anterolateral soft ankle whereas the complete tearing of
CFL can communicate the ankle joint and synovial sheath peroneal tendons
Rupture of CFL is rarely associated with superior peroneal retinaculum tear
The CFL is tensioned during dorsiflexion pulling on peroneal tendons laterally
so that absence of its displacement is sign of a complete tear
Within a damaged ligament can also observe calcifications that often
correspond to fragments of avulsion bone
During the ultrasound can be performed forced maneuvers to detect to joint
laxity and ligament injuries The anterior drawer test is performed with the feet
hanging over the edge of the examination table while the forefoot is pulled
anteriorly when the foot is in plantar flexion and inversion This maneuver
helps differentiate partial tears (grade II) of the ATFL to complete (grade III)
where the anterior displacement of the talus on the tibia open a crack in the
substance becoming more visible the ligament injury
The sindesmosys sprains are up to 10 of ankle
injuries happening in eversion and pronation
movements (like the deltoid ligament injury) and
primarily affect the anterior tibiofibular ligament (ATFL)
the failure is frequently associated with fracture of the
fibula
According to the place of employment are 4 degrees
useful for prognostic evaluation and therapeutic strategy
choice
Grade I stretch or partial tear of the ATFL
Grade II complete tearing but only the ATFL
Grade III complete tear of the ATFL and partial CFL
Grade IV complete tear of the ATFL and CFL
The grade I and II injuries usually scarred without any
significant instability whereas grade III and IV injuries
can cause chronic pain and require surgical treatment
Thickened but continued ATFL right in relation to the partial rupture
Grade 111 sprain of right ATFL
Thickened anterior talofibular ligament with calcifications and a partial rupture
Thickened tibiofibular ligament after trauma
Anterior Talofibular Ligament Partial Tear and Elastography
Tibio fibular ligament rupture with bony avulsion
Complete rupture of right ATFL
Bony avulsion with radiographic evidence as visible calcification in a grade III sprain ATFL
Moderately thickened and hypoechoic ATFL
Discontinuity of the ATFL with fluid surrounding the torn ends (arrow)
Thickening and hypoechogenicity of the fibular end of the ligament seen here passing over the subtalar joint which contains a small of fluid
Complete disruption to the tibiofibular ligament with bony irregularity of particularly the tibial margin and fluid in the gap
MEDIAL COMPARTMENTBecause of the low incidence of eversion ankle
sprains and the thickness of the deltoid ligament
is rarely injured in isolation and when the injury
does not usually full thickness Usually
accompanied by lesions of the medial malleolus
and lateral displacement of the talus with
consequent widening of the ankle mortise
Ultrasound is useful for differentiating ligament
injury of the posterior tibial tendon injury
(TP) adjacent they have similar symptoms
The inability to visualize the deltoid ligament may
indicate tear but this is not considered a reliable
sign as its full ultrasound is not always possible
Partial medial ligament rupture
Thickened heterogeneous abnormal deltoid demonstrating hyperemia
Ultrasonogram showing a disrupted deltoid ligament with the probe in the coronal plane The white arrow indicates the medial malleolus the blue arrow indicates the talus and the red arrows indicate the disrupted deltoid ligament (A) Radiograph showing the same injury (B)
bullJOINT AND BONE DISORDERSUltrasound reliably detect spills mild (gt 2 ml) inside
of the ankle joint by exploring the front and rear
recess as well as areas of synovial proliferation and
may even display using the colour Doppler
hyperemic areas in arthritis patients
The intraarticular joints are displayed surrounded
fluid in one of the recesses of the ankle or subtalar
joint Sonographically diagnosed when changing position to perform flexion and extension Fracture of the lateral process of the talus is overlooked up to 50 of cases with plain radiography Ultrasound may suspect the presence of focal cortical disruption helping further to exclude concomitant ligament injury
Rheumatoid arthritis with synovial thickening (1) and erosion of the tibia (2)
Infectious arthritis with a pus filled anterior recess of the ankle
Arthritis and tenosynovitis of the ankle in a patient with rheumatoid arthritis
bullTUMOURSUltrasound can differentiate between a mass complex
and solid and a cystic in addition to verifying the
existence of accessory muscles (peroneus fourth
accessory flexor digitorum longus and accessory
soleus) As in any other location can be found
neoformative soft tissue tumors inflammatory
infectious etc
Ganglions of this location are more often symptomatic
and larger with multiple partitions
branched and lobed edges Differential diagnosis must
be made with tenosynovitis abscesses seromas and
varicosities
Neurogenic tumours are described as pathognomonic
homogeneous hypoechoic oval mass in continuity with
a nerve of origin
Ganglion cysts are non-malignant cystic masses that occur in association with musculoskeletal structures They are sometimes also simply referred to as ganglia or a ganglion but should not be confused with the anatomical term ganglion UltrasoundThe vast majority are anechoic to hypoechoic on ultrasound and have well defined margins Many demonstrate internal septations as well as acoustic enhancement A synovial cyst is a small fluid-filled sac or pouch that can develop over a tendon or joint creating a mass under the skin Synovial cyst is rare in ankle joint A synovial cyst may or may not be painful depending on their size and location
Ganglion cyst in the foot with bony erosion between navicular and cuneiform bones
Tarsal synovial cyst
Anechoic ganglion situated in the sinus tarsi fat between the talus and calcaneous
Plantar fasciitis (PF) refers to inflammation of the
plantar fascia of the foot It is considered the most common cause of heel pain
Clinical presentation Pain on the undersurface of the heel on weight bearing is the principal complaint It can be worse when weight is borne after a period of rest (eg in the morning) and eases with walking Passive dorsiflexion of the toes may exacerbates discomfort
UltrasoundOften the initial imaging modality of choice Ultrasound typically shows increased thickness of the fascia and a hypoechoic fascia
Thickened hypoechoic origin of the plantar fascia which has a convex superior margin
Complete avulsion of the plantar fascia from the calcaneal tubercle
Plantar fasciitis
bull LOCATING FOREIGN BODIES AND FRACTURES
As in any other location the ankle
area is also subsidiary host foreign
whose classification location and
existence can be defined perfectly by
ultrasound Being a focused study to
the area of interest and with great
resolution for surface structures can
be considered more resolute
examination to screen these cases
Osseous diseases and fractures | Sonography discovered Medial Malleolus Fracture
Ultrasound examination of left ankle A Longitudinal sonogram left ankle demonstrates a wooden foreign body B Transverse view left ankle Note the hypervascularity in the inflamed area C Corresponding X-ray of left ankle Note the swelling on the lateral aspect No foreign body is visible
Thank You
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 ligament scan plane Calcaneo-fibular ligament
ATFL scan plane Anterior Talo-fibula ligament (ATFL)
Ultrasound of the Peroneus Longus tendon insertion The insertion is to the lateral edge of the 1st cuneiform with some fibers extending to the base of the 1st metatarsal
Anterior AnkleTibio-fibula ligamentExtensor Digitorum tendon(s)Extensor Hallucis LongusTibialis anteriorExtensor retinaculum
Tibio fibula ligament scan plane Normal Tibio fibula ligament
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 its own tendon - the extensor hallucis)
Extensor hallucis scan plane Longitudinal extensor hallucis longus tendon
Tibialis Anterior scan plane Longitudinal Tibialis Anterior tendon
Medial AnkleTibialis Posterior tendonFlexor Digitorum tendonFlexor Hallucis Longus tendonDeltoid ligamentPosterior tibial nerve
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 amp Harry) If including the neurovascular bundle - Tom Dick And Very Nervous Harry
Deltoid Ligament scan plane Use plenty of gel and have the probe tip overlie the malleolar tip
Because of its obliquity you cannotreadily see all aspects of the ligament
Posterior AnkleAchilles tendonRetrocalcaneal (Kagers) fat-pad
Scan plane for the Achilles tendon Normal Achilles tendon longitudinal panorama
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 edema Guidance of injection aspiration or biopsy Relationship of normal anatomy and pathology to each other Some bony pathologyLIMITATIONSIt is recognised that ultrasound cannot adequately assess the deltoid ligament the ankle mortice and some inter-tarsal ligamentsEQUIPMENT SELECTION AND TECHNIQUEUse 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 TECHNIQUELATERAL 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 ANKLEPatient 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 mobilizing 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 calcaneumThe deltoid ligament Is poorly assessed with ultrasoundPosterior tibial nerve The neurovascular bundle is easily seen posterior to the medial malleolusPOSTERIOR 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 (Kagers) fat padThe calf muscles and plantaris tendon should also be assessed as clinically indicated
An ankle series should include the following minimum imagesPeroneus tendons - long trans + peroneus brevis insertionCalcaneo-fibular ligamentAnterior talo-fibula ligamentTibio-Fibula ligamentExtensor digitorum tendonExtensor hallucis longus tendonTibialis anterior tendonTibialis posterior tendonFlexor digitorum tendonFlexor hallucis longusAchilles tendon and retro calcaneal bursaDocument the normal anatomy Any pathology found in 2 planes(ligament tears or thickening synovial bulgingcysts joint effusion gross bony changes) including measurements and any vascularity
MAIN INDICATIONS OFTHE ANKLE ULTRASONOGRAPHIC STUDY
Tendon pathology of the different compartments
of the ankle
bull Evaluation of ligament injuries
bull Bone and joint disorders (synovitis chondral
and osteochondral lesions occult fractures)
bull Retroachilles and preachilles bursitis
bull Characterization of tumors (accessory muscles ganglia
neurogenic tumours soft tissue abscesses etc)
bull Localization of foreign bodies
ABNORMALITIES OF TENDONS
Tendon injuries include tenosynovitis tendinosis
rupture and instability
POSTERIOR COMPARTMENTACHILLES TENDINOPATHY
Can be classified as tendinosis and paratendinitis The isolated
paratendinitis shows intratendinous normal structure exist paratendinitis
spill shown irregularities in the edges of the tendon adhesions and
scarring associated paratendon and a heterogeneous aspect preachilles
fat pad In the tendinosis there is in swelling of the tendon usually
bilateral and textural heterogeneity intratendinous focal hypoechoic areas
TEAR OF ACHILLESThe rupture site is located generally between the 2 and 6 cm from the insertion into the calcaneous in the called critical zone of relative hypovascularityIn ultrasound complete rupture of the Achilles tendon is seen as a focal defect
between the broken ends of the tendon In the acute phase ends are contiguous but the defect may be filled by the anechoic or hypoechoic hematoma In most cases paratendon remains intact as a envelope straight echogenic contouring breakage As a sign associated can exist distortion of the fibrillar configuration and loss of parallelism of the tendon fibers Other signs are indicative fat herniation into the defect better visualization of the plantar tendon and the existence of a posterior acoustic shadowing at the site of the tear (useful sign to differentiate partial thickness tears)
Complete rupture of the Achilles tendon with focal defect between
the ends of the tendon and posterior acoustic shadowing at the
site of the tear useful sign to differentiate partial thickness tears
Patient with psoriasis which identifies tendinosis and Achilles tendon swelling
bilateral and textural heterogeneity with intratendinous focal hypoechoic areas
Ultrasound and radiological correlation calcified Achilles
enthesitis Calcaneal spur as associated finding
Discreetly thickened right Achilles tendon at its insertion combining linear hyperechoic
and hypoechoic areas on small breaks intrasubstance and calcifications of the enthesis
Fat herniation into the defect by complete tear of the Achilles tendon
Complete tear of the Achilles tendon with retraction
of ends and integrity thin plantaris tendon
Tendinosis versus partial tear of Achilles tendon
bullPREACHILLES AND RETROACHILLES BURSITIS
Although bursitis can occur in isolation often are
related and systemic inflammatory diseases
In the ultrasound examination the distended
retrocalcaneal and preachilles appears are a
hypoechoic structure shaped coma interposed
between the Achilles tendon and the posterosuperior
aspect of the calcaneous Care must be taken not to
confuse it with the fatty space Kager containing oval
lobules of hyperechoic fat When bursitis is a
manifestation of synovitis is appreciated
hypervascular area with Doppler ultrasound
In the retroachilles bursitis exists thickening and
collection of fluid in the subcutaneous tissue
superficial to the tendon retrocalcaneal portion
Bursitis preachilles with typical morphology appreciating accumulation of fluid
in a coma between the anterior portion of the Achilles tendon and the calcaneous
Bursitis preachiacutelea that associated synovitis showing hyperemia with increased Doppler flow
Rheumatoid arthritis with retrocalcaneal bursitis (1) and calcaneal erosions (2)
ACCESSORY NAVICULAR BONEIn the distal insertion site may exist TP 2 types of bones
accessories
Accessory navicular bone type I (os tibiale externum) size
between the 2 and 6 mm can be contained within the TP and
being positioned immediately proximal posteromedial to the
navicular bone It generally produces symptoms and should
not be confused with a tendon calcification or avulsion
fracture
Type II accessory navicular bone is an accessory
ossification centre of the navicular bone with size between
9 and 12 mm triangular shaped and articulated through a
synchondrosis of the posterior and medial navicular bone
It insertion site of some fibers of TP and is associated with a
syndrome of pain and increased incidence of tendon rupture
caused by abnormal overloads Osteoarthritic changes may
underlie this synchondrosis which mimic tendon pathology
Accessory navicular bone within the posterior tibial tendon as anatomical variant
ANTERIOR COMPARTMENTThe tendons of the anterior ankle compared
with the rest of the ankle tendons are rarely
affected by disease The anterior tibial tendon
is the most prone to abnormalities like
tendinopathy tenosynovitis and its place
between the most frequent rupture is extensor
retinaculum and insertion into the first
cuneiform and the base of the first metatarsal
Sometimes the retracted tendon stump causes
a nodule on the anteromedial aspect of the
distal portion of the leg making clinically
confused with a tumour or cyst
Distal insertion tendinopathy of the anterior tibial tendon with increased vascularity
Tenosynovitis of the anterior tibial tendon with effusion
Anterior tibial tendon tenosynovitis with intratendinous ruptures
Anterior tibial tendon rupture with retraction of the tendon
Tenosynovitis of the extensor digitorum tendons with a synovial effusion
Tenosynovitis of the extensor digitorum tendon with hypervascularized thickened tendon and synovium and synovial fluid
Rheumatoid arthritis with tenosynovitis of the extensor digitorum and peroneal tendons
Thickening of the extensor hallucis longus tendon caused by osteosynthesis material
Multicystic non vascularized intramuscular mass in the extensor digitorum brevis muscle
LATERAL COMPARTMENTTENOSYNOVITIS OF THE PERONEAL TENDONSThe main sign of ultrasound is the presence of liquid inside the
common synovial sheath whereas usually tendinous
morphology is preserved We must differentiate tenosynovitis of
a spill within the common peroneal sheath secondary to a tear of
calcaneofibular ligament (PCL) The ultrasound diagnosis is the detection of the tendons in a lateral plane relative to the distal portion of the lateral malleolus instead of behind it The dynamic exploration foot dorsiflexion as both eversion may help identify cases of intermittent subluxation In long-standing disease can be observed fusiform thickening
of the peroneal tendons at the tip of the malleolus The complete tears of the peroneus brevis tendon (PC) and peroneus longus (PL) are rare occurring in the area of the lateral malleolus or midfoot Seen in patients with ankle sprains or history of chronic instability especially if they suffer widespread diseases (RA DM) or treated with corticosteroids The peroneal tendon ruptures causing the inability to eversion of the foot and cavus foot varus
Important thickening of both peroneal tendons (longus and brevis) associated
with moderate amount of fluid and thickening of the synovial sheath
Discreet amount of fluid in the common sheath of the peroneal tendons
associated with disorganization and a heterogeneous appearance
peroneus brevis tendon related to longitudinal rupture
Peroneal tenosynovitis and osteosynthesis
Tenosynovitis of the peroneal tendons and an intratendinous rupture of the short peroneal tendon
Intratendinous rupture and cyst in the peroneus brevis tendon
Peroneus quartus with an accessory muscle next to the peroneus longus and brevis tendons
Tumor next to the peroneal tendons that proved to be a benign fibrous mass
MEDIAL COMPARTMENT
ANOMALIES POSTERIOR TIBIAL TENDON (TP)
It is the most frequently injured in this compartment with ruptures
in asymptomatic middle-aged obese women as a result of
widespread disease (RA seronegative Spondyloarthropathy) or
associated with bone fractures It causes a gradual collapse of the
medial longitudinal arch with hindfoot valgus deformity and
excessive forefoot pronation
The presence of small vessels in inflammatory diseases
intratendinosis can simulate a fissuration tendon confusion can be ignored using colour Doppler Another possible diagnostic difficulty is when the undamaged tendon flexor digitorum longus (FLD) moves back and simulates the TP unbroken but it is smaller and in this case we only see in the groove retromalleolar 1 only tendon
Ultrasound has also proven to be an effective resource for identifying alterations associated tendon tenosynovitis serosa and hypertrophicSubluxation and dislocation anteriorly and medial TP relative to internal
malleolus is rare and valued sonographically placing the foot in dorsiflexion with forced supination
Thickening moderate amount of fluid surrounding calcifications and
hyperemia affecting the sheath and the posterior tibial tendon related
to chronic tenosynovitis in patient affects rheumatoid arthritis
Thickening moderate amount of surrounding fluid and calcifications (arrow) affecting the
posterior tibial tendon related to chronic tenosynovitis in patient affects rheumatoid arthritis
Tenosynovitis of the posterior tibial tendon caused by a bony ridge at the insertion of the retinaculum The retinaculum is thickened and the tendon subluxates
Psoriatic arthritis Ankle Grayscale examination Posterior tibial tendon on longitudinal (a) and transverse (b) scan Marked tendon sheath widening with homogeneous anechoic aspect (asterisks) of the content indicating an exudative tenosynovitis Note as the normal fibrillar echotexture is conserved Hand Flexor tendons of second finger The volar longitudinal (c) and transverse scan (d) shows a tendon sheath widening with signs of synovial proliferation presence of intense power Doppler signal surrounding the tendon and micro interruption of the margin (arrow) e Wrist Extensor carpi ulnaris tendon (sixth compartment of the extensor tendons ecu) on lateral longitudinal (e) and transverse (f) scan Chronic tenosynovitis with clear areas of low of echogenicity and loss of the continuity of tendon fibrils indicative of partial tendon tear (arrows) Moreover note the presence of power Doppler signal within the interruption indicating still activity of the inflammatory process g Dactylitis Volar longitudinal scan using the ldquoextended viewrdquo technique showing proliferative tenosynovitis of the finger flexor tendon (circle) exudative synovitis of both proximal and distal interphalangeal joint (white asterisks) and edema of the peritendinous tissue (black asterisks) TP posterior tibial tendon mm medial malleolus DP distal phalanx mp middle phalanx cu cubital bone ft flexor tendons
Tenosynovitis of the posterior tibial (1) and flexor digitorum longus tendon (2)
Tibialis Posterior Tendon rupture
Tenosynovitis of the posterior tibial tendon the flexor digitorum tendon and flexor hallucis longus tendon
Tenosynovitis of the tendons on the medial side in the left ankle
bullLIGAMENT INJURIESThe ligament partial tear ligament shows a hypoechoic
areas swollen with internal focal or diffuse In the complete
ruptures within the substance of the divided ligament rift is
observed corresponding to the hematoma hypoechoic and
the free ends of the divided ligament can be and retracted
appreciated corrugated in contrast with normal
appearance straight
Grade I Mild stretching of the ligament without breakage
or instability
Grade II Partial tearing of the ligament
Grade III Complete tearing
Degrees depending on the severity of the injury and the
place of employment
LATERAL COMPARTMENTThese injuries occur secondary to inversion sprains with internal rotation of
the foot combined with ankle plantar flexion
The anterior talar fibular ligament tears (ATFL) usually occur as isolated
involvement (70) or associated with calcaneal fibular ligament (CFL) (20-40)
but the posterior talar fibular ligament (PTFL) affects only major trauma
involving ankle dislocation
ATFL breaks is associated with breakage of the joint capsule and synovial fluid
extravasation into the anterolateral soft ankle whereas the complete tearing of
CFL can communicate the ankle joint and synovial sheath peroneal tendons
Rupture of CFL is rarely associated with superior peroneal retinaculum tear
The CFL is tensioned during dorsiflexion pulling on peroneal tendons laterally
so that absence of its displacement is sign of a complete tear
Within a damaged ligament can also observe calcifications that often
correspond to fragments of avulsion bone
During the ultrasound can be performed forced maneuvers to detect to joint
laxity and ligament injuries The anterior drawer test is performed with the feet
hanging over the edge of the examination table while the forefoot is pulled
anteriorly when the foot is in plantar flexion and inversion This maneuver
helps differentiate partial tears (grade II) of the ATFL to complete (grade III)
where the anterior displacement of the talus on the tibia open a crack in the
substance becoming more visible the ligament injury
The sindesmosys sprains are up to 10 of ankle
injuries happening in eversion and pronation
movements (like the deltoid ligament injury) and
primarily affect the anterior tibiofibular ligament (ATFL)
the failure is frequently associated with fracture of the
fibula
According to the place of employment are 4 degrees
useful for prognostic evaluation and therapeutic strategy
choice
Grade I stretch or partial tear of the ATFL
Grade II complete tearing but only the ATFL
Grade III complete tear of the ATFL and partial CFL
Grade IV complete tear of the ATFL and CFL
The grade I and II injuries usually scarred without any
significant instability whereas grade III and IV injuries
can cause chronic pain and require surgical treatment
Thickened but continued ATFL right in relation to the partial rupture
Grade 111 sprain of right ATFL
Thickened anterior talofibular ligament with calcifications and a partial rupture
Thickened tibiofibular ligament after trauma
Anterior Talofibular Ligament Partial Tear and Elastography
Tibio fibular ligament rupture with bony avulsion
Complete rupture of right ATFL
Bony avulsion with radiographic evidence as visible calcification in a grade III sprain ATFL
Moderately thickened and hypoechoic ATFL
Discontinuity of the ATFL with fluid surrounding the torn ends (arrow)
Thickening and hypoechogenicity of the fibular end of the ligament seen here passing over the subtalar joint which contains a small of fluid
Complete disruption to the tibiofibular ligament with bony irregularity of particularly the tibial margin and fluid in the gap
MEDIAL COMPARTMENTBecause of the low incidence of eversion ankle
sprains and the thickness of the deltoid ligament
is rarely injured in isolation and when the injury
does not usually full thickness Usually
accompanied by lesions of the medial malleolus
and lateral displacement of the talus with
consequent widening of the ankle mortise
Ultrasound is useful for differentiating ligament
injury of the posterior tibial tendon injury
(TP) adjacent they have similar symptoms
The inability to visualize the deltoid ligament may
indicate tear but this is not considered a reliable
sign as its full ultrasound is not always possible
Partial medial ligament rupture
Thickened heterogeneous abnormal deltoid demonstrating hyperemia
Ultrasonogram showing a disrupted deltoid ligament with the probe in the coronal plane The white arrow indicates the medial malleolus the blue arrow indicates the talus and the red arrows indicate the disrupted deltoid ligament (A) Radiograph showing the same injury (B)
bullJOINT AND BONE DISORDERSUltrasound reliably detect spills mild (gt 2 ml) inside
of the ankle joint by exploring the front and rear
recess as well as areas of synovial proliferation and
may even display using the colour Doppler
hyperemic areas in arthritis patients
The intraarticular joints are displayed surrounded
fluid in one of the recesses of the ankle or subtalar
joint Sonographically diagnosed when changing position to perform flexion and extension Fracture of the lateral process of the talus is overlooked up to 50 of cases with plain radiography Ultrasound may suspect the presence of focal cortical disruption helping further to exclude concomitant ligament injury
Rheumatoid arthritis with synovial thickening (1) and erosion of the tibia (2)
Infectious arthritis with a pus filled anterior recess of the ankle
Arthritis and tenosynovitis of the ankle in a patient with rheumatoid arthritis
bullTUMOURSUltrasound can differentiate between a mass complex
and solid and a cystic in addition to verifying the
existence of accessory muscles (peroneus fourth
accessory flexor digitorum longus and accessory
soleus) As in any other location can be found
neoformative soft tissue tumors inflammatory
infectious etc
Ganglions of this location are more often symptomatic
and larger with multiple partitions
branched and lobed edges Differential diagnosis must
be made with tenosynovitis abscesses seromas and
varicosities
Neurogenic tumours are described as pathognomonic
homogeneous hypoechoic oval mass in continuity with
a nerve of origin
Ganglion cysts are non-malignant cystic masses that occur in association with musculoskeletal structures They are sometimes also simply referred to as ganglia or a ganglion but should not be confused with the anatomical term ganglion UltrasoundThe vast majority are anechoic to hypoechoic on ultrasound and have well defined margins Many demonstrate internal septations as well as acoustic enhancement A synovial cyst is a small fluid-filled sac or pouch that can develop over a tendon or joint creating a mass under the skin Synovial cyst is rare in ankle joint A synovial cyst may or may not be painful depending on their size and location
Ganglion cyst in the foot with bony erosion between navicular and cuneiform bones
Tarsal synovial cyst
Anechoic ganglion situated in the sinus tarsi fat between the talus and calcaneous
Plantar fasciitis (PF) refers to inflammation of the
plantar fascia of the foot It is considered the most common cause of heel pain
Clinical presentation Pain on the undersurface of the heel on weight bearing is the principal complaint It can be worse when weight is borne after a period of rest (eg in the morning) and eases with walking Passive dorsiflexion of the toes may exacerbates discomfort
UltrasoundOften the initial imaging modality of choice Ultrasound typically shows increased thickness of the fascia and a hypoechoic fascia
Thickened hypoechoic origin of the plantar fascia which has a convex superior margin
Complete avulsion of the plantar fascia from the calcaneal tubercle
Plantar fasciitis
bull LOCATING FOREIGN BODIES AND FRACTURES
As in any other location the ankle
area is also subsidiary host foreign
whose classification location and
existence can be defined perfectly by
ultrasound Being a focused study to
the area of interest and with great
resolution for surface structures can
be considered more resolute
examination to screen these cases
Osseous diseases and fractures | Sonography discovered Medial Malleolus Fracture
Ultrasound examination of left ankle A Longitudinal sonogram left ankle demonstrates a wooden foreign body B Transverse view left ankle Note the hypervascularity in the inflamed area C Corresponding X-ray of left ankle Note the swelling on the lateral aspect No foreign body is visible
Thank You
Calcaneo fibula ligament scan plane Calcaneo-fibular ligament
ATFL scan plane Anterior Talo-fibula ligament (ATFL)
Ultrasound of the Peroneus Longus tendon insertion The insertion is to the lateral edge of the 1st cuneiform with some fibers extending to the base of the 1st metatarsal
Anterior AnkleTibio-fibula ligamentExtensor Digitorum tendon(s)Extensor Hallucis LongusTibialis anteriorExtensor retinaculum
Tibio fibula ligament scan plane Normal Tibio fibula ligament
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 its own tendon - the extensor hallucis)
Extensor hallucis scan plane Longitudinal extensor hallucis longus tendon
Tibialis Anterior scan plane Longitudinal Tibialis Anterior tendon
Medial AnkleTibialis Posterior tendonFlexor Digitorum tendonFlexor Hallucis Longus tendonDeltoid ligamentPosterior tibial nerve
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 amp Harry) If including the neurovascular bundle - Tom Dick And Very Nervous Harry
Deltoid Ligament scan plane Use plenty of gel and have the probe tip overlie the malleolar tip
Because of its obliquity you cannotreadily see all aspects of the ligament
Posterior AnkleAchilles tendonRetrocalcaneal (Kagers) fat-pad
Scan plane for the Achilles tendon Normal Achilles tendon longitudinal panorama
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 edema Guidance of injection aspiration or biopsy Relationship of normal anatomy and pathology to each other Some bony pathologyLIMITATIONSIt is recognised that ultrasound cannot adequately assess the deltoid ligament the ankle mortice and some inter-tarsal ligamentsEQUIPMENT SELECTION AND TECHNIQUEUse 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 TECHNIQUELATERAL 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 ANKLEPatient 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 mobilizing 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 calcaneumThe deltoid ligament Is poorly assessed with ultrasoundPosterior tibial nerve The neurovascular bundle is easily seen posterior to the medial malleolusPOSTERIOR 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 (Kagers) fat padThe calf muscles and plantaris tendon should also be assessed as clinically indicated
An ankle series should include the following minimum imagesPeroneus tendons - long trans + peroneus brevis insertionCalcaneo-fibular ligamentAnterior talo-fibula ligamentTibio-Fibula ligamentExtensor digitorum tendonExtensor hallucis longus tendonTibialis anterior tendonTibialis posterior tendonFlexor digitorum tendonFlexor hallucis longusAchilles tendon and retro calcaneal bursaDocument the normal anatomy Any pathology found in 2 planes(ligament tears or thickening synovial bulgingcysts joint effusion gross bony changes) including measurements and any vascularity
MAIN INDICATIONS OFTHE ANKLE ULTRASONOGRAPHIC STUDY
Tendon pathology of the different compartments
of the ankle
bull Evaluation of ligament injuries
bull Bone and joint disorders (synovitis chondral
and osteochondral lesions occult fractures)
bull Retroachilles and preachilles bursitis
bull Characterization of tumors (accessory muscles ganglia
neurogenic tumours soft tissue abscesses etc)
bull Localization of foreign bodies
ABNORMALITIES OF TENDONS
Tendon injuries include tenosynovitis tendinosis
rupture and instability
POSTERIOR COMPARTMENTACHILLES TENDINOPATHY
Can be classified as tendinosis and paratendinitis The isolated
paratendinitis shows intratendinous normal structure exist paratendinitis
spill shown irregularities in the edges of the tendon adhesions and
scarring associated paratendon and a heterogeneous aspect preachilles
fat pad In the tendinosis there is in swelling of the tendon usually
bilateral and textural heterogeneity intratendinous focal hypoechoic areas
TEAR OF ACHILLESThe rupture site is located generally between the 2 and 6 cm from the insertion into the calcaneous in the called critical zone of relative hypovascularityIn ultrasound complete rupture of the Achilles tendon is seen as a focal defect
between the broken ends of the tendon In the acute phase ends are contiguous but the defect may be filled by the anechoic or hypoechoic hematoma In most cases paratendon remains intact as a envelope straight echogenic contouring breakage As a sign associated can exist distortion of the fibrillar configuration and loss of parallelism of the tendon fibers Other signs are indicative fat herniation into the defect better visualization of the plantar tendon and the existence of a posterior acoustic shadowing at the site of the tear (useful sign to differentiate partial thickness tears)
Complete rupture of the Achilles tendon with focal defect between
the ends of the tendon and posterior acoustic shadowing at the
site of the tear useful sign to differentiate partial thickness tears
Patient with psoriasis which identifies tendinosis and Achilles tendon swelling
bilateral and textural heterogeneity with intratendinous focal hypoechoic areas
Ultrasound and radiological correlation calcified Achilles
enthesitis Calcaneal spur as associated finding
Discreetly thickened right Achilles tendon at its insertion combining linear hyperechoic
and hypoechoic areas on small breaks intrasubstance and calcifications of the enthesis
Fat herniation into the defect by complete tear of the Achilles tendon
Complete tear of the Achilles tendon with retraction
of ends and integrity thin plantaris tendon
Tendinosis versus partial tear of Achilles tendon
bullPREACHILLES AND RETROACHILLES BURSITIS
Although bursitis can occur in isolation often are
related and systemic inflammatory diseases
In the ultrasound examination the distended
retrocalcaneal and preachilles appears are a
hypoechoic structure shaped coma interposed
between the Achilles tendon and the posterosuperior
aspect of the calcaneous Care must be taken not to
confuse it with the fatty space Kager containing oval
lobules of hyperechoic fat When bursitis is a
manifestation of synovitis is appreciated
hypervascular area with Doppler ultrasound
In the retroachilles bursitis exists thickening and
collection of fluid in the subcutaneous tissue
superficial to the tendon retrocalcaneal portion
Bursitis preachilles with typical morphology appreciating accumulation of fluid
in a coma between the anterior portion of the Achilles tendon and the calcaneous
Bursitis preachiacutelea that associated synovitis showing hyperemia with increased Doppler flow
Rheumatoid arthritis with retrocalcaneal bursitis (1) and calcaneal erosions (2)
ACCESSORY NAVICULAR BONEIn the distal insertion site may exist TP 2 types of bones
accessories
Accessory navicular bone type I (os tibiale externum) size
between the 2 and 6 mm can be contained within the TP and
being positioned immediately proximal posteromedial to the
navicular bone It generally produces symptoms and should
not be confused with a tendon calcification or avulsion
fracture
Type II accessory navicular bone is an accessory
ossification centre of the navicular bone with size between
9 and 12 mm triangular shaped and articulated through a
synchondrosis of the posterior and medial navicular bone
It insertion site of some fibers of TP and is associated with a
syndrome of pain and increased incidence of tendon rupture
caused by abnormal overloads Osteoarthritic changes may
underlie this synchondrosis which mimic tendon pathology
Accessory navicular bone within the posterior tibial tendon as anatomical variant
ANTERIOR COMPARTMENTThe tendons of the anterior ankle compared
with the rest of the ankle tendons are rarely
affected by disease The anterior tibial tendon
is the most prone to abnormalities like
tendinopathy tenosynovitis and its place
between the most frequent rupture is extensor
retinaculum and insertion into the first
cuneiform and the base of the first metatarsal
Sometimes the retracted tendon stump causes
a nodule on the anteromedial aspect of the
distal portion of the leg making clinically
confused with a tumour or cyst
Distal insertion tendinopathy of the anterior tibial tendon with increased vascularity
Tenosynovitis of the anterior tibial tendon with effusion
Anterior tibial tendon tenosynovitis with intratendinous ruptures
Anterior tibial tendon rupture with retraction of the tendon
Tenosynovitis of the extensor digitorum tendons with a synovial effusion
Tenosynovitis of the extensor digitorum tendon with hypervascularized thickened tendon and synovium and synovial fluid
Rheumatoid arthritis with tenosynovitis of the extensor digitorum and peroneal tendons
Thickening of the extensor hallucis longus tendon caused by osteosynthesis material
Multicystic non vascularized intramuscular mass in the extensor digitorum brevis muscle
LATERAL COMPARTMENTTENOSYNOVITIS OF THE PERONEAL TENDONSThe main sign of ultrasound is the presence of liquid inside the
common synovial sheath whereas usually tendinous
morphology is preserved We must differentiate tenosynovitis of
a spill within the common peroneal sheath secondary to a tear of
calcaneofibular ligament (PCL) The ultrasound diagnosis is the detection of the tendons in a lateral plane relative to the distal portion of the lateral malleolus instead of behind it The dynamic exploration foot dorsiflexion as both eversion may help identify cases of intermittent subluxation In long-standing disease can be observed fusiform thickening
of the peroneal tendons at the tip of the malleolus The complete tears of the peroneus brevis tendon (PC) and peroneus longus (PL) are rare occurring in the area of the lateral malleolus or midfoot Seen in patients with ankle sprains or history of chronic instability especially if they suffer widespread diseases (RA DM) or treated with corticosteroids The peroneal tendon ruptures causing the inability to eversion of the foot and cavus foot varus
Important thickening of both peroneal tendons (longus and brevis) associated
with moderate amount of fluid and thickening of the synovial sheath
Discreet amount of fluid in the common sheath of the peroneal tendons
associated with disorganization and a heterogeneous appearance
peroneus brevis tendon related to longitudinal rupture
Peroneal tenosynovitis and osteosynthesis
Tenosynovitis of the peroneal tendons and an intratendinous rupture of the short peroneal tendon
Intratendinous rupture and cyst in the peroneus brevis tendon
Peroneus quartus with an accessory muscle next to the peroneus longus and brevis tendons
Tumor next to the peroneal tendons that proved to be a benign fibrous mass
MEDIAL COMPARTMENT
ANOMALIES POSTERIOR TIBIAL TENDON (TP)
It is the most frequently injured in this compartment with ruptures
in asymptomatic middle-aged obese women as a result of
widespread disease (RA seronegative Spondyloarthropathy) or
associated with bone fractures It causes a gradual collapse of the
medial longitudinal arch with hindfoot valgus deformity and
excessive forefoot pronation
The presence of small vessels in inflammatory diseases
intratendinosis can simulate a fissuration tendon confusion can be ignored using colour Doppler Another possible diagnostic difficulty is when the undamaged tendon flexor digitorum longus (FLD) moves back and simulates the TP unbroken but it is smaller and in this case we only see in the groove retromalleolar 1 only tendon
Ultrasound has also proven to be an effective resource for identifying alterations associated tendon tenosynovitis serosa and hypertrophicSubluxation and dislocation anteriorly and medial TP relative to internal
malleolus is rare and valued sonographically placing the foot in dorsiflexion with forced supination
Thickening moderate amount of fluid surrounding calcifications and
hyperemia affecting the sheath and the posterior tibial tendon related
to chronic tenosynovitis in patient affects rheumatoid arthritis
Thickening moderate amount of surrounding fluid and calcifications (arrow) affecting the
posterior tibial tendon related to chronic tenosynovitis in patient affects rheumatoid arthritis
Tenosynovitis of the posterior tibial tendon caused by a bony ridge at the insertion of the retinaculum The retinaculum is thickened and the tendon subluxates
Psoriatic arthritis Ankle Grayscale examination Posterior tibial tendon on longitudinal (a) and transverse (b) scan Marked tendon sheath widening with homogeneous anechoic aspect (asterisks) of the content indicating an exudative tenosynovitis Note as the normal fibrillar echotexture is conserved Hand Flexor tendons of second finger The volar longitudinal (c) and transverse scan (d) shows a tendon sheath widening with signs of synovial proliferation presence of intense power Doppler signal surrounding the tendon and micro interruption of the margin (arrow) e Wrist Extensor carpi ulnaris tendon (sixth compartment of the extensor tendons ecu) on lateral longitudinal (e) and transverse (f) scan Chronic tenosynovitis with clear areas of low of echogenicity and loss of the continuity of tendon fibrils indicative of partial tendon tear (arrows) Moreover note the presence of power Doppler signal within the interruption indicating still activity of the inflammatory process g Dactylitis Volar longitudinal scan using the ldquoextended viewrdquo technique showing proliferative tenosynovitis of the finger flexor tendon (circle) exudative synovitis of both proximal and distal interphalangeal joint (white asterisks) and edema of the peritendinous tissue (black asterisks) TP posterior tibial tendon mm medial malleolus DP distal phalanx mp middle phalanx cu cubital bone ft flexor tendons
Tenosynovitis of the posterior tibial (1) and flexor digitorum longus tendon (2)
Tibialis Posterior Tendon rupture
Tenosynovitis of the posterior tibial tendon the flexor digitorum tendon and flexor hallucis longus tendon
Tenosynovitis of the tendons on the medial side in the left ankle
bullLIGAMENT INJURIESThe ligament partial tear ligament shows a hypoechoic
areas swollen with internal focal or diffuse In the complete
ruptures within the substance of the divided ligament rift is
observed corresponding to the hematoma hypoechoic and
the free ends of the divided ligament can be and retracted
appreciated corrugated in contrast with normal
appearance straight
Grade I Mild stretching of the ligament without breakage
or instability
Grade II Partial tearing of the ligament
Grade III Complete tearing
Degrees depending on the severity of the injury and the
place of employment
LATERAL COMPARTMENTThese injuries occur secondary to inversion sprains with internal rotation of
the foot combined with ankle plantar flexion
The anterior talar fibular ligament tears (ATFL) usually occur as isolated
involvement (70) or associated with calcaneal fibular ligament (CFL) (20-40)
but the posterior talar fibular ligament (PTFL) affects only major trauma
involving ankle dislocation
ATFL breaks is associated with breakage of the joint capsule and synovial fluid
extravasation into the anterolateral soft ankle whereas the complete tearing of
CFL can communicate the ankle joint and synovial sheath peroneal tendons
Rupture of CFL is rarely associated with superior peroneal retinaculum tear
The CFL is tensioned during dorsiflexion pulling on peroneal tendons laterally
so that absence of its displacement is sign of a complete tear
Within a damaged ligament can also observe calcifications that often
correspond to fragments of avulsion bone
During the ultrasound can be performed forced maneuvers to detect to joint
laxity and ligament injuries The anterior drawer test is performed with the feet
hanging over the edge of the examination table while the forefoot is pulled
anteriorly when the foot is in plantar flexion and inversion This maneuver
helps differentiate partial tears (grade II) of the ATFL to complete (grade III)
where the anterior displacement of the talus on the tibia open a crack in the
substance becoming more visible the ligament injury
The sindesmosys sprains are up to 10 of ankle
injuries happening in eversion and pronation
movements (like the deltoid ligament injury) and
primarily affect the anterior tibiofibular ligament (ATFL)
the failure is frequently associated with fracture of the
fibula
According to the place of employment are 4 degrees
useful for prognostic evaluation and therapeutic strategy
choice
Grade I stretch or partial tear of the ATFL
Grade II complete tearing but only the ATFL
Grade III complete tear of the ATFL and partial CFL
Grade IV complete tear of the ATFL and CFL
The grade I and II injuries usually scarred without any
significant instability whereas grade III and IV injuries
can cause chronic pain and require surgical treatment
Thickened but continued ATFL right in relation to the partial rupture
Grade 111 sprain of right ATFL
Thickened anterior talofibular ligament with calcifications and a partial rupture
Thickened tibiofibular ligament after trauma
Anterior Talofibular Ligament Partial Tear and Elastography
Tibio fibular ligament rupture with bony avulsion
Complete rupture of right ATFL
Bony avulsion with radiographic evidence as visible calcification in a grade III sprain ATFL
Moderately thickened and hypoechoic ATFL
Discontinuity of the ATFL with fluid surrounding the torn ends (arrow)
Thickening and hypoechogenicity of the fibular end of the ligament seen here passing over the subtalar joint which contains a small of fluid
Complete disruption to the tibiofibular ligament with bony irregularity of particularly the tibial margin and fluid in the gap
MEDIAL COMPARTMENTBecause of the low incidence of eversion ankle
sprains and the thickness of the deltoid ligament
is rarely injured in isolation and when the injury
does not usually full thickness Usually
accompanied by lesions of the medial malleolus
and lateral displacement of the talus with
consequent widening of the ankle mortise
Ultrasound is useful for differentiating ligament
injury of the posterior tibial tendon injury
(TP) adjacent they have similar symptoms
The inability to visualize the deltoid ligament may
indicate tear but this is not considered a reliable
sign as its full ultrasound is not always possible
Partial medial ligament rupture
Thickened heterogeneous abnormal deltoid demonstrating hyperemia
Ultrasonogram showing a disrupted deltoid ligament with the probe in the coronal plane The white arrow indicates the medial malleolus the blue arrow indicates the talus and the red arrows indicate the disrupted deltoid ligament (A) Radiograph showing the same injury (B)
bullJOINT AND BONE DISORDERSUltrasound reliably detect spills mild (gt 2 ml) inside
of the ankle joint by exploring the front and rear
recess as well as areas of synovial proliferation and
may even display using the colour Doppler
hyperemic areas in arthritis patients
The intraarticular joints are displayed surrounded
fluid in one of the recesses of the ankle or subtalar
joint Sonographically diagnosed when changing position to perform flexion and extension Fracture of the lateral process of the talus is overlooked up to 50 of cases with plain radiography Ultrasound may suspect the presence of focal cortical disruption helping further to exclude concomitant ligament injury
Rheumatoid arthritis with synovial thickening (1) and erosion of the tibia (2)
Infectious arthritis with a pus filled anterior recess of the ankle
Arthritis and tenosynovitis of the ankle in a patient with rheumatoid arthritis
bullTUMOURSUltrasound can differentiate between a mass complex
and solid and a cystic in addition to verifying the
existence of accessory muscles (peroneus fourth
accessory flexor digitorum longus and accessory
soleus) As in any other location can be found
neoformative soft tissue tumors inflammatory
infectious etc
Ganglions of this location are more often symptomatic
and larger with multiple partitions
branched and lobed edges Differential diagnosis must
be made with tenosynovitis abscesses seromas and
varicosities
Neurogenic tumours are described as pathognomonic
homogeneous hypoechoic oval mass in continuity with
a nerve of origin
Ganglion cysts are non-malignant cystic masses that occur in association with musculoskeletal structures They are sometimes also simply referred to as ganglia or a ganglion but should not be confused with the anatomical term ganglion UltrasoundThe vast majority are anechoic to hypoechoic on ultrasound and have well defined margins Many demonstrate internal septations as well as acoustic enhancement A synovial cyst is a small fluid-filled sac or pouch that can develop over a tendon or joint creating a mass under the skin Synovial cyst is rare in ankle joint A synovial cyst may or may not be painful depending on their size and location
Ganglion cyst in the foot with bony erosion between navicular and cuneiform bones
Tarsal synovial cyst
Anechoic ganglion situated in the sinus tarsi fat between the talus and calcaneous
Plantar fasciitis (PF) refers to inflammation of the
plantar fascia of the foot It is considered the most common cause of heel pain
Clinical presentation Pain on the undersurface of the heel on weight bearing is the principal complaint It can be worse when weight is borne after a period of rest (eg in the morning) and eases with walking Passive dorsiflexion of the toes may exacerbates discomfort
UltrasoundOften the initial imaging modality of choice Ultrasound typically shows increased thickness of the fascia and a hypoechoic fascia
Thickened hypoechoic origin of the plantar fascia which has a convex superior margin
Complete avulsion of the plantar fascia from the calcaneal tubercle
Plantar fasciitis
bull LOCATING FOREIGN BODIES AND FRACTURES
As in any other location the ankle
area is also subsidiary host foreign
whose classification location and
existence can be defined perfectly by
ultrasound Being a focused study to
the area of interest and with great
resolution for surface structures can
be considered more resolute
examination to screen these cases
Osseous diseases and fractures | Sonography discovered Medial Malleolus Fracture
Ultrasound examination of left ankle A Longitudinal sonogram left ankle demonstrates a wooden foreign body B Transverse view left ankle Note the hypervascularity in the inflamed area C Corresponding X-ray of left ankle Note the swelling on the lateral aspect No foreign body is visible
Thank You
ATFL scan plane Anterior Talo-fibula ligament (ATFL)
Ultrasound of the Peroneus Longus tendon insertion The insertion is to the lateral edge of the 1st cuneiform with some fibers extending to the base of the 1st metatarsal
Anterior AnkleTibio-fibula ligamentExtensor Digitorum tendon(s)Extensor Hallucis LongusTibialis anteriorExtensor retinaculum
Tibio fibula ligament scan plane Normal Tibio fibula ligament
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 its own tendon - the extensor hallucis)
Extensor hallucis scan plane Longitudinal extensor hallucis longus tendon
Tibialis Anterior scan plane Longitudinal Tibialis Anterior tendon
Medial AnkleTibialis Posterior tendonFlexor Digitorum tendonFlexor Hallucis Longus tendonDeltoid ligamentPosterior tibial nerve
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 amp Harry) If including the neurovascular bundle - Tom Dick And Very Nervous Harry
Deltoid Ligament scan plane Use plenty of gel and have the probe tip overlie the malleolar tip
Because of its obliquity you cannotreadily see all aspects of the ligament
Posterior AnkleAchilles tendonRetrocalcaneal (Kagers) fat-pad
Scan plane for the Achilles tendon Normal Achilles tendon longitudinal panorama
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 edema Guidance of injection aspiration or biopsy Relationship of normal anatomy and pathology to each other Some bony pathologyLIMITATIONSIt is recognised that ultrasound cannot adequately assess the deltoid ligament the ankle mortice and some inter-tarsal ligamentsEQUIPMENT SELECTION AND TECHNIQUEUse 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 TECHNIQUELATERAL 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 ANKLEPatient 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 mobilizing 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 calcaneumThe deltoid ligament Is poorly assessed with ultrasoundPosterior tibial nerve The neurovascular bundle is easily seen posterior to the medial malleolusPOSTERIOR 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 (Kagers) fat padThe calf muscles and plantaris tendon should also be assessed as clinically indicated
An ankle series should include the following minimum imagesPeroneus tendons - long trans + peroneus brevis insertionCalcaneo-fibular ligamentAnterior talo-fibula ligamentTibio-Fibula ligamentExtensor digitorum tendonExtensor hallucis longus tendonTibialis anterior tendonTibialis posterior tendonFlexor digitorum tendonFlexor hallucis longusAchilles tendon and retro calcaneal bursaDocument the normal anatomy Any pathology found in 2 planes(ligament tears or thickening synovial bulgingcysts joint effusion gross bony changes) including measurements and any vascularity
MAIN INDICATIONS OFTHE ANKLE ULTRASONOGRAPHIC STUDY
Tendon pathology of the different compartments
of the ankle
bull Evaluation of ligament injuries
bull Bone and joint disorders (synovitis chondral
and osteochondral lesions occult fractures)
bull Retroachilles and preachilles bursitis
bull Characterization of tumors (accessory muscles ganglia
neurogenic tumours soft tissue abscesses etc)
bull Localization of foreign bodies
ABNORMALITIES OF TENDONS
Tendon injuries include tenosynovitis tendinosis
rupture and instability
POSTERIOR COMPARTMENTACHILLES TENDINOPATHY
Can be classified as tendinosis and paratendinitis The isolated
paratendinitis shows intratendinous normal structure exist paratendinitis
spill shown irregularities in the edges of the tendon adhesions and
scarring associated paratendon and a heterogeneous aspect preachilles
fat pad In the tendinosis there is in swelling of the tendon usually
bilateral and textural heterogeneity intratendinous focal hypoechoic areas
TEAR OF ACHILLESThe rupture site is located generally between the 2 and 6 cm from the insertion into the calcaneous in the called critical zone of relative hypovascularityIn ultrasound complete rupture of the Achilles tendon is seen as a focal defect
between the broken ends of the tendon In the acute phase ends are contiguous but the defect may be filled by the anechoic or hypoechoic hematoma In most cases paratendon remains intact as a envelope straight echogenic contouring breakage As a sign associated can exist distortion of the fibrillar configuration and loss of parallelism of the tendon fibers Other signs are indicative fat herniation into the defect better visualization of the plantar tendon and the existence of a posterior acoustic shadowing at the site of the tear (useful sign to differentiate partial thickness tears)
Complete rupture of the Achilles tendon with focal defect between
the ends of the tendon and posterior acoustic shadowing at the
site of the tear useful sign to differentiate partial thickness tears
Patient with psoriasis which identifies tendinosis and Achilles tendon swelling
bilateral and textural heterogeneity with intratendinous focal hypoechoic areas
Ultrasound and radiological correlation calcified Achilles
enthesitis Calcaneal spur as associated finding
Discreetly thickened right Achilles tendon at its insertion combining linear hyperechoic
and hypoechoic areas on small breaks intrasubstance and calcifications of the enthesis
Fat herniation into the defect by complete tear of the Achilles tendon
Complete tear of the Achilles tendon with retraction
of ends and integrity thin plantaris tendon
Tendinosis versus partial tear of Achilles tendon
bullPREACHILLES AND RETROACHILLES BURSITIS
Although bursitis can occur in isolation often are
related and systemic inflammatory diseases
In the ultrasound examination the distended
retrocalcaneal and preachilles appears are a
hypoechoic structure shaped coma interposed
between the Achilles tendon and the posterosuperior
aspect of the calcaneous Care must be taken not to
confuse it with the fatty space Kager containing oval
lobules of hyperechoic fat When bursitis is a
manifestation of synovitis is appreciated
hypervascular area with Doppler ultrasound
In the retroachilles bursitis exists thickening and
collection of fluid in the subcutaneous tissue
superficial to the tendon retrocalcaneal portion
Bursitis preachilles with typical morphology appreciating accumulation of fluid
in a coma between the anterior portion of the Achilles tendon and the calcaneous
Bursitis preachiacutelea that associated synovitis showing hyperemia with increased Doppler flow
Rheumatoid arthritis with retrocalcaneal bursitis (1) and calcaneal erosions (2)
ACCESSORY NAVICULAR BONEIn the distal insertion site may exist TP 2 types of bones
accessories
Accessory navicular bone type I (os tibiale externum) size
between the 2 and 6 mm can be contained within the TP and
being positioned immediately proximal posteromedial to the
navicular bone It generally produces symptoms and should
not be confused with a tendon calcification or avulsion
fracture
Type II accessory navicular bone is an accessory
ossification centre of the navicular bone with size between
9 and 12 mm triangular shaped and articulated through a
synchondrosis of the posterior and medial navicular bone
It insertion site of some fibers of TP and is associated with a
syndrome of pain and increased incidence of tendon rupture
caused by abnormal overloads Osteoarthritic changes may
underlie this synchondrosis which mimic tendon pathology
Accessory navicular bone within the posterior tibial tendon as anatomical variant
ANTERIOR COMPARTMENTThe tendons of the anterior ankle compared
with the rest of the ankle tendons are rarely
affected by disease The anterior tibial tendon
is the most prone to abnormalities like
tendinopathy tenosynovitis and its place
between the most frequent rupture is extensor
retinaculum and insertion into the first
cuneiform and the base of the first metatarsal
Sometimes the retracted tendon stump causes
a nodule on the anteromedial aspect of the
distal portion of the leg making clinically
confused with a tumour or cyst
Distal insertion tendinopathy of the anterior tibial tendon with increased vascularity
Tenosynovitis of the anterior tibial tendon with effusion
Anterior tibial tendon tenosynovitis with intratendinous ruptures
Anterior tibial tendon rupture with retraction of the tendon
Tenosynovitis of the extensor digitorum tendons with a synovial effusion
Tenosynovitis of the extensor digitorum tendon with hypervascularized thickened tendon and synovium and synovial fluid
Rheumatoid arthritis with tenosynovitis of the extensor digitorum and peroneal tendons
Thickening of the extensor hallucis longus tendon caused by osteosynthesis material
Multicystic non vascularized intramuscular mass in the extensor digitorum brevis muscle
LATERAL COMPARTMENTTENOSYNOVITIS OF THE PERONEAL TENDONSThe main sign of ultrasound is the presence of liquid inside the
common synovial sheath whereas usually tendinous
morphology is preserved We must differentiate tenosynovitis of
a spill within the common peroneal sheath secondary to a tear of
calcaneofibular ligament (PCL) The ultrasound diagnosis is the detection of the tendons in a lateral plane relative to the distal portion of the lateral malleolus instead of behind it The dynamic exploration foot dorsiflexion as both eversion may help identify cases of intermittent subluxation In long-standing disease can be observed fusiform thickening
of the peroneal tendons at the tip of the malleolus The complete tears of the peroneus brevis tendon (PC) and peroneus longus (PL) are rare occurring in the area of the lateral malleolus or midfoot Seen in patients with ankle sprains or history of chronic instability especially if they suffer widespread diseases (RA DM) or treated with corticosteroids The peroneal tendon ruptures causing the inability to eversion of the foot and cavus foot varus
Important thickening of both peroneal tendons (longus and brevis) associated
with moderate amount of fluid and thickening of the synovial sheath
Discreet amount of fluid in the common sheath of the peroneal tendons
associated with disorganization and a heterogeneous appearance
peroneus brevis tendon related to longitudinal rupture
Peroneal tenosynovitis and osteosynthesis
Tenosynovitis of the peroneal tendons and an intratendinous rupture of the short peroneal tendon
Intratendinous rupture and cyst in the peroneus brevis tendon
Peroneus quartus with an accessory muscle next to the peroneus longus and brevis tendons
Tumor next to the peroneal tendons that proved to be a benign fibrous mass
MEDIAL COMPARTMENT
ANOMALIES POSTERIOR TIBIAL TENDON (TP)
It is the most frequently injured in this compartment with ruptures
in asymptomatic middle-aged obese women as a result of
widespread disease (RA seronegative Spondyloarthropathy) or
associated with bone fractures It causes a gradual collapse of the
medial longitudinal arch with hindfoot valgus deformity and
excessive forefoot pronation
The presence of small vessels in inflammatory diseases
intratendinosis can simulate a fissuration tendon confusion can be ignored using colour Doppler Another possible diagnostic difficulty is when the undamaged tendon flexor digitorum longus (FLD) moves back and simulates the TP unbroken but it is smaller and in this case we only see in the groove retromalleolar 1 only tendon
Ultrasound has also proven to be an effective resource for identifying alterations associated tendon tenosynovitis serosa and hypertrophicSubluxation and dislocation anteriorly and medial TP relative to internal
malleolus is rare and valued sonographically placing the foot in dorsiflexion with forced supination
Thickening moderate amount of fluid surrounding calcifications and
hyperemia affecting the sheath and the posterior tibial tendon related
to chronic tenosynovitis in patient affects rheumatoid arthritis
Thickening moderate amount of surrounding fluid and calcifications (arrow) affecting the
posterior tibial tendon related to chronic tenosynovitis in patient affects rheumatoid arthritis
Tenosynovitis of the posterior tibial tendon caused by a bony ridge at the insertion of the retinaculum The retinaculum is thickened and the tendon subluxates
Psoriatic arthritis Ankle Grayscale examination Posterior tibial tendon on longitudinal (a) and transverse (b) scan Marked tendon sheath widening with homogeneous anechoic aspect (asterisks) of the content indicating an exudative tenosynovitis Note as the normal fibrillar echotexture is conserved Hand Flexor tendons of second finger The volar longitudinal (c) and transverse scan (d) shows a tendon sheath widening with signs of synovial proliferation presence of intense power Doppler signal surrounding the tendon and micro interruption of the margin (arrow) e Wrist Extensor carpi ulnaris tendon (sixth compartment of the extensor tendons ecu) on lateral longitudinal (e) and transverse (f) scan Chronic tenosynovitis with clear areas of low of echogenicity and loss of the continuity of tendon fibrils indicative of partial tendon tear (arrows) Moreover note the presence of power Doppler signal within the interruption indicating still activity of the inflammatory process g Dactylitis Volar longitudinal scan using the ldquoextended viewrdquo technique showing proliferative tenosynovitis of the finger flexor tendon (circle) exudative synovitis of both proximal and distal interphalangeal joint (white asterisks) and edema of the peritendinous tissue (black asterisks) TP posterior tibial tendon mm medial malleolus DP distal phalanx mp middle phalanx cu cubital bone ft flexor tendons
Tenosynovitis of the posterior tibial (1) and flexor digitorum longus tendon (2)
Tibialis Posterior Tendon rupture
Tenosynovitis of the posterior tibial tendon the flexor digitorum tendon and flexor hallucis longus tendon
Tenosynovitis of the tendons on the medial side in the left ankle
bullLIGAMENT INJURIESThe ligament partial tear ligament shows a hypoechoic
areas swollen with internal focal or diffuse In the complete
ruptures within the substance of the divided ligament rift is
observed corresponding to the hematoma hypoechoic and
the free ends of the divided ligament can be and retracted
appreciated corrugated in contrast with normal
appearance straight
Grade I Mild stretching of the ligament without breakage
or instability
Grade II Partial tearing of the ligament
Grade III Complete tearing
Degrees depending on the severity of the injury and the
place of employment
LATERAL COMPARTMENTThese injuries occur secondary to inversion sprains with internal rotation of
the foot combined with ankle plantar flexion
The anterior talar fibular ligament tears (ATFL) usually occur as isolated
involvement (70) or associated with calcaneal fibular ligament (CFL) (20-40)
but the posterior talar fibular ligament (PTFL) affects only major trauma
involving ankle dislocation
ATFL breaks is associated with breakage of the joint capsule and synovial fluid
extravasation into the anterolateral soft ankle whereas the complete tearing of
CFL can communicate the ankle joint and synovial sheath peroneal tendons
Rupture of CFL is rarely associated with superior peroneal retinaculum tear
The CFL is tensioned during dorsiflexion pulling on peroneal tendons laterally
so that absence of its displacement is sign of a complete tear
Within a damaged ligament can also observe calcifications that often
correspond to fragments of avulsion bone
During the ultrasound can be performed forced maneuvers to detect to joint
laxity and ligament injuries The anterior drawer test is performed with the feet
hanging over the edge of the examination table while the forefoot is pulled
anteriorly when the foot is in plantar flexion and inversion This maneuver
helps differentiate partial tears (grade II) of the ATFL to complete (grade III)
where the anterior displacement of the talus on the tibia open a crack in the
substance becoming more visible the ligament injury
The sindesmosys sprains are up to 10 of ankle
injuries happening in eversion and pronation
movements (like the deltoid ligament injury) and
primarily affect the anterior tibiofibular ligament (ATFL)
the failure is frequently associated with fracture of the
fibula
According to the place of employment are 4 degrees
useful for prognostic evaluation and therapeutic strategy
choice
Grade I stretch or partial tear of the ATFL
Grade II complete tearing but only the ATFL
Grade III complete tear of the ATFL and partial CFL
Grade IV complete tear of the ATFL and CFL
The grade I and II injuries usually scarred without any
significant instability whereas grade III and IV injuries
can cause chronic pain and require surgical treatment
Thickened but continued ATFL right in relation to the partial rupture
Grade 111 sprain of right ATFL
Thickened anterior talofibular ligament with calcifications and a partial rupture
Thickened tibiofibular ligament after trauma
Anterior Talofibular Ligament Partial Tear and Elastography
Tibio fibular ligament rupture with bony avulsion
Complete rupture of right ATFL
Bony avulsion with radiographic evidence as visible calcification in a grade III sprain ATFL
Moderately thickened and hypoechoic ATFL
Discontinuity of the ATFL with fluid surrounding the torn ends (arrow)
Thickening and hypoechogenicity of the fibular end of the ligament seen here passing over the subtalar joint which contains a small of fluid
Complete disruption to the tibiofibular ligament with bony irregularity of particularly the tibial margin and fluid in the gap
MEDIAL COMPARTMENTBecause of the low incidence of eversion ankle
sprains and the thickness of the deltoid ligament
is rarely injured in isolation and when the injury
does not usually full thickness Usually
accompanied by lesions of the medial malleolus
and lateral displacement of the talus with
consequent widening of the ankle mortise
Ultrasound is useful for differentiating ligament
injury of the posterior tibial tendon injury
(TP) adjacent they have similar symptoms
The inability to visualize the deltoid ligament may
indicate tear but this is not considered a reliable
sign as its full ultrasound is not always possible
Partial medial ligament rupture
Thickened heterogeneous abnormal deltoid demonstrating hyperemia
Ultrasonogram showing a disrupted deltoid ligament with the probe in the coronal plane The white arrow indicates the medial malleolus the blue arrow indicates the talus and the red arrows indicate the disrupted deltoid ligament (A) Radiograph showing the same injury (B)
bullJOINT AND BONE DISORDERSUltrasound reliably detect spills mild (gt 2 ml) inside
of the ankle joint by exploring the front and rear
recess as well as areas of synovial proliferation and
may even display using the colour Doppler
hyperemic areas in arthritis patients
The intraarticular joints are displayed surrounded
fluid in one of the recesses of the ankle or subtalar
joint Sonographically diagnosed when changing position to perform flexion and extension Fracture of the lateral process of the talus is overlooked up to 50 of cases with plain radiography Ultrasound may suspect the presence of focal cortical disruption helping further to exclude concomitant ligament injury
Rheumatoid arthritis with synovial thickening (1) and erosion of the tibia (2)
Infectious arthritis with a pus filled anterior recess of the ankle
Arthritis and tenosynovitis of the ankle in a patient with rheumatoid arthritis
bullTUMOURSUltrasound can differentiate between a mass complex
and solid and a cystic in addition to verifying the
existence of accessory muscles (peroneus fourth
accessory flexor digitorum longus and accessory
soleus) As in any other location can be found
neoformative soft tissue tumors inflammatory
infectious etc
Ganglions of this location are more often symptomatic
and larger with multiple partitions
branched and lobed edges Differential diagnosis must
be made with tenosynovitis abscesses seromas and
varicosities
Neurogenic tumours are described as pathognomonic
homogeneous hypoechoic oval mass in continuity with
a nerve of origin
Ganglion cysts are non-malignant cystic masses that occur in association with musculoskeletal structures They are sometimes also simply referred to as ganglia or a ganglion but should not be confused with the anatomical term ganglion UltrasoundThe vast majority are anechoic to hypoechoic on ultrasound and have well defined margins Many demonstrate internal septations as well as acoustic enhancement A synovial cyst is a small fluid-filled sac or pouch that can develop over a tendon or joint creating a mass under the skin Synovial cyst is rare in ankle joint A synovial cyst may or may not be painful depending on their size and location
Ganglion cyst in the foot with bony erosion between navicular and cuneiform bones
Tarsal synovial cyst
Anechoic ganglion situated in the sinus tarsi fat between the talus and calcaneous
Plantar fasciitis (PF) refers to inflammation of the
plantar fascia of the foot It is considered the most common cause of heel pain
Clinical presentation Pain on the undersurface of the heel on weight bearing is the principal complaint It can be worse when weight is borne after a period of rest (eg in the morning) and eases with walking Passive dorsiflexion of the toes may exacerbates discomfort
UltrasoundOften the initial imaging modality of choice Ultrasound typically shows increased thickness of the fascia and a hypoechoic fascia
Thickened hypoechoic origin of the plantar fascia which has a convex superior margin
Complete avulsion of the plantar fascia from the calcaneal tubercle
Plantar fasciitis
bull LOCATING FOREIGN BODIES AND FRACTURES
As in any other location the ankle
area is also subsidiary host foreign
whose classification location and
existence can be defined perfectly by
ultrasound Being a focused study to
the area of interest and with great
resolution for surface structures can
be considered more resolute
examination to screen these cases
Osseous diseases and fractures | Sonography discovered Medial Malleolus Fracture
Ultrasound examination of left ankle A Longitudinal sonogram left ankle demonstrates a wooden foreign body B Transverse view left ankle Note the hypervascularity in the inflamed area C Corresponding X-ray of left ankle Note the swelling on the lateral aspect No foreign body is visible
Thank You
Ultrasound of the Peroneus Longus tendon insertion The insertion is to the lateral edge of the 1st cuneiform with some fibers extending to the base of the 1st metatarsal
Anterior AnkleTibio-fibula ligamentExtensor Digitorum tendon(s)Extensor Hallucis LongusTibialis anteriorExtensor retinaculum
Tibio fibula ligament scan plane Normal Tibio fibula ligament
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 its own tendon - the extensor hallucis)
Extensor hallucis scan plane Longitudinal extensor hallucis longus tendon
Tibialis Anterior scan plane Longitudinal Tibialis Anterior tendon
Medial AnkleTibialis Posterior tendonFlexor Digitorum tendonFlexor Hallucis Longus tendonDeltoid ligamentPosterior tibial nerve
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 amp Harry) If including the neurovascular bundle - Tom Dick And Very Nervous Harry
Deltoid Ligament scan plane Use plenty of gel and have the probe tip overlie the malleolar tip
Because of its obliquity you cannotreadily see all aspects of the ligament
Posterior AnkleAchilles tendonRetrocalcaneal (Kagers) fat-pad
Scan plane for the Achilles tendon Normal Achilles tendon longitudinal panorama
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 edema Guidance of injection aspiration or biopsy Relationship of normal anatomy and pathology to each other Some bony pathologyLIMITATIONSIt is recognised that ultrasound cannot adequately assess the deltoid ligament the ankle mortice and some inter-tarsal ligamentsEQUIPMENT SELECTION AND TECHNIQUEUse 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 TECHNIQUELATERAL 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 ANKLEPatient 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 mobilizing 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 calcaneumThe deltoid ligament Is poorly assessed with ultrasoundPosterior tibial nerve The neurovascular bundle is easily seen posterior to the medial malleolusPOSTERIOR 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 (Kagers) fat padThe calf muscles and plantaris tendon should also be assessed as clinically indicated
An ankle series should include the following minimum imagesPeroneus tendons - long trans + peroneus brevis insertionCalcaneo-fibular ligamentAnterior talo-fibula ligamentTibio-Fibula ligamentExtensor digitorum tendonExtensor hallucis longus tendonTibialis anterior tendonTibialis posterior tendonFlexor digitorum tendonFlexor hallucis longusAchilles tendon and retro calcaneal bursaDocument the normal anatomy Any pathology found in 2 planes(ligament tears or thickening synovial bulgingcysts joint effusion gross bony changes) including measurements and any vascularity
MAIN INDICATIONS OFTHE ANKLE ULTRASONOGRAPHIC STUDY
Tendon pathology of the different compartments
of the ankle
bull Evaluation of ligament injuries
bull Bone and joint disorders (synovitis chondral
and osteochondral lesions occult fractures)
bull Retroachilles and preachilles bursitis
bull Characterization of tumors (accessory muscles ganglia
neurogenic tumours soft tissue abscesses etc)
bull Localization of foreign bodies
ABNORMALITIES OF TENDONS
Tendon injuries include tenosynovitis tendinosis
rupture and instability
POSTERIOR COMPARTMENTACHILLES TENDINOPATHY
Can be classified as tendinosis and paratendinitis The isolated
paratendinitis shows intratendinous normal structure exist paratendinitis
spill shown irregularities in the edges of the tendon adhesions and
scarring associated paratendon and a heterogeneous aspect preachilles
fat pad In the tendinosis there is in swelling of the tendon usually
bilateral and textural heterogeneity intratendinous focal hypoechoic areas
TEAR OF ACHILLESThe rupture site is located generally between the 2 and 6 cm from the insertion into the calcaneous in the called critical zone of relative hypovascularityIn ultrasound complete rupture of the Achilles tendon is seen as a focal defect
between the broken ends of the tendon In the acute phase ends are contiguous but the defect may be filled by the anechoic or hypoechoic hematoma In most cases paratendon remains intact as a envelope straight echogenic contouring breakage As a sign associated can exist distortion of the fibrillar configuration and loss of parallelism of the tendon fibers Other signs are indicative fat herniation into the defect better visualization of the plantar tendon and the existence of a posterior acoustic shadowing at the site of the tear (useful sign to differentiate partial thickness tears)
Complete rupture of the Achilles tendon with focal defect between
the ends of the tendon and posterior acoustic shadowing at the
site of the tear useful sign to differentiate partial thickness tears
Patient with psoriasis which identifies tendinosis and Achilles tendon swelling
bilateral and textural heterogeneity with intratendinous focal hypoechoic areas
Ultrasound and radiological correlation calcified Achilles
enthesitis Calcaneal spur as associated finding
Discreetly thickened right Achilles tendon at its insertion combining linear hyperechoic
and hypoechoic areas on small breaks intrasubstance and calcifications of the enthesis
Fat herniation into the defect by complete tear of the Achilles tendon
Complete tear of the Achilles tendon with retraction
of ends and integrity thin plantaris tendon
Tendinosis versus partial tear of Achilles tendon
bullPREACHILLES AND RETROACHILLES BURSITIS
Although bursitis can occur in isolation often are
related and systemic inflammatory diseases
In the ultrasound examination the distended
retrocalcaneal and preachilles appears are a
hypoechoic structure shaped coma interposed
between the Achilles tendon and the posterosuperior
aspect of the calcaneous Care must be taken not to
confuse it with the fatty space Kager containing oval
lobules of hyperechoic fat When bursitis is a
manifestation of synovitis is appreciated
hypervascular area with Doppler ultrasound
In the retroachilles bursitis exists thickening and
collection of fluid in the subcutaneous tissue
superficial to the tendon retrocalcaneal portion
Bursitis preachilles with typical morphology appreciating accumulation of fluid
in a coma between the anterior portion of the Achilles tendon and the calcaneous
Bursitis preachiacutelea that associated synovitis showing hyperemia with increased Doppler flow
Rheumatoid arthritis with retrocalcaneal bursitis (1) and calcaneal erosions (2)
ACCESSORY NAVICULAR BONEIn the distal insertion site may exist TP 2 types of bones
accessories
Accessory navicular bone type I (os tibiale externum) size
between the 2 and 6 mm can be contained within the TP and
being positioned immediately proximal posteromedial to the
navicular bone It generally produces symptoms and should
not be confused with a tendon calcification or avulsion
fracture
Type II accessory navicular bone is an accessory
ossification centre of the navicular bone with size between
9 and 12 mm triangular shaped and articulated through a
synchondrosis of the posterior and medial navicular bone
It insertion site of some fibers of TP and is associated with a
syndrome of pain and increased incidence of tendon rupture
caused by abnormal overloads Osteoarthritic changes may
underlie this synchondrosis which mimic tendon pathology
Accessory navicular bone within the posterior tibial tendon as anatomical variant
ANTERIOR COMPARTMENTThe tendons of the anterior ankle compared
with the rest of the ankle tendons are rarely
affected by disease The anterior tibial tendon
is the most prone to abnormalities like
tendinopathy tenosynovitis and its place
between the most frequent rupture is extensor
retinaculum and insertion into the first
cuneiform and the base of the first metatarsal
Sometimes the retracted tendon stump causes
a nodule on the anteromedial aspect of the
distal portion of the leg making clinically
confused with a tumour or cyst
Distal insertion tendinopathy of the anterior tibial tendon with increased vascularity
Tenosynovitis of the anterior tibial tendon with effusion
Anterior tibial tendon tenosynovitis with intratendinous ruptures
Anterior tibial tendon rupture with retraction of the tendon
Tenosynovitis of the extensor digitorum tendons with a synovial effusion
Tenosynovitis of the extensor digitorum tendon with hypervascularized thickened tendon and synovium and synovial fluid
Rheumatoid arthritis with tenosynovitis of the extensor digitorum and peroneal tendons
Thickening of the extensor hallucis longus tendon caused by osteosynthesis material
Multicystic non vascularized intramuscular mass in the extensor digitorum brevis muscle
LATERAL COMPARTMENTTENOSYNOVITIS OF THE PERONEAL TENDONSThe main sign of ultrasound is the presence of liquid inside the
common synovial sheath whereas usually tendinous
morphology is preserved We must differentiate tenosynovitis of
a spill within the common peroneal sheath secondary to a tear of
calcaneofibular ligament (PCL) The ultrasound diagnosis is the detection of the tendons in a lateral plane relative to the distal portion of the lateral malleolus instead of behind it The dynamic exploration foot dorsiflexion as both eversion may help identify cases of intermittent subluxation In long-standing disease can be observed fusiform thickening
of the peroneal tendons at the tip of the malleolus The complete tears of the peroneus brevis tendon (PC) and peroneus longus (PL) are rare occurring in the area of the lateral malleolus or midfoot Seen in patients with ankle sprains or history of chronic instability especially if they suffer widespread diseases (RA DM) or treated with corticosteroids The peroneal tendon ruptures causing the inability to eversion of the foot and cavus foot varus
Important thickening of both peroneal tendons (longus and brevis) associated
with moderate amount of fluid and thickening of the synovial sheath
Discreet amount of fluid in the common sheath of the peroneal tendons
associated with disorganization and a heterogeneous appearance
peroneus brevis tendon related to longitudinal rupture
Peroneal tenosynovitis and osteosynthesis
Tenosynovitis of the peroneal tendons and an intratendinous rupture of the short peroneal tendon
Intratendinous rupture and cyst in the peroneus brevis tendon
Peroneus quartus with an accessory muscle next to the peroneus longus and brevis tendons
Tumor next to the peroneal tendons that proved to be a benign fibrous mass
MEDIAL COMPARTMENT
ANOMALIES POSTERIOR TIBIAL TENDON (TP)
It is the most frequently injured in this compartment with ruptures
in asymptomatic middle-aged obese women as a result of
widespread disease (RA seronegative Spondyloarthropathy) or
associated with bone fractures It causes a gradual collapse of the
medial longitudinal arch with hindfoot valgus deformity and
excessive forefoot pronation
The presence of small vessels in inflammatory diseases
intratendinosis can simulate a fissuration tendon confusion can be ignored using colour Doppler Another possible diagnostic difficulty is when the undamaged tendon flexor digitorum longus (FLD) moves back and simulates the TP unbroken but it is smaller and in this case we only see in the groove retromalleolar 1 only tendon
Ultrasound has also proven to be an effective resource for identifying alterations associated tendon tenosynovitis serosa and hypertrophicSubluxation and dislocation anteriorly and medial TP relative to internal
malleolus is rare and valued sonographically placing the foot in dorsiflexion with forced supination
Thickening moderate amount of fluid surrounding calcifications and
hyperemia affecting the sheath and the posterior tibial tendon related
to chronic tenosynovitis in patient affects rheumatoid arthritis
Thickening moderate amount of surrounding fluid and calcifications (arrow) affecting the
posterior tibial tendon related to chronic tenosynovitis in patient affects rheumatoid arthritis
Tenosynovitis of the posterior tibial tendon caused by a bony ridge at the insertion of the retinaculum The retinaculum is thickened and the tendon subluxates
Psoriatic arthritis Ankle Grayscale examination Posterior tibial tendon on longitudinal (a) and transverse (b) scan Marked tendon sheath widening with homogeneous anechoic aspect (asterisks) of the content indicating an exudative tenosynovitis Note as the normal fibrillar echotexture is conserved Hand Flexor tendons of second finger The volar longitudinal (c) and transverse scan (d) shows a tendon sheath widening with signs of synovial proliferation presence of intense power Doppler signal surrounding the tendon and micro interruption of the margin (arrow) e Wrist Extensor carpi ulnaris tendon (sixth compartment of the extensor tendons ecu) on lateral longitudinal (e) and transverse (f) scan Chronic tenosynovitis with clear areas of low of echogenicity and loss of the continuity of tendon fibrils indicative of partial tendon tear (arrows) Moreover note the presence of power Doppler signal within the interruption indicating still activity of the inflammatory process g Dactylitis Volar longitudinal scan using the ldquoextended viewrdquo technique showing proliferative tenosynovitis of the finger flexor tendon (circle) exudative synovitis of both proximal and distal interphalangeal joint (white asterisks) and edema of the peritendinous tissue (black asterisks) TP posterior tibial tendon mm medial malleolus DP distal phalanx mp middle phalanx cu cubital bone ft flexor tendons
Tenosynovitis of the posterior tibial (1) and flexor digitorum longus tendon (2)
Tibialis Posterior Tendon rupture
Tenosynovitis of the posterior tibial tendon the flexor digitorum tendon and flexor hallucis longus tendon
Tenosynovitis of the tendons on the medial side in the left ankle
bullLIGAMENT INJURIESThe ligament partial tear ligament shows a hypoechoic
areas swollen with internal focal or diffuse In the complete
ruptures within the substance of the divided ligament rift is
observed corresponding to the hematoma hypoechoic and
the free ends of the divided ligament can be and retracted
appreciated corrugated in contrast with normal
appearance straight
Grade I Mild stretching of the ligament without breakage
or instability
Grade II Partial tearing of the ligament
Grade III Complete tearing
Degrees depending on the severity of the injury and the
place of employment
LATERAL COMPARTMENTThese injuries occur secondary to inversion sprains with internal rotation of
the foot combined with ankle plantar flexion
The anterior talar fibular ligament tears (ATFL) usually occur as isolated
involvement (70) or associated with calcaneal fibular ligament (CFL) (20-40)
but the posterior talar fibular ligament (PTFL) affects only major trauma
involving ankle dislocation
ATFL breaks is associated with breakage of the joint capsule and synovial fluid
extravasation into the anterolateral soft ankle whereas the complete tearing of
CFL can communicate the ankle joint and synovial sheath peroneal tendons
Rupture of CFL is rarely associated with superior peroneal retinaculum tear
The CFL is tensioned during dorsiflexion pulling on peroneal tendons laterally
so that absence of its displacement is sign of a complete tear
Within a damaged ligament can also observe calcifications that often
correspond to fragments of avulsion bone
During the ultrasound can be performed forced maneuvers to detect to joint
laxity and ligament injuries The anterior drawer test is performed with the feet
hanging over the edge of the examination table while the forefoot is pulled
anteriorly when the foot is in plantar flexion and inversion This maneuver
helps differentiate partial tears (grade II) of the ATFL to complete (grade III)
where the anterior displacement of the talus on the tibia open a crack in the
substance becoming more visible the ligament injury
The sindesmosys sprains are up to 10 of ankle
injuries happening in eversion and pronation
movements (like the deltoid ligament injury) and
primarily affect the anterior tibiofibular ligament (ATFL)
the failure is frequently associated with fracture of the
fibula
According to the place of employment are 4 degrees
useful for prognostic evaluation and therapeutic strategy
choice
Grade I stretch or partial tear of the ATFL
Grade II complete tearing but only the ATFL
Grade III complete tear of the ATFL and partial CFL
Grade IV complete tear of the ATFL and CFL
The grade I and II injuries usually scarred without any
significant instability whereas grade III and IV injuries
can cause chronic pain and require surgical treatment
Thickened but continued ATFL right in relation to the partial rupture
Grade 111 sprain of right ATFL
Thickened anterior talofibular ligament with calcifications and a partial rupture
Thickened tibiofibular ligament after trauma
Anterior Talofibular Ligament Partial Tear and Elastography
Tibio fibular ligament rupture with bony avulsion
Complete rupture of right ATFL
Bony avulsion with radiographic evidence as visible calcification in a grade III sprain ATFL
Moderately thickened and hypoechoic ATFL
Discontinuity of the ATFL with fluid surrounding the torn ends (arrow)
Thickening and hypoechogenicity of the fibular end of the ligament seen here passing over the subtalar joint which contains a small of fluid
Complete disruption to the tibiofibular ligament with bony irregularity of particularly the tibial margin and fluid in the gap
MEDIAL COMPARTMENTBecause of the low incidence of eversion ankle
sprains and the thickness of the deltoid ligament
is rarely injured in isolation and when the injury
does not usually full thickness Usually
accompanied by lesions of the medial malleolus
and lateral displacement of the talus with
consequent widening of the ankle mortise
Ultrasound is useful for differentiating ligament
injury of the posterior tibial tendon injury
(TP) adjacent they have similar symptoms
The inability to visualize the deltoid ligament may
indicate tear but this is not considered a reliable
sign as its full ultrasound is not always possible
Partial medial ligament rupture
Thickened heterogeneous abnormal deltoid demonstrating hyperemia
Ultrasonogram showing a disrupted deltoid ligament with the probe in the coronal plane The white arrow indicates the medial malleolus the blue arrow indicates the talus and the red arrows indicate the disrupted deltoid ligament (A) Radiograph showing the same injury (B)
bullJOINT AND BONE DISORDERSUltrasound reliably detect spills mild (gt 2 ml) inside
of the ankle joint by exploring the front and rear
recess as well as areas of synovial proliferation and
may even display using the colour Doppler
hyperemic areas in arthritis patients
The intraarticular joints are displayed surrounded
fluid in one of the recesses of the ankle or subtalar
joint Sonographically diagnosed when changing position to perform flexion and extension Fracture of the lateral process of the talus is overlooked up to 50 of cases with plain radiography Ultrasound may suspect the presence of focal cortical disruption helping further to exclude concomitant ligament injury
Rheumatoid arthritis with synovial thickening (1) and erosion of the tibia (2)
Infectious arthritis with a pus filled anterior recess of the ankle
Arthritis and tenosynovitis of the ankle in a patient with rheumatoid arthritis
bullTUMOURSUltrasound can differentiate between a mass complex
and solid and a cystic in addition to verifying the
existence of accessory muscles (peroneus fourth
accessory flexor digitorum longus and accessory
soleus) As in any other location can be found
neoformative soft tissue tumors inflammatory
infectious etc
Ganglions of this location are more often symptomatic
and larger with multiple partitions
branched and lobed edges Differential diagnosis must
be made with tenosynovitis abscesses seromas and
varicosities
Neurogenic tumours are described as pathognomonic
homogeneous hypoechoic oval mass in continuity with
a nerve of origin
Ganglion cysts are non-malignant cystic masses that occur in association with musculoskeletal structures They are sometimes also simply referred to as ganglia or a ganglion but should not be confused with the anatomical term ganglion UltrasoundThe vast majority are anechoic to hypoechoic on ultrasound and have well defined margins Many demonstrate internal septations as well as acoustic enhancement A synovial cyst is a small fluid-filled sac or pouch that can develop over a tendon or joint creating a mass under the skin Synovial cyst is rare in ankle joint A synovial cyst may or may not be painful depending on their size and location
Ganglion cyst in the foot with bony erosion between navicular and cuneiform bones
Tarsal synovial cyst
Anechoic ganglion situated in the sinus tarsi fat between the talus and calcaneous
Plantar fasciitis (PF) refers to inflammation of the
plantar fascia of the foot It is considered the most common cause of heel pain
Clinical presentation Pain on the undersurface of the heel on weight bearing is the principal complaint It can be worse when weight is borne after a period of rest (eg in the morning) and eases with walking Passive dorsiflexion of the toes may exacerbates discomfort
UltrasoundOften the initial imaging modality of choice Ultrasound typically shows increased thickness of the fascia and a hypoechoic fascia
Thickened hypoechoic origin of the plantar fascia which has a convex superior margin
Complete avulsion of the plantar fascia from the calcaneal tubercle
Plantar fasciitis
bull LOCATING FOREIGN BODIES AND FRACTURES
As in any other location the ankle
area is also subsidiary host foreign
whose classification location and
existence can be defined perfectly by
ultrasound Being a focused study to
the area of interest and with great
resolution for surface structures can
be considered more resolute
examination to screen these cases
Osseous diseases and fractures | Sonography discovered Medial Malleolus Fracture
Ultrasound examination of left ankle A Longitudinal sonogram left ankle demonstrates a wooden foreign body B Transverse view left ankle Note the hypervascularity in the inflamed area C Corresponding X-ray of left ankle Note the swelling on the lateral aspect No foreign body is visible
Thank You
Anterior AnkleTibio-fibula ligamentExtensor Digitorum tendon(s)Extensor Hallucis LongusTibialis anteriorExtensor retinaculum
Tibio fibula ligament scan plane Normal Tibio fibula ligament
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 its own tendon - the extensor hallucis)
Extensor hallucis scan plane Longitudinal extensor hallucis longus tendon
Tibialis Anterior scan plane Longitudinal Tibialis Anterior tendon
Medial AnkleTibialis Posterior tendonFlexor Digitorum tendonFlexor Hallucis Longus tendonDeltoid ligamentPosterior tibial nerve
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 amp Harry) If including the neurovascular bundle - Tom Dick And Very Nervous Harry
Deltoid Ligament scan plane Use plenty of gel and have the probe tip overlie the malleolar tip
Because of its obliquity you cannotreadily see all aspects of the ligament
Posterior AnkleAchilles tendonRetrocalcaneal (Kagers) fat-pad
Scan plane for the Achilles tendon Normal Achilles tendon longitudinal panorama
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 edema Guidance of injection aspiration or biopsy Relationship of normal anatomy and pathology to each other Some bony pathologyLIMITATIONSIt is recognised that ultrasound cannot adequately assess the deltoid ligament the ankle mortice and some inter-tarsal ligamentsEQUIPMENT SELECTION AND TECHNIQUEUse 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 TECHNIQUELATERAL 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 ANKLEPatient 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 mobilizing 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 calcaneumThe deltoid ligament Is poorly assessed with ultrasoundPosterior tibial nerve The neurovascular bundle is easily seen posterior to the medial malleolusPOSTERIOR 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 (Kagers) fat padThe calf muscles and plantaris tendon should also be assessed as clinically indicated
An ankle series should include the following minimum imagesPeroneus tendons - long trans + peroneus brevis insertionCalcaneo-fibular ligamentAnterior talo-fibula ligamentTibio-Fibula ligamentExtensor digitorum tendonExtensor hallucis longus tendonTibialis anterior tendonTibialis posterior tendonFlexor digitorum tendonFlexor hallucis longusAchilles tendon and retro calcaneal bursaDocument the normal anatomy Any pathology found in 2 planes(ligament tears or thickening synovial bulgingcysts joint effusion gross bony changes) including measurements and any vascularity
MAIN INDICATIONS OFTHE ANKLE ULTRASONOGRAPHIC STUDY
Tendon pathology of the different compartments
of the ankle
bull Evaluation of ligament injuries
bull Bone and joint disorders (synovitis chondral
and osteochondral lesions occult fractures)
bull Retroachilles and preachilles bursitis
bull Characterization of tumors (accessory muscles ganglia
neurogenic tumours soft tissue abscesses etc)
bull Localization of foreign bodies
ABNORMALITIES OF TENDONS
Tendon injuries include tenosynovitis tendinosis
rupture and instability
POSTERIOR COMPARTMENTACHILLES TENDINOPATHY
Can be classified as tendinosis and paratendinitis The isolated
paratendinitis shows intratendinous normal structure exist paratendinitis
spill shown irregularities in the edges of the tendon adhesions and
scarring associated paratendon and a heterogeneous aspect preachilles
fat pad In the tendinosis there is in swelling of the tendon usually
bilateral and textural heterogeneity intratendinous focal hypoechoic areas
TEAR OF ACHILLESThe rupture site is located generally between the 2 and 6 cm from the insertion into the calcaneous in the called critical zone of relative hypovascularityIn ultrasound complete rupture of the Achilles tendon is seen as a focal defect
between the broken ends of the tendon In the acute phase ends are contiguous but the defect may be filled by the anechoic or hypoechoic hematoma In most cases paratendon remains intact as a envelope straight echogenic contouring breakage As a sign associated can exist distortion of the fibrillar configuration and loss of parallelism of the tendon fibers Other signs are indicative fat herniation into the defect better visualization of the plantar tendon and the existence of a posterior acoustic shadowing at the site of the tear (useful sign to differentiate partial thickness tears)
Complete rupture of the Achilles tendon with focal defect between
the ends of the tendon and posterior acoustic shadowing at the
site of the tear useful sign to differentiate partial thickness tears
Patient with psoriasis which identifies tendinosis and Achilles tendon swelling
bilateral and textural heterogeneity with intratendinous focal hypoechoic areas
Ultrasound and radiological correlation calcified Achilles
enthesitis Calcaneal spur as associated finding
Discreetly thickened right Achilles tendon at its insertion combining linear hyperechoic
and hypoechoic areas on small breaks intrasubstance and calcifications of the enthesis
Fat herniation into the defect by complete tear of the Achilles tendon
Complete tear of the Achilles tendon with retraction
of ends and integrity thin plantaris tendon
Tendinosis versus partial tear of Achilles tendon
bullPREACHILLES AND RETROACHILLES BURSITIS
Although bursitis can occur in isolation often are
related and systemic inflammatory diseases
In the ultrasound examination the distended
retrocalcaneal and preachilles appears are a
hypoechoic structure shaped coma interposed
between the Achilles tendon and the posterosuperior
aspect of the calcaneous Care must be taken not to
confuse it with the fatty space Kager containing oval
lobules of hyperechoic fat When bursitis is a
manifestation of synovitis is appreciated
hypervascular area with Doppler ultrasound
In the retroachilles bursitis exists thickening and
collection of fluid in the subcutaneous tissue
superficial to the tendon retrocalcaneal portion
Bursitis preachilles with typical morphology appreciating accumulation of fluid
in a coma between the anterior portion of the Achilles tendon and the calcaneous
Bursitis preachiacutelea that associated synovitis showing hyperemia with increased Doppler flow
Rheumatoid arthritis with retrocalcaneal bursitis (1) and calcaneal erosions (2)
ACCESSORY NAVICULAR BONEIn the distal insertion site may exist TP 2 types of bones
accessories
Accessory navicular bone type I (os tibiale externum) size
between the 2 and 6 mm can be contained within the TP and
being positioned immediately proximal posteromedial to the
navicular bone It generally produces symptoms and should
not be confused with a tendon calcification or avulsion
fracture
Type II accessory navicular bone is an accessory
ossification centre of the navicular bone with size between
9 and 12 mm triangular shaped and articulated through a
synchondrosis of the posterior and medial navicular bone
It insertion site of some fibers of TP and is associated with a
syndrome of pain and increased incidence of tendon rupture
caused by abnormal overloads Osteoarthritic changes may
underlie this synchondrosis which mimic tendon pathology
Accessory navicular bone within the posterior tibial tendon as anatomical variant
ANTERIOR COMPARTMENTThe tendons of the anterior ankle compared
with the rest of the ankle tendons are rarely
affected by disease The anterior tibial tendon
is the most prone to abnormalities like
tendinopathy tenosynovitis and its place
between the most frequent rupture is extensor
retinaculum and insertion into the first
cuneiform and the base of the first metatarsal
Sometimes the retracted tendon stump causes
a nodule on the anteromedial aspect of the
distal portion of the leg making clinically
confused with a tumour or cyst
Distal insertion tendinopathy of the anterior tibial tendon with increased vascularity
Tenosynovitis of the anterior tibial tendon with effusion
Anterior tibial tendon tenosynovitis with intratendinous ruptures
Anterior tibial tendon rupture with retraction of the tendon
Tenosynovitis of the extensor digitorum tendons with a synovial effusion
Tenosynovitis of the extensor digitorum tendon with hypervascularized thickened tendon and synovium and synovial fluid
Rheumatoid arthritis with tenosynovitis of the extensor digitorum and peroneal tendons
Thickening of the extensor hallucis longus tendon caused by osteosynthesis material
Multicystic non vascularized intramuscular mass in the extensor digitorum brevis muscle
LATERAL COMPARTMENTTENOSYNOVITIS OF THE PERONEAL TENDONSThe main sign of ultrasound is the presence of liquid inside the
common synovial sheath whereas usually tendinous
morphology is preserved We must differentiate tenosynovitis of
a spill within the common peroneal sheath secondary to a tear of
calcaneofibular ligament (PCL) The ultrasound diagnosis is the detection of the tendons in a lateral plane relative to the distal portion of the lateral malleolus instead of behind it The dynamic exploration foot dorsiflexion as both eversion may help identify cases of intermittent subluxation In long-standing disease can be observed fusiform thickening
of the peroneal tendons at the tip of the malleolus The complete tears of the peroneus brevis tendon (PC) and peroneus longus (PL) are rare occurring in the area of the lateral malleolus or midfoot Seen in patients with ankle sprains or history of chronic instability especially if they suffer widespread diseases (RA DM) or treated with corticosteroids The peroneal tendon ruptures causing the inability to eversion of the foot and cavus foot varus
Important thickening of both peroneal tendons (longus and brevis) associated
with moderate amount of fluid and thickening of the synovial sheath
Discreet amount of fluid in the common sheath of the peroneal tendons
associated with disorganization and a heterogeneous appearance
peroneus brevis tendon related to longitudinal rupture
Peroneal tenosynovitis and osteosynthesis
Tenosynovitis of the peroneal tendons and an intratendinous rupture of the short peroneal tendon
Intratendinous rupture and cyst in the peroneus brevis tendon
Peroneus quartus with an accessory muscle next to the peroneus longus and brevis tendons
Tumor next to the peroneal tendons that proved to be a benign fibrous mass
MEDIAL COMPARTMENT
ANOMALIES POSTERIOR TIBIAL TENDON (TP)
It is the most frequently injured in this compartment with ruptures
in asymptomatic middle-aged obese women as a result of
widespread disease (RA seronegative Spondyloarthropathy) or
associated with bone fractures It causes a gradual collapse of the
medial longitudinal arch with hindfoot valgus deformity and
excessive forefoot pronation
The presence of small vessels in inflammatory diseases
intratendinosis can simulate a fissuration tendon confusion can be ignored using colour Doppler Another possible diagnostic difficulty is when the undamaged tendon flexor digitorum longus (FLD) moves back and simulates the TP unbroken but it is smaller and in this case we only see in the groove retromalleolar 1 only tendon
Ultrasound has also proven to be an effective resource for identifying alterations associated tendon tenosynovitis serosa and hypertrophicSubluxation and dislocation anteriorly and medial TP relative to internal
malleolus is rare and valued sonographically placing the foot in dorsiflexion with forced supination
Thickening moderate amount of fluid surrounding calcifications and
hyperemia affecting the sheath and the posterior tibial tendon related
to chronic tenosynovitis in patient affects rheumatoid arthritis
Thickening moderate amount of surrounding fluid and calcifications (arrow) affecting the
posterior tibial tendon related to chronic tenosynovitis in patient affects rheumatoid arthritis
Tenosynovitis of the posterior tibial tendon caused by a bony ridge at the insertion of the retinaculum The retinaculum is thickened and the tendon subluxates
Psoriatic arthritis Ankle Grayscale examination Posterior tibial tendon on longitudinal (a) and transverse (b) scan Marked tendon sheath widening with homogeneous anechoic aspect (asterisks) of the content indicating an exudative tenosynovitis Note as the normal fibrillar echotexture is conserved Hand Flexor tendons of second finger The volar longitudinal (c) and transverse scan (d) shows a tendon sheath widening with signs of synovial proliferation presence of intense power Doppler signal surrounding the tendon and micro interruption of the margin (arrow) e Wrist Extensor carpi ulnaris tendon (sixth compartment of the extensor tendons ecu) on lateral longitudinal (e) and transverse (f) scan Chronic tenosynovitis with clear areas of low of echogenicity and loss of the continuity of tendon fibrils indicative of partial tendon tear (arrows) Moreover note the presence of power Doppler signal within the interruption indicating still activity of the inflammatory process g Dactylitis Volar longitudinal scan using the ldquoextended viewrdquo technique showing proliferative tenosynovitis of the finger flexor tendon (circle) exudative synovitis of both proximal and distal interphalangeal joint (white asterisks) and edema of the peritendinous tissue (black asterisks) TP posterior tibial tendon mm medial malleolus DP distal phalanx mp middle phalanx cu cubital bone ft flexor tendons
Tenosynovitis of the posterior tibial (1) and flexor digitorum longus tendon (2)
Tibialis Posterior Tendon rupture
Tenosynovitis of the posterior tibial tendon the flexor digitorum tendon and flexor hallucis longus tendon
Tenosynovitis of the tendons on the medial side in the left ankle
bullLIGAMENT INJURIESThe ligament partial tear ligament shows a hypoechoic
areas swollen with internal focal or diffuse In the complete
ruptures within the substance of the divided ligament rift is
observed corresponding to the hematoma hypoechoic and
the free ends of the divided ligament can be and retracted
appreciated corrugated in contrast with normal
appearance straight
Grade I Mild stretching of the ligament without breakage
or instability
Grade II Partial tearing of the ligament
Grade III Complete tearing
Degrees depending on the severity of the injury and the
place of employment
LATERAL COMPARTMENTThese injuries occur secondary to inversion sprains with internal rotation of
the foot combined with ankle plantar flexion
The anterior talar fibular ligament tears (ATFL) usually occur as isolated
involvement (70) or associated with calcaneal fibular ligament (CFL) (20-40)
but the posterior talar fibular ligament (PTFL) affects only major trauma
involving ankle dislocation
ATFL breaks is associated with breakage of the joint capsule and synovial fluid
extravasation into the anterolateral soft ankle whereas the complete tearing of
CFL can communicate the ankle joint and synovial sheath peroneal tendons
Rupture of CFL is rarely associated with superior peroneal retinaculum tear
The CFL is tensioned during dorsiflexion pulling on peroneal tendons laterally
so that absence of its displacement is sign of a complete tear
Within a damaged ligament can also observe calcifications that often
correspond to fragments of avulsion bone
During the ultrasound can be performed forced maneuvers to detect to joint
laxity and ligament injuries The anterior drawer test is performed with the feet
hanging over the edge of the examination table while the forefoot is pulled
anteriorly when the foot is in plantar flexion and inversion This maneuver
helps differentiate partial tears (grade II) of the ATFL to complete (grade III)
where the anterior displacement of the talus on the tibia open a crack in the
substance becoming more visible the ligament injury
The sindesmosys sprains are up to 10 of ankle
injuries happening in eversion and pronation
movements (like the deltoid ligament injury) and
primarily affect the anterior tibiofibular ligament (ATFL)
the failure is frequently associated with fracture of the
fibula
According to the place of employment are 4 degrees
useful for prognostic evaluation and therapeutic strategy
choice
Grade I stretch or partial tear of the ATFL
Grade II complete tearing but only the ATFL
Grade III complete tear of the ATFL and partial CFL
Grade IV complete tear of the ATFL and CFL
The grade I and II injuries usually scarred without any
significant instability whereas grade III and IV injuries
can cause chronic pain and require surgical treatment
Thickened but continued ATFL right in relation to the partial rupture
Grade 111 sprain of right ATFL
Thickened anterior talofibular ligament with calcifications and a partial rupture
Thickened tibiofibular ligament after trauma
Anterior Talofibular Ligament Partial Tear and Elastography
Tibio fibular ligament rupture with bony avulsion
Complete rupture of right ATFL
Bony avulsion with radiographic evidence as visible calcification in a grade III sprain ATFL
Moderately thickened and hypoechoic ATFL
Discontinuity of the ATFL with fluid surrounding the torn ends (arrow)
Thickening and hypoechogenicity of the fibular end of the ligament seen here passing over the subtalar joint which contains a small of fluid
Complete disruption to the tibiofibular ligament with bony irregularity of particularly the tibial margin and fluid in the gap
MEDIAL COMPARTMENTBecause of the low incidence of eversion ankle
sprains and the thickness of the deltoid ligament
is rarely injured in isolation and when the injury
does not usually full thickness Usually
accompanied by lesions of the medial malleolus
and lateral displacement of the talus with
consequent widening of the ankle mortise
Ultrasound is useful for differentiating ligament
injury of the posterior tibial tendon injury
(TP) adjacent they have similar symptoms
The inability to visualize the deltoid ligament may
indicate tear but this is not considered a reliable
sign as its full ultrasound is not always possible
Partial medial ligament rupture
Thickened heterogeneous abnormal deltoid demonstrating hyperemia
Ultrasonogram showing a disrupted deltoid ligament with the probe in the coronal plane The white arrow indicates the medial malleolus the blue arrow indicates the talus and the red arrows indicate the disrupted deltoid ligament (A) Radiograph showing the same injury (B)
bullJOINT AND BONE DISORDERSUltrasound reliably detect spills mild (gt 2 ml) inside
of the ankle joint by exploring the front and rear
recess as well as areas of synovial proliferation and
may even display using the colour Doppler
hyperemic areas in arthritis patients
The intraarticular joints are displayed surrounded
fluid in one of the recesses of the ankle or subtalar
joint Sonographically diagnosed when changing position to perform flexion and extension Fracture of the lateral process of the talus is overlooked up to 50 of cases with plain radiography Ultrasound may suspect the presence of focal cortical disruption helping further to exclude concomitant ligament injury
Rheumatoid arthritis with synovial thickening (1) and erosion of the tibia (2)
Infectious arthritis with a pus filled anterior recess of the ankle
Arthritis and tenosynovitis of the ankle in a patient with rheumatoid arthritis
bullTUMOURSUltrasound can differentiate between a mass complex
and solid and a cystic in addition to verifying the
existence of accessory muscles (peroneus fourth
accessory flexor digitorum longus and accessory
soleus) As in any other location can be found
neoformative soft tissue tumors inflammatory
infectious etc
Ganglions of this location are more often symptomatic
and larger with multiple partitions
branched and lobed edges Differential diagnosis must
be made with tenosynovitis abscesses seromas and
varicosities
Neurogenic tumours are described as pathognomonic
homogeneous hypoechoic oval mass in continuity with
a nerve of origin
Ganglion cysts are non-malignant cystic masses that occur in association with musculoskeletal structures They are sometimes also simply referred to as ganglia or a ganglion but should not be confused with the anatomical term ganglion UltrasoundThe vast majority are anechoic to hypoechoic on ultrasound and have well defined margins Many demonstrate internal septations as well as acoustic enhancement A synovial cyst is a small fluid-filled sac or pouch that can develop over a tendon or joint creating a mass under the skin Synovial cyst is rare in ankle joint A synovial cyst may or may not be painful depending on their size and location
Ganglion cyst in the foot with bony erosion between navicular and cuneiform bones
Tarsal synovial cyst
Anechoic ganglion situated in the sinus tarsi fat between the talus and calcaneous
Plantar fasciitis (PF) refers to inflammation of the
plantar fascia of the foot It is considered the most common cause of heel pain
Clinical presentation Pain on the undersurface of the heel on weight bearing is the principal complaint It can be worse when weight is borne after a period of rest (eg in the morning) and eases with walking Passive dorsiflexion of the toes may exacerbates discomfort
UltrasoundOften the initial imaging modality of choice Ultrasound typically shows increased thickness of the fascia and a hypoechoic fascia
Thickened hypoechoic origin of the plantar fascia which has a convex superior margin
Complete avulsion of the plantar fascia from the calcaneal tubercle
Plantar fasciitis
bull LOCATING FOREIGN BODIES AND FRACTURES
As in any other location the ankle
area is also subsidiary host foreign
whose classification location and
existence can be defined perfectly by
ultrasound Being a focused study to
the area of interest and with great
resolution for surface structures can
be considered more resolute
examination to screen these cases
Osseous diseases and fractures | Sonography discovered Medial Malleolus Fracture
Ultrasound examination of left ankle A Longitudinal sonogram left ankle demonstrates a wooden foreign body B Transverse view left ankle Note the hypervascularity in the inflamed area C Corresponding X-ray of left ankle Note the swelling on the lateral aspect No foreign body is visible
Thank You
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 its own tendon - the extensor hallucis)
Extensor hallucis scan plane Longitudinal extensor hallucis longus tendon
Tibialis Anterior scan plane Longitudinal Tibialis Anterior tendon
Medial AnkleTibialis Posterior tendonFlexor Digitorum tendonFlexor Hallucis Longus tendonDeltoid ligamentPosterior tibial nerve
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 amp Harry) If including the neurovascular bundle - Tom Dick And Very Nervous Harry
Deltoid Ligament scan plane Use plenty of gel and have the probe tip overlie the malleolar tip
Because of its obliquity you cannotreadily see all aspects of the ligament
Posterior AnkleAchilles tendonRetrocalcaneal (Kagers) fat-pad
Scan plane for the Achilles tendon Normal Achilles tendon longitudinal panorama
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 edema Guidance of injection aspiration or biopsy Relationship of normal anatomy and pathology to each other Some bony pathologyLIMITATIONSIt is recognised that ultrasound cannot adequately assess the deltoid ligament the ankle mortice and some inter-tarsal ligamentsEQUIPMENT SELECTION AND TECHNIQUEUse 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 TECHNIQUELATERAL 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 ANKLEPatient 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 mobilizing 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 calcaneumThe deltoid ligament Is poorly assessed with ultrasoundPosterior tibial nerve The neurovascular bundle is easily seen posterior to the medial malleolusPOSTERIOR 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 (Kagers) fat padThe calf muscles and plantaris tendon should also be assessed as clinically indicated
An ankle series should include the following minimum imagesPeroneus tendons - long trans + peroneus brevis insertionCalcaneo-fibular ligamentAnterior talo-fibula ligamentTibio-Fibula ligamentExtensor digitorum tendonExtensor hallucis longus tendonTibialis anterior tendonTibialis posterior tendonFlexor digitorum tendonFlexor hallucis longusAchilles tendon and retro calcaneal bursaDocument the normal anatomy Any pathology found in 2 planes(ligament tears or thickening synovial bulgingcysts joint effusion gross bony changes) including measurements and any vascularity
MAIN INDICATIONS OFTHE ANKLE ULTRASONOGRAPHIC STUDY
Tendon pathology of the different compartments
of the ankle
bull Evaluation of ligament injuries
bull Bone and joint disorders (synovitis chondral
and osteochondral lesions occult fractures)
bull Retroachilles and preachilles bursitis
bull Characterization of tumors (accessory muscles ganglia
neurogenic tumours soft tissue abscesses etc)
bull Localization of foreign bodies
ABNORMALITIES OF TENDONS
Tendon injuries include tenosynovitis tendinosis
rupture and instability
POSTERIOR COMPARTMENTACHILLES TENDINOPATHY
Can be classified as tendinosis and paratendinitis The isolated
paratendinitis shows intratendinous normal structure exist paratendinitis
spill shown irregularities in the edges of the tendon adhesions and
scarring associated paratendon and a heterogeneous aspect preachilles
fat pad In the tendinosis there is in swelling of the tendon usually
bilateral and textural heterogeneity intratendinous focal hypoechoic areas
TEAR OF ACHILLESThe rupture site is located generally between the 2 and 6 cm from the insertion into the calcaneous in the called critical zone of relative hypovascularityIn ultrasound complete rupture of the Achilles tendon is seen as a focal defect
between the broken ends of the tendon In the acute phase ends are contiguous but the defect may be filled by the anechoic or hypoechoic hematoma In most cases paratendon remains intact as a envelope straight echogenic contouring breakage As a sign associated can exist distortion of the fibrillar configuration and loss of parallelism of the tendon fibers Other signs are indicative fat herniation into the defect better visualization of the plantar tendon and the existence of a posterior acoustic shadowing at the site of the tear (useful sign to differentiate partial thickness tears)
Complete rupture of the Achilles tendon with focal defect between
the ends of the tendon and posterior acoustic shadowing at the
site of the tear useful sign to differentiate partial thickness tears
Patient with psoriasis which identifies tendinosis and Achilles tendon swelling
bilateral and textural heterogeneity with intratendinous focal hypoechoic areas
Ultrasound and radiological correlation calcified Achilles
enthesitis Calcaneal spur as associated finding
Discreetly thickened right Achilles tendon at its insertion combining linear hyperechoic
and hypoechoic areas on small breaks intrasubstance and calcifications of the enthesis
Fat herniation into the defect by complete tear of the Achilles tendon
Complete tear of the Achilles tendon with retraction
of ends and integrity thin plantaris tendon
Tendinosis versus partial tear of Achilles tendon
bullPREACHILLES AND RETROACHILLES BURSITIS
Although bursitis can occur in isolation often are
related and systemic inflammatory diseases
In the ultrasound examination the distended
retrocalcaneal and preachilles appears are a
hypoechoic structure shaped coma interposed
between the Achilles tendon and the posterosuperior
aspect of the calcaneous Care must be taken not to
confuse it with the fatty space Kager containing oval
lobules of hyperechoic fat When bursitis is a
manifestation of synovitis is appreciated
hypervascular area with Doppler ultrasound
In the retroachilles bursitis exists thickening and
collection of fluid in the subcutaneous tissue
superficial to the tendon retrocalcaneal portion
Bursitis preachilles with typical morphology appreciating accumulation of fluid
in a coma between the anterior portion of the Achilles tendon and the calcaneous
Bursitis preachiacutelea that associated synovitis showing hyperemia with increased Doppler flow
Rheumatoid arthritis with retrocalcaneal bursitis (1) and calcaneal erosions (2)
ACCESSORY NAVICULAR BONEIn the distal insertion site may exist TP 2 types of bones
accessories
Accessory navicular bone type I (os tibiale externum) size
between the 2 and 6 mm can be contained within the TP and
being positioned immediately proximal posteromedial to the
navicular bone It generally produces symptoms and should
not be confused with a tendon calcification or avulsion
fracture
Type II accessory navicular bone is an accessory
ossification centre of the navicular bone with size between
9 and 12 mm triangular shaped and articulated through a
synchondrosis of the posterior and medial navicular bone
It insertion site of some fibers of TP and is associated with a
syndrome of pain and increased incidence of tendon rupture
caused by abnormal overloads Osteoarthritic changes may
underlie this synchondrosis which mimic tendon pathology
Accessory navicular bone within the posterior tibial tendon as anatomical variant
ANTERIOR COMPARTMENTThe tendons of the anterior ankle compared
with the rest of the ankle tendons are rarely
affected by disease The anterior tibial tendon
is the most prone to abnormalities like
tendinopathy tenosynovitis and its place
between the most frequent rupture is extensor
retinaculum and insertion into the first
cuneiform and the base of the first metatarsal
Sometimes the retracted tendon stump causes
a nodule on the anteromedial aspect of the
distal portion of the leg making clinically
confused with a tumour or cyst
Distal insertion tendinopathy of the anterior tibial tendon with increased vascularity
Tenosynovitis of the anterior tibial tendon with effusion
Anterior tibial tendon tenosynovitis with intratendinous ruptures
Anterior tibial tendon rupture with retraction of the tendon
Tenosynovitis of the extensor digitorum tendons with a synovial effusion
Tenosynovitis of the extensor digitorum tendon with hypervascularized thickened tendon and synovium and synovial fluid
Rheumatoid arthritis with tenosynovitis of the extensor digitorum and peroneal tendons
Thickening of the extensor hallucis longus tendon caused by osteosynthesis material
Multicystic non vascularized intramuscular mass in the extensor digitorum brevis muscle
LATERAL COMPARTMENTTENOSYNOVITIS OF THE PERONEAL TENDONSThe main sign of ultrasound is the presence of liquid inside the
common synovial sheath whereas usually tendinous
morphology is preserved We must differentiate tenosynovitis of
a spill within the common peroneal sheath secondary to a tear of
calcaneofibular ligament (PCL) The ultrasound diagnosis is the detection of the tendons in a lateral plane relative to the distal portion of the lateral malleolus instead of behind it The dynamic exploration foot dorsiflexion as both eversion may help identify cases of intermittent subluxation In long-standing disease can be observed fusiform thickening
of the peroneal tendons at the tip of the malleolus The complete tears of the peroneus brevis tendon (PC) and peroneus longus (PL) are rare occurring in the area of the lateral malleolus or midfoot Seen in patients with ankle sprains or history of chronic instability especially if they suffer widespread diseases (RA DM) or treated with corticosteroids The peroneal tendon ruptures causing the inability to eversion of the foot and cavus foot varus
Important thickening of both peroneal tendons (longus and brevis) associated
with moderate amount of fluid and thickening of the synovial sheath
Discreet amount of fluid in the common sheath of the peroneal tendons
associated with disorganization and a heterogeneous appearance
peroneus brevis tendon related to longitudinal rupture
Peroneal tenosynovitis and osteosynthesis
Tenosynovitis of the peroneal tendons and an intratendinous rupture of the short peroneal tendon
Intratendinous rupture and cyst in the peroneus brevis tendon
Peroneus quartus with an accessory muscle next to the peroneus longus and brevis tendons
Tumor next to the peroneal tendons that proved to be a benign fibrous mass
MEDIAL COMPARTMENT
ANOMALIES POSTERIOR TIBIAL TENDON (TP)
It is the most frequently injured in this compartment with ruptures
in asymptomatic middle-aged obese women as a result of
widespread disease (RA seronegative Spondyloarthropathy) or
associated with bone fractures It causes a gradual collapse of the
medial longitudinal arch with hindfoot valgus deformity and
excessive forefoot pronation
The presence of small vessels in inflammatory diseases
intratendinosis can simulate a fissuration tendon confusion can be ignored using colour Doppler Another possible diagnostic difficulty is when the undamaged tendon flexor digitorum longus (FLD) moves back and simulates the TP unbroken but it is smaller and in this case we only see in the groove retromalleolar 1 only tendon
Ultrasound has also proven to be an effective resource for identifying alterations associated tendon tenosynovitis serosa and hypertrophicSubluxation and dislocation anteriorly and medial TP relative to internal
malleolus is rare and valued sonographically placing the foot in dorsiflexion with forced supination
Thickening moderate amount of fluid surrounding calcifications and
hyperemia affecting the sheath and the posterior tibial tendon related
to chronic tenosynovitis in patient affects rheumatoid arthritis
Thickening moderate amount of surrounding fluid and calcifications (arrow) affecting the
posterior tibial tendon related to chronic tenosynovitis in patient affects rheumatoid arthritis
Tenosynovitis of the posterior tibial tendon caused by a bony ridge at the insertion of the retinaculum The retinaculum is thickened and the tendon subluxates
Psoriatic arthritis Ankle Grayscale examination Posterior tibial tendon on longitudinal (a) and transverse (b) scan Marked tendon sheath widening with homogeneous anechoic aspect (asterisks) of the content indicating an exudative tenosynovitis Note as the normal fibrillar echotexture is conserved Hand Flexor tendons of second finger The volar longitudinal (c) and transverse scan (d) shows a tendon sheath widening with signs of synovial proliferation presence of intense power Doppler signal surrounding the tendon and micro interruption of the margin (arrow) e Wrist Extensor carpi ulnaris tendon (sixth compartment of the extensor tendons ecu) on lateral longitudinal (e) and transverse (f) scan Chronic tenosynovitis with clear areas of low of echogenicity and loss of the continuity of tendon fibrils indicative of partial tendon tear (arrows) Moreover note the presence of power Doppler signal within the interruption indicating still activity of the inflammatory process g Dactylitis Volar longitudinal scan using the ldquoextended viewrdquo technique showing proliferative tenosynovitis of the finger flexor tendon (circle) exudative synovitis of both proximal and distal interphalangeal joint (white asterisks) and edema of the peritendinous tissue (black asterisks) TP posterior tibial tendon mm medial malleolus DP distal phalanx mp middle phalanx cu cubital bone ft flexor tendons
Tenosynovitis of the posterior tibial (1) and flexor digitorum longus tendon (2)
Tibialis Posterior Tendon rupture
Tenosynovitis of the posterior tibial tendon the flexor digitorum tendon and flexor hallucis longus tendon
Tenosynovitis of the tendons on the medial side in the left ankle
bullLIGAMENT INJURIESThe ligament partial tear ligament shows a hypoechoic
areas swollen with internal focal or diffuse In the complete
ruptures within the substance of the divided ligament rift is
observed corresponding to the hematoma hypoechoic and
the free ends of the divided ligament can be and retracted
appreciated corrugated in contrast with normal
appearance straight
Grade I Mild stretching of the ligament without breakage
or instability
Grade II Partial tearing of the ligament
Grade III Complete tearing
Degrees depending on the severity of the injury and the
place of employment
LATERAL COMPARTMENTThese injuries occur secondary to inversion sprains with internal rotation of
the foot combined with ankle plantar flexion
The anterior talar fibular ligament tears (ATFL) usually occur as isolated
involvement (70) or associated with calcaneal fibular ligament (CFL) (20-40)
but the posterior talar fibular ligament (PTFL) affects only major trauma
involving ankle dislocation
ATFL breaks is associated with breakage of the joint capsule and synovial fluid
extravasation into the anterolateral soft ankle whereas the complete tearing of
CFL can communicate the ankle joint and synovial sheath peroneal tendons
Rupture of CFL is rarely associated with superior peroneal retinaculum tear
The CFL is tensioned during dorsiflexion pulling on peroneal tendons laterally
so that absence of its displacement is sign of a complete tear
Within a damaged ligament can also observe calcifications that often
correspond to fragments of avulsion bone
During the ultrasound can be performed forced maneuvers to detect to joint
laxity and ligament injuries The anterior drawer test is performed with the feet
hanging over the edge of the examination table while the forefoot is pulled
anteriorly when the foot is in plantar flexion and inversion This maneuver
helps differentiate partial tears (grade II) of the ATFL to complete (grade III)
where the anterior displacement of the talus on the tibia open a crack in the
substance becoming more visible the ligament injury
The sindesmosys sprains are up to 10 of ankle
injuries happening in eversion and pronation
movements (like the deltoid ligament injury) and
primarily affect the anterior tibiofibular ligament (ATFL)
the failure is frequently associated with fracture of the
fibula
According to the place of employment are 4 degrees
useful for prognostic evaluation and therapeutic strategy
choice
Grade I stretch or partial tear of the ATFL
Grade II complete tearing but only the ATFL
Grade III complete tear of the ATFL and partial CFL
Grade IV complete tear of the ATFL and CFL
The grade I and II injuries usually scarred without any
significant instability whereas grade III and IV injuries
can cause chronic pain and require surgical treatment
Thickened but continued ATFL right in relation to the partial rupture
Grade 111 sprain of right ATFL
Thickened anterior talofibular ligament with calcifications and a partial rupture
Thickened tibiofibular ligament after trauma
Anterior Talofibular Ligament Partial Tear and Elastography
Tibio fibular ligament rupture with bony avulsion
Complete rupture of right ATFL
Bony avulsion with radiographic evidence as visible calcification in a grade III sprain ATFL
Moderately thickened and hypoechoic ATFL
Discontinuity of the ATFL with fluid surrounding the torn ends (arrow)
Thickening and hypoechogenicity of the fibular end of the ligament seen here passing over the subtalar joint which contains a small of fluid
Complete disruption to the tibiofibular ligament with bony irregularity of particularly the tibial margin and fluid in the gap
MEDIAL COMPARTMENTBecause of the low incidence of eversion ankle
sprains and the thickness of the deltoid ligament
is rarely injured in isolation and when the injury
does not usually full thickness Usually
accompanied by lesions of the medial malleolus
and lateral displacement of the talus with
consequent widening of the ankle mortise
Ultrasound is useful for differentiating ligament
injury of the posterior tibial tendon injury
(TP) adjacent they have similar symptoms
The inability to visualize the deltoid ligament may
indicate tear but this is not considered a reliable
sign as its full ultrasound is not always possible
Partial medial ligament rupture
Thickened heterogeneous abnormal deltoid demonstrating hyperemia
Ultrasonogram showing a disrupted deltoid ligament with the probe in the coronal plane The white arrow indicates the medial malleolus the blue arrow indicates the talus and the red arrows indicate the disrupted deltoid ligament (A) Radiograph showing the same injury (B)
bullJOINT AND BONE DISORDERSUltrasound reliably detect spills mild (gt 2 ml) inside
of the ankle joint by exploring the front and rear
recess as well as areas of synovial proliferation and
may even display using the colour Doppler
hyperemic areas in arthritis patients
The intraarticular joints are displayed surrounded
fluid in one of the recesses of the ankle or subtalar
joint Sonographically diagnosed when changing position to perform flexion and extension Fracture of the lateral process of the talus is overlooked up to 50 of cases with plain radiography Ultrasound may suspect the presence of focal cortical disruption helping further to exclude concomitant ligament injury
Rheumatoid arthritis with synovial thickening (1) and erosion of the tibia (2)
Infectious arthritis with a pus filled anterior recess of the ankle
Arthritis and tenosynovitis of the ankle in a patient with rheumatoid arthritis
bullTUMOURSUltrasound can differentiate between a mass complex
and solid and a cystic in addition to verifying the
existence of accessory muscles (peroneus fourth
accessory flexor digitorum longus and accessory
soleus) As in any other location can be found
neoformative soft tissue tumors inflammatory
infectious etc
Ganglions of this location are more often symptomatic
and larger with multiple partitions
branched and lobed edges Differential diagnosis must
be made with tenosynovitis abscesses seromas and
varicosities
Neurogenic tumours are described as pathognomonic
homogeneous hypoechoic oval mass in continuity with
a nerve of origin
Ganglion cysts are non-malignant cystic masses that occur in association with musculoskeletal structures They are sometimes also simply referred to as ganglia or a ganglion but should not be confused with the anatomical term ganglion UltrasoundThe vast majority are anechoic to hypoechoic on ultrasound and have well defined margins Many demonstrate internal septations as well as acoustic enhancement A synovial cyst is a small fluid-filled sac or pouch that can develop over a tendon or joint creating a mass under the skin Synovial cyst is rare in ankle joint A synovial cyst may or may not be painful depending on their size and location
Ganglion cyst in the foot with bony erosion between navicular and cuneiform bones
Tarsal synovial cyst
Anechoic ganglion situated in the sinus tarsi fat between the talus and calcaneous
Plantar fasciitis (PF) refers to inflammation of the
plantar fascia of the foot It is considered the most common cause of heel pain
Clinical presentation Pain on the undersurface of the heel on weight bearing is the principal complaint It can be worse when weight is borne after a period of rest (eg in the morning) and eases with walking Passive dorsiflexion of the toes may exacerbates discomfort
UltrasoundOften the initial imaging modality of choice Ultrasound typically shows increased thickness of the fascia and a hypoechoic fascia
Thickened hypoechoic origin of the plantar fascia which has a convex superior margin
Complete avulsion of the plantar fascia from the calcaneal tubercle
Plantar fasciitis
bull LOCATING FOREIGN BODIES AND FRACTURES
As in any other location the ankle
area is also subsidiary host foreign
whose classification location and
existence can be defined perfectly by
ultrasound Being a focused study to
the area of interest and with great
resolution for surface structures can
be considered more resolute
examination to screen these cases
Osseous diseases and fractures | Sonography discovered Medial Malleolus Fracture
Ultrasound examination of left ankle A Longitudinal sonogram left ankle demonstrates a wooden foreign body B Transverse view left ankle Note the hypervascularity in the inflamed area C Corresponding X-ray of left ankle Note the swelling on the lateral aspect No foreign body is visible
Thank You
Extensor hallucis scan plane Longitudinal extensor hallucis longus tendon
Tibialis Anterior scan plane Longitudinal Tibialis Anterior tendon
Medial AnkleTibialis Posterior tendonFlexor Digitorum tendonFlexor Hallucis Longus tendonDeltoid ligamentPosterior tibial nerve
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 amp Harry) If including the neurovascular bundle - Tom Dick And Very Nervous Harry
Deltoid Ligament scan plane Use plenty of gel and have the probe tip overlie the malleolar tip
Because of its obliquity you cannotreadily see all aspects of the ligament
Posterior AnkleAchilles tendonRetrocalcaneal (Kagers) fat-pad
Scan plane for the Achilles tendon Normal Achilles tendon longitudinal panorama
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 edema Guidance of injection aspiration or biopsy Relationship of normal anatomy and pathology to each other Some bony pathologyLIMITATIONSIt is recognised that ultrasound cannot adequately assess the deltoid ligament the ankle mortice and some inter-tarsal ligamentsEQUIPMENT SELECTION AND TECHNIQUEUse 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 TECHNIQUELATERAL 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 ANKLEPatient 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 mobilizing 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 calcaneumThe deltoid ligament Is poorly assessed with ultrasoundPosterior tibial nerve The neurovascular bundle is easily seen posterior to the medial malleolusPOSTERIOR 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 (Kagers) fat padThe calf muscles and plantaris tendon should also be assessed as clinically indicated
An ankle series should include the following minimum imagesPeroneus tendons - long trans + peroneus brevis insertionCalcaneo-fibular ligamentAnterior talo-fibula ligamentTibio-Fibula ligamentExtensor digitorum tendonExtensor hallucis longus tendonTibialis anterior tendonTibialis posterior tendonFlexor digitorum tendonFlexor hallucis longusAchilles tendon and retro calcaneal bursaDocument the normal anatomy Any pathology found in 2 planes(ligament tears or thickening synovial bulgingcysts joint effusion gross bony changes) including measurements and any vascularity
MAIN INDICATIONS OFTHE ANKLE ULTRASONOGRAPHIC STUDY
Tendon pathology of the different compartments
of the ankle
bull Evaluation of ligament injuries
bull Bone and joint disorders (synovitis chondral
and osteochondral lesions occult fractures)
bull Retroachilles and preachilles bursitis
bull Characterization of tumors (accessory muscles ganglia
neurogenic tumours soft tissue abscesses etc)
bull Localization of foreign bodies
ABNORMALITIES OF TENDONS
Tendon injuries include tenosynovitis tendinosis
rupture and instability
POSTERIOR COMPARTMENTACHILLES TENDINOPATHY
Can be classified as tendinosis and paratendinitis The isolated
paratendinitis shows intratendinous normal structure exist paratendinitis
spill shown irregularities in the edges of the tendon adhesions and
scarring associated paratendon and a heterogeneous aspect preachilles
fat pad In the tendinosis there is in swelling of the tendon usually
bilateral and textural heterogeneity intratendinous focal hypoechoic areas
TEAR OF ACHILLESThe rupture site is located generally between the 2 and 6 cm from the insertion into the calcaneous in the called critical zone of relative hypovascularityIn ultrasound complete rupture of the Achilles tendon is seen as a focal defect
between the broken ends of the tendon In the acute phase ends are contiguous but the defect may be filled by the anechoic or hypoechoic hematoma In most cases paratendon remains intact as a envelope straight echogenic contouring breakage As a sign associated can exist distortion of the fibrillar configuration and loss of parallelism of the tendon fibers Other signs are indicative fat herniation into the defect better visualization of the plantar tendon and the existence of a posterior acoustic shadowing at the site of the tear (useful sign to differentiate partial thickness tears)
Complete rupture of the Achilles tendon with focal defect between
the ends of the tendon and posterior acoustic shadowing at the
site of the tear useful sign to differentiate partial thickness tears
Patient with psoriasis which identifies tendinosis and Achilles tendon swelling
bilateral and textural heterogeneity with intratendinous focal hypoechoic areas
Ultrasound and radiological correlation calcified Achilles
enthesitis Calcaneal spur as associated finding
Discreetly thickened right Achilles tendon at its insertion combining linear hyperechoic
and hypoechoic areas on small breaks intrasubstance and calcifications of the enthesis
Fat herniation into the defect by complete tear of the Achilles tendon
Complete tear of the Achilles tendon with retraction
of ends and integrity thin plantaris tendon
Tendinosis versus partial tear of Achilles tendon
bullPREACHILLES AND RETROACHILLES BURSITIS
Although bursitis can occur in isolation often are
related and systemic inflammatory diseases
In the ultrasound examination the distended
retrocalcaneal and preachilles appears are a
hypoechoic structure shaped coma interposed
between the Achilles tendon and the posterosuperior
aspect of the calcaneous Care must be taken not to
confuse it with the fatty space Kager containing oval
lobules of hyperechoic fat When bursitis is a
manifestation of synovitis is appreciated
hypervascular area with Doppler ultrasound
In the retroachilles bursitis exists thickening and
collection of fluid in the subcutaneous tissue
superficial to the tendon retrocalcaneal portion
Bursitis preachilles with typical morphology appreciating accumulation of fluid
in a coma between the anterior portion of the Achilles tendon and the calcaneous
Bursitis preachiacutelea that associated synovitis showing hyperemia with increased Doppler flow
Rheumatoid arthritis with retrocalcaneal bursitis (1) and calcaneal erosions (2)
ACCESSORY NAVICULAR BONEIn the distal insertion site may exist TP 2 types of bones
accessories
Accessory navicular bone type I (os tibiale externum) size
between the 2 and 6 mm can be contained within the TP and
being positioned immediately proximal posteromedial to the
navicular bone It generally produces symptoms and should
not be confused with a tendon calcification or avulsion
fracture
Type II accessory navicular bone is an accessory
ossification centre of the navicular bone with size between
9 and 12 mm triangular shaped and articulated through a
synchondrosis of the posterior and medial navicular bone
It insertion site of some fibers of TP and is associated with a
syndrome of pain and increased incidence of tendon rupture
caused by abnormal overloads Osteoarthritic changes may
underlie this synchondrosis which mimic tendon pathology
Accessory navicular bone within the posterior tibial tendon as anatomical variant
ANTERIOR COMPARTMENTThe tendons of the anterior ankle compared
with the rest of the ankle tendons are rarely
affected by disease The anterior tibial tendon
is the most prone to abnormalities like
tendinopathy tenosynovitis and its place
between the most frequent rupture is extensor
retinaculum and insertion into the first
cuneiform and the base of the first metatarsal
Sometimes the retracted tendon stump causes
a nodule on the anteromedial aspect of the
distal portion of the leg making clinically
confused with a tumour or cyst
Distal insertion tendinopathy of the anterior tibial tendon with increased vascularity
Tenosynovitis of the anterior tibial tendon with effusion
Anterior tibial tendon tenosynovitis with intratendinous ruptures
Anterior tibial tendon rupture with retraction of the tendon
Tenosynovitis of the extensor digitorum tendons with a synovial effusion
Tenosynovitis of the extensor digitorum tendon with hypervascularized thickened tendon and synovium and synovial fluid
Rheumatoid arthritis with tenosynovitis of the extensor digitorum and peroneal tendons
Thickening of the extensor hallucis longus tendon caused by osteosynthesis material
Multicystic non vascularized intramuscular mass in the extensor digitorum brevis muscle
LATERAL COMPARTMENTTENOSYNOVITIS OF THE PERONEAL TENDONSThe main sign of ultrasound is the presence of liquid inside the
common synovial sheath whereas usually tendinous
morphology is preserved We must differentiate tenosynovitis of
a spill within the common peroneal sheath secondary to a tear of
calcaneofibular ligament (PCL) The ultrasound diagnosis is the detection of the tendons in a lateral plane relative to the distal portion of the lateral malleolus instead of behind it The dynamic exploration foot dorsiflexion as both eversion may help identify cases of intermittent subluxation In long-standing disease can be observed fusiform thickening
of the peroneal tendons at the tip of the malleolus The complete tears of the peroneus brevis tendon (PC) and peroneus longus (PL) are rare occurring in the area of the lateral malleolus or midfoot Seen in patients with ankle sprains or history of chronic instability especially if they suffer widespread diseases (RA DM) or treated with corticosteroids The peroneal tendon ruptures causing the inability to eversion of the foot and cavus foot varus
Important thickening of both peroneal tendons (longus and brevis) associated
with moderate amount of fluid and thickening of the synovial sheath
Discreet amount of fluid in the common sheath of the peroneal tendons
associated with disorganization and a heterogeneous appearance
peroneus brevis tendon related to longitudinal rupture
Peroneal tenosynovitis and osteosynthesis
Tenosynovitis of the peroneal tendons and an intratendinous rupture of the short peroneal tendon
Intratendinous rupture and cyst in the peroneus brevis tendon
Peroneus quartus with an accessory muscle next to the peroneus longus and brevis tendons
Tumor next to the peroneal tendons that proved to be a benign fibrous mass
MEDIAL COMPARTMENT
ANOMALIES POSTERIOR TIBIAL TENDON (TP)
It is the most frequently injured in this compartment with ruptures
in asymptomatic middle-aged obese women as a result of
widespread disease (RA seronegative Spondyloarthropathy) or
associated with bone fractures It causes a gradual collapse of the
medial longitudinal arch with hindfoot valgus deformity and
excessive forefoot pronation
The presence of small vessels in inflammatory diseases
intratendinosis can simulate a fissuration tendon confusion can be ignored using colour Doppler Another possible diagnostic difficulty is when the undamaged tendon flexor digitorum longus (FLD) moves back and simulates the TP unbroken but it is smaller and in this case we only see in the groove retromalleolar 1 only tendon
Ultrasound has also proven to be an effective resource for identifying alterations associated tendon tenosynovitis serosa and hypertrophicSubluxation and dislocation anteriorly and medial TP relative to internal
malleolus is rare and valued sonographically placing the foot in dorsiflexion with forced supination
Thickening moderate amount of fluid surrounding calcifications and
hyperemia affecting the sheath and the posterior tibial tendon related
to chronic tenosynovitis in patient affects rheumatoid arthritis
Thickening moderate amount of surrounding fluid and calcifications (arrow) affecting the
posterior tibial tendon related to chronic tenosynovitis in patient affects rheumatoid arthritis
Tenosynovitis of the posterior tibial tendon caused by a bony ridge at the insertion of the retinaculum The retinaculum is thickened and the tendon subluxates
Psoriatic arthritis Ankle Grayscale examination Posterior tibial tendon on longitudinal (a) and transverse (b) scan Marked tendon sheath widening with homogeneous anechoic aspect (asterisks) of the content indicating an exudative tenosynovitis Note as the normal fibrillar echotexture is conserved Hand Flexor tendons of second finger The volar longitudinal (c) and transverse scan (d) shows a tendon sheath widening with signs of synovial proliferation presence of intense power Doppler signal surrounding the tendon and micro interruption of the margin (arrow) e Wrist Extensor carpi ulnaris tendon (sixth compartment of the extensor tendons ecu) on lateral longitudinal (e) and transverse (f) scan Chronic tenosynovitis with clear areas of low of echogenicity and loss of the continuity of tendon fibrils indicative of partial tendon tear (arrows) Moreover note the presence of power Doppler signal within the interruption indicating still activity of the inflammatory process g Dactylitis Volar longitudinal scan using the ldquoextended viewrdquo technique showing proliferative tenosynovitis of the finger flexor tendon (circle) exudative synovitis of both proximal and distal interphalangeal joint (white asterisks) and edema of the peritendinous tissue (black asterisks) TP posterior tibial tendon mm medial malleolus DP distal phalanx mp middle phalanx cu cubital bone ft flexor tendons
Tenosynovitis of the posterior tibial (1) and flexor digitorum longus tendon (2)
Tibialis Posterior Tendon rupture
Tenosynovitis of the posterior tibial tendon the flexor digitorum tendon and flexor hallucis longus tendon
Tenosynovitis of the tendons on the medial side in the left ankle
bullLIGAMENT INJURIESThe ligament partial tear ligament shows a hypoechoic
areas swollen with internal focal or diffuse In the complete
ruptures within the substance of the divided ligament rift is
observed corresponding to the hematoma hypoechoic and
the free ends of the divided ligament can be and retracted
appreciated corrugated in contrast with normal
appearance straight
Grade I Mild stretching of the ligament without breakage
or instability
Grade II Partial tearing of the ligament
Grade III Complete tearing
Degrees depending on the severity of the injury and the
place of employment
LATERAL COMPARTMENTThese injuries occur secondary to inversion sprains with internal rotation of
the foot combined with ankle plantar flexion
The anterior talar fibular ligament tears (ATFL) usually occur as isolated
involvement (70) or associated with calcaneal fibular ligament (CFL) (20-40)
but the posterior talar fibular ligament (PTFL) affects only major trauma
involving ankle dislocation
ATFL breaks is associated with breakage of the joint capsule and synovial fluid
extravasation into the anterolateral soft ankle whereas the complete tearing of
CFL can communicate the ankle joint and synovial sheath peroneal tendons
Rupture of CFL is rarely associated with superior peroneal retinaculum tear
The CFL is tensioned during dorsiflexion pulling on peroneal tendons laterally
so that absence of its displacement is sign of a complete tear
Within a damaged ligament can also observe calcifications that often
correspond to fragments of avulsion bone
During the ultrasound can be performed forced maneuvers to detect to joint
laxity and ligament injuries The anterior drawer test is performed with the feet
hanging over the edge of the examination table while the forefoot is pulled
anteriorly when the foot is in plantar flexion and inversion This maneuver
helps differentiate partial tears (grade II) of the ATFL to complete (grade III)
where the anterior displacement of the talus on the tibia open a crack in the
substance becoming more visible the ligament injury
The sindesmosys sprains are up to 10 of ankle
injuries happening in eversion and pronation
movements (like the deltoid ligament injury) and
primarily affect the anterior tibiofibular ligament (ATFL)
the failure is frequently associated with fracture of the
fibula
According to the place of employment are 4 degrees
useful for prognostic evaluation and therapeutic strategy
choice
Grade I stretch or partial tear of the ATFL
Grade II complete tearing but only the ATFL
Grade III complete tear of the ATFL and partial CFL
Grade IV complete tear of the ATFL and CFL
The grade I and II injuries usually scarred without any
significant instability whereas grade III and IV injuries
can cause chronic pain and require surgical treatment
Thickened but continued ATFL right in relation to the partial rupture
Grade 111 sprain of right ATFL
Thickened anterior talofibular ligament with calcifications and a partial rupture
Thickened tibiofibular ligament after trauma
Anterior Talofibular Ligament Partial Tear and Elastography
Tibio fibular ligament rupture with bony avulsion
Complete rupture of right ATFL
Bony avulsion with radiographic evidence as visible calcification in a grade III sprain ATFL
Moderately thickened and hypoechoic ATFL
Discontinuity of the ATFL with fluid surrounding the torn ends (arrow)
Thickening and hypoechogenicity of the fibular end of the ligament seen here passing over the subtalar joint which contains a small of fluid
Complete disruption to the tibiofibular ligament with bony irregularity of particularly the tibial margin and fluid in the gap
MEDIAL COMPARTMENTBecause of the low incidence of eversion ankle
sprains and the thickness of the deltoid ligament
is rarely injured in isolation and when the injury
does not usually full thickness Usually
accompanied by lesions of the medial malleolus
and lateral displacement of the talus with
consequent widening of the ankle mortise
Ultrasound is useful for differentiating ligament
injury of the posterior tibial tendon injury
(TP) adjacent they have similar symptoms
The inability to visualize the deltoid ligament may
indicate tear but this is not considered a reliable
sign as its full ultrasound is not always possible
Partial medial ligament rupture
Thickened heterogeneous abnormal deltoid demonstrating hyperemia
Ultrasonogram showing a disrupted deltoid ligament with the probe in the coronal plane The white arrow indicates the medial malleolus the blue arrow indicates the talus and the red arrows indicate the disrupted deltoid ligament (A) Radiograph showing the same injury (B)
bullJOINT AND BONE DISORDERSUltrasound reliably detect spills mild (gt 2 ml) inside
of the ankle joint by exploring the front and rear
recess as well as areas of synovial proliferation and
may even display using the colour Doppler
hyperemic areas in arthritis patients
The intraarticular joints are displayed surrounded
fluid in one of the recesses of the ankle or subtalar
joint Sonographically diagnosed when changing position to perform flexion and extension Fracture of the lateral process of the talus is overlooked up to 50 of cases with plain radiography Ultrasound may suspect the presence of focal cortical disruption helping further to exclude concomitant ligament injury
Rheumatoid arthritis with synovial thickening (1) and erosion of the tibia (2)
Infectious arthritis with a pus filled anterior recess of the ankle
Arthritis and tenosynovitis of the ankle in a patient with rheumatoid arthritis
bullTUMOURSUltrasound can differentiate between a mass complex
and solid and a cystic in addition to verifying the
existence of accessory muscles (peroneus fourth
accessory flexor digitorum longus and accessory
soleus) As in any other location can be found
neoformative soft tissue tumors inflammatory
infectious etc
Ganglions of this location are more often symptomatic
and larger with multiple partitions
branched and lobed edges Differential diagnosis must
be made with tenosynovitis abscesses seromas and
varicosities
Neurogenic tumours are described as pathognomonic
homogeneous hypoechoic oval mass in continuity with
a nerve of origin
Ganglion cysts are non-malignant cystic masses that occur in association with musculoskeletal structures They are sometimes also simply referred to as ganglia or a ganglion but should not be confused with the anatomical term ganglion UltrasoundThe vast majority are anechoic to hypoechoic on ultrasound and have well defined margins Many demonstrate internal septations as well as acoustic enhancement A synovial cyst is a small fluid-filled sac or pouch that can develop over a tendon or joint creating a mass under the skin Synovial cyst is rare in ankle joint A synovial cyst may or may not be painful depending on their size and location
Ganglion cyst in the foot with bony erosion between navicular and cuneiform bones
Tarsal synovial cyst
Anechoic ganglion situated in the sinus tarsi fat between the talus and calcaneous
Plantar fasciitis (PF) refers to inflammation of the
plantar fascia of the foot It is considered the most common cause of heel pain
Clinical presentation Pain on the undersurface of the heel on weight bearing is the principal complaint It can be worse when weight is borne after a period of rest (eg in the morning) and eases with walking Passive dorsiflexion of the toes may exacerbates discomfort
UltrasoundOften the initial imaging modality of choice Ultrasound typically shows increased thickness of the fascia and a hypoechoic fascia
Thickened hypoechoic origin of the plantar fascia which has a convex superior margin
Complete avulsion of the plantar fascia from the calcaneal tubercle
Plantar fasciitis
bull LOCATING FOREIGN BODIES AND FRACTURES
As in any other location the ankle
area is also subsidiary host foreign
whose classification location and
existence can be defined perfectly by
ultrasound Being a focused study to
the area of interest and with great
resolution for surface structures can
be considered more resolute
examination to screen these cases
Osseous diseases and fractures | Sonography discovered Medial Malleolus Fracture
Ultrasound examination of left ankle A Longitudinal sonogram left ankle demonstrates a wooden foreign body B Transverse view left ankle Note the hypervascularity in the inflamed area C Corresponding X-ray of left ankle Note the swelling on the lateral aspect No foreign body is visible
Thank You
Tibialis Anterior scan plane Longitudinal Tibialis Anterior tendon
Medial AnkleTibialis Posterior tendonFlexor Digitorum tendonFlexor Hallucis Longus tendonDeltoid ligamentPosterior tibial nerve
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 amp Harry) If including the neurovascular bundle - Tom Dick And Very Nervous Harry
Deltoid Ligament scan plane Use plenty of gel and have the probe tip overlie the malleolar tip
Because of its obliquity you cannotreadily see all aspects of the ligament
Posterior AnkleAchilles tendonRetrocalcaneal (Kagers) fat-pad
Scan plane for the Achilles tendon Normal Achilles tendon longitudinal panorama
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 edema Guidance of injection aspiration or biopsy Relationship of normal anatomy and pathology to each other Some bony pathologyLIMITATIONSIt is recognised that ultrasound cannot adequately assess the deltoid ligament the ankle mortice and some inter-tarsal ligamentsEQUIPMENT SELECTION AND TECHNIQUEUse 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 TECHNIQUELATERAL 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 ANKLEPatient 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 mobilizing 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 calcaneumThe deltoid ligament Is poorly assessed with ultrasoundPosterior tibial nerve The neurovascular bundle is easily seen posterior to the medial malleolusPOSTERIOR 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 (Kagers) fat padThe calf muscles and plantaris tendon should also be assessed as clinically indicated
An ankle series should include the following minimum imagesPeroneus tendons - long trans + peroneus brevis insertionCalcaneo-fibular ligamentAnterior talo-fibula ligamentTibio-Fibula ligamentExtensor digitorum tendonExtensor hallucis longus tendonTibialis anterior tendonTibialis posterior tendonFlexor digitorum tendonFlexor hallucis longusAchilles tendon and retro calcaneal bursaDocument the normal anatomy Any pathology found in 2 planes(ligament tears or thickening synovial bulgingcysts joint effusion gross bony changes) including measurements and any vascularity
MAIN INDICATIONS OFTHE ANKLE ULTRASONOGRAPHIC STUDY
Tendon pathology of the different compartments
of the ankle
bull Evaluation of ligament injuries
bull Bone and joint disorders (synovitis chondral
and osteochondral lesions occult fractures)
bull Retroachilles and preachilles bursitis
bull Characterization of tumors (accessory muscles ganglia
neurogenic tumours soft tissue abscesses etc)
bull Localization of foreign bodies
ABNORMALITIES OF TENDONS
Tendon injuries include tenosynovitis tendinosis
rupture and instability
POSTERIOR COMPARTMENTACHILLES TENDINOPATHY
Can be classified as tendinosis and paratendinitis The isolated
paratendinitis shows intratendinous normal structure exist paratendinitis
spill shown irregularities in the edges of the tendon adhesions and
scarring associated paratendon and a heterogeneous aspect preachilles
fat pad In the tendinosis there is in swelling of the tendon usually
bilateral and textural heterogeneity intratendinous focal hypoechoic areas
TEAR OF ACHILLESThe rupture site is located generally between the 2 and 6 cm from the insertion into the calcaneous in the called critical zone of relative hypovascularityIn ultrasound complete rupture of the Achilles tendon is seen as a focal defect
between the broken ends of the tendon In the acute phase ends are contiguous but the defect may be filled by the anechoic or hypoechoic hematoma In most cases paratendon remains intact as a envelope straight echogenic contouring breakage As a sign associated can exist distortion of the fibrillar configuration and loss of parallelism of the tendon fibers Other signs are indicative fat herniation into the defect better visualization of the plantar tendon and the existence of a posterior acoustic shadowing at the site of the tear (useful sign to differentiate partial thickness tears)
Complete rupture of the Achilles tendon with focal defect between
the ends of the tendon and posterior acoustic shadowing at the
site of the tear useful sign to differentiate partial thickness tears
Patient with psoriasis which identifies tendinosis and Achilles tendon swelling
bilateral and textural heterogeneity with intratendinous focal hypoechoic areas
Ultrasound and radiological correlation calcified Achilles
enthesitis Calcaneal spur as associated finding
Discreetly thickened right Achilles tendon at its insertion combining linear hyperechoic
and hypoechoic areas on small breaks intrasubstance and calcifications of the enthesis
Fat herniation into the defect by complete tear of the Achilles tendon
Complete tear of the Achilles tendon with retraction
of ends and integrity thin plantaris tendon
Tendinosis versus partial tear of Achilles tendon
bullPREACHILLES AND RETROACHILLES BURSITIS
Although bursitis can occur in isolation often are
related and systemic inflammatory diseases
In the ultrasound examination the distended
retrocalcaneal and preachilles appears are a
hypoechoic structure shaped coma interposed
between the Achilles tendon and the posterosuperior
aspect of the calcaneous Care must be taken not to
confuse it with the fatty space Kager containing oval
lobules of hyperechoic fat When bursitis is a
manifestation of synovitis is appreciated
hypervascular area with Doppler ultrasound
In the retroachilles bursitis exists thickening and
collection of fluid in the subcutaneous tissue
superficial to the tendon retrocalcaneal portion
Bursitis preachilles with typical morphology appreciating accumulation of fluid
in a coma between the anterior portion of the Achilles tendon and the calcaneous
Bursitis preachiacutelea that associated synovitis showing hyperemia with increased Doppler flow
Rheumatoid arthritis with retrocalcaneal bursitis (1) and calcaneal erosions (2)
ACCESSORY NAVICULAR BONEIn the distal insertion site may exist TP 2 types of bones
accessories
Accessory navicular bone type I (os tibiale externum) size
between the 2 and 6 mm can be contained within the TP and
being positioned immediately proximal posteromedial to the
navicular bone It generally produces symptoms and should
not be confused with a tendon calcification or avulsion
fracture
Type II accessory navicular bone is an accessory
ossification centre of the navicular bone with size between
9 and 12 mm triangular shaped and articulated through a
synchondrosis of the posterior and medial navicular bone
It insertion site of some fibers of TP and is associated with a
syndrome of pain and increased incidence of tendon rupture
caused by abnormal overloads Osteoarthritic changes may
underlie this synchondrosis which mimic tendon pathology
Accessory navicular bone within the posterior tibial tendon as anatomical variant
ANTERIOR COMPARTMENTThe tendons of the anterior ankle compared
with the rest of the ankle tendons are rarely
affected by disease The anterior tibial tendon
is the most prone to abnormalities like
tendinopathy tenosynovitis and its place
between the most frequent rupture is extensor
retinaculum and insertion into the first
cuneiform and the base of the first metatarsal
Sometimes the retracted tendon stump causes
a nodule on the anteromedial aspect of the
distal portion of the leg making clinically
confused with a tumour or cyst
Distal insertion tendinopathy of the anterior tibial tendon with increased vascularity
Tenosynovitis of the anterior tibial tendon with effusion
Anterior tibial tendon tenosynovitis with intratendinous ruptures
Anterior tibial tendon rupture with retraction of the tendon
Tenosynovitis of the extensor digitorum tendons with a synovial effusion
Tenosynovitis of the extensor digitorum tendon with hypervascularized thickened tendon and synovium and synovial fluid
Rheumatoid arthritis with tenosynovitis of the extensor digitorum and peroneal tendons
Thickening of the extensor hallucis longus tendon caused by osteosynthesis material
Multicystic non vascularized intramuscular mass in the extensor digitorum brevis muscle
LATERAL COMPARTMENTTENOSYNOVITIS OF THE PERONEAL TENDONSThe main sign of ultrasound is the presence of liquid inside the
common synovial sheath whereas usually tendinous
morphology is preserved We must differentiate tenosynovitis of
a spill within the common peroneal sheath secondary to a tear of
calcaneofibular ligament (PCL) The ultrasound diagnosis is the detection of the tendons in a lateral plane relative to the distal portion of the lateral malleolus instead of behind it The dynamic exploration foot dorsiflexion as both eversion may help identify cases of intermittent subluxation In long-standing disease can be observed fusiform thickening
of the peroneal tendons at the tip of the malleolus The complete tears of the peroneus brevis tendon (PC) and peroneus longus (PL) are rare occurring in the area of the lateral malleolus or midfoot Seen in patients with ankle sprains or history of chronic instability especially if they suffer widespread diseases (RA DM) or treated with corticosteroids The peroneal tendon ruptures causing the inability to eversion of the foot and cavus foot varus
Important thickening of both peroneal tendons (longus and brevis) associated
with moderate amount of fluid and thickening of the synovial sheath
Discreet amount of fluid in the common sheath of the peroneal tendons
associated with disorganization and a heterogeneous appearance
peroneus brevis tendon related to longitudinal rupture
Peroneal tenosynovitis and osteosynthesis
Tenosynovitis of the peroneal tendons and an intratendinous rupture of the short peroneal tendon
Intratendinous rupture and cyst in the peroneus brevis tendon
Peroneus quartus with an accessory muscle next to the peroneus longus and brevis tendons
Tumor next to the peroneal tendons that proved to be a benign fibrous mass
MEDIAL COMPARTMENT
ANOMALIES POSTERIOR TIBIAL TENDON (TP)
It is the most frequently injured in this compartment with ruptures
in asymptomatic middle-aged obese women as a result of
widespread disease (RA seronegative Spondyloarthropathy) or
associated with bone fractures It causes a gradual collapse of the
medial longitudinal arch with hindfoot valgus deformity and
excessive forefoot pronation
The presence of small vessels in inflammatory diseases
intratendinosis can simulate a fissuration tendon confusion can be ignored using colour Doppler Another possible diagnostic difficulty is when the undamaged tendon flexor digitorum longus (FLD) moves back and simulates the TP unbroken but it is smaller and in this case we only see in the groove retromalleolar 1 only tendon
Ultrasound has also proven to be an effective resource for identifying alterations associated tendon tenosynovitis serosa and hypertrophicSubluxation and dislocation anteriorly and medial TP relative to internal
malleolus is rare and valued sonographically placing the foot in dorsiflexion with forced supination
Thickening moderate amount of fluid surrounding calcifications and
hyperemia affecting the sheath and the posterior tibial tendon related
to chronic tenosynovitis in patient affects rheumatoid arthritis
Thickening moderate amount of surrounding fluid and calcifications (arrow) affecting the
posterior tibial tendon related to chronic tenosynovitis in patient affects rheumatoid arthritis
Tenosynovitis of the posterior tibial tendon caused by a bony ridge at the insertion of the retinaculum The retinaculum is thickened and the tendon subluxates
Psoriatic arthritis Ankle Grayscale examination Posterior tibial tendon on longitudinal (a) and transverse (b) scan Marked tendon sheath widening with homogeneous anechoic aspect (asterisks) of the content indicating an exudative tenosynovitis Note as the normal fibrillar echotexture is conserved Hand Flexor tendons of second finger The volar longitudinal (c) and transverse scan (d) shows a tendon sheath widening with signs of synovial proliferation presence of intense power Doppler signal surrounding the tendon and micro interruption of the margin (arrow) e Wrist Extensor carpi ulnaris tendon (sixth compartment of the extensor tendons ecu) on lateral longitudinal (e) and transverse (f) scan Chronic tenosynovitis with clear areas of low of echogenicity and loss of the continuity of tendon fibrils indicative of partial tendon tear (arrows) Moreover note the presence of power Doppler signal within the interruption indicating still activity of the inflammatory process g Dactylitis Volar longitudinal scan using the ldquoextended viewrdquo technique showing proliferative tenosynovitis of the finger flexor tendon (circle) exudative synovitis of both proximal and distal interphalangeal joint (white asterisks) and edema of the peritendinous tissue (black asterisks) TP posterior tibial tendon mm medial malleolus DP distal phalanx mp middle phalanx cu cubital bone ft flexor tendons
Tenosynovitis of the posterior tibial (1) and flexor digitorum longus tendon (2)
Tibialis Posterior Tendon rupture
Tenosynovitis of the posterior tibial tendon the flexor digitorum tendon and flexor hallucis longus tendon
Tenosynovitis of the tendons on the medial side in the left ankle
bullLIGAMENT INJURIESThe ligament partial tear ligament shows a hypoechoic
areas swollen with internal focal or diffuse In the complete
ruptures within the substance of the divided ligament rift is
observed corresponding to the hematoma hypoechoic and
the free ends of the divided ligament can be and retracted
appreciated corrugated in contrast with normal
appearance straight
Grade I Mild stretching of the ligament without breakage
or instability
Grade II Partial tearing of the ligament
Grade III Complete tearing
Degrees depending on the severity of the injury and the
place of employment
LATERAL COMPARTMENTThese injuries occur secondary to inversion sprains with internal rotation of
the foot combined with ankle plantar flexion
The anterior talar fibular ligament tears (ATFL) usually occur as isolated
involvement (70) or associated with calcaneal fibular ligament (CFL) (20-40)
but the posterior talar fibular ligament (PTFL) affects only major trauma
involving ankle dislocation
ATFL breaks is associated with breakage of the joint capsule and synovial fluid
extravasation into the anterolateral soft ankle whereas the complete tearing of
CFL can communicate the ankle joint and synovial sheath peroneal tendons
Rupture of CFL is rarely associated with superior peroneal retinaculum tear
The CFL is tensioned during dorsiflexion pulling on peroneal tendons laterally
so that absence of its displacement is sign of a complete tear
Within a damaged ligament can also observe calcifications that often
correspond to fragments of avulsion bone
During the ultrasound can be performed forced maneuvers to detect to joint
laxity and ligament injuries The anterior drawer test is performed with the feet
hanging over the edge of the examination table while the forefoot is pulled
anteriorly when the foot is in plantar flexion and inversion This maneuver
helps differentiate partial tears (grade II) of the ATFL to complete (grade III)
where the anterior displacement of the talus on the tibia open a crack in the
substance becoming more visible the ligament injury
The sindesmosys sprains are up to 10 of ankle
injuries happening in eversion and pronation
movements (like the deltoid ligament injury) and
primarily affect the anterior tibiofibular ligament (ATFL)
the failure is frequently associated with fracture of the
fibula
According to the place of employment are 4 degrees
useful for prognostic evaluation and therapeutic strategy
choice
Grade I stretch or partial tear of the ATFL
Grade II complete tearing but only the ATFL
Grade III complete tear of the ATFL and partial CFL
Grade IV complete tear of the ATFL and CFL
The grade I and II injuries usually scarred without any
significant instability whereas grade III and IV injuries
can cause chronic pain and require surgical treatment
Thickened but continued ATFL right in relation to the partial rupture
Grade 111 sprain of right ATFL
Thickened anterior talofibular ligament with calcifications and a partial rupture
Thickened tibiofibular ligament after trauma
Anterior Talofibular Ligament Partial Tear and Elastography
Tibio fibular ligament rupture with bony avulsion
Complete rupture of right ATFL
Bony avulsion with radiographic evidence as visible calcification in a grade III sprain ATFL
Moderately thickened and hypoechoic ATFL
Discontinuity of the ATFL with fluid surrounding the torn ends (arrow)
Thickening and hypoechogenicity of the fibular end of the ligament seen here passing over the subtalar joint which contains a small of fluid
Complete disruption to the tibiofibular ligament with bony irregularity of particularly the tibial margin and fluid in the gap
MEDIAL COMPARTMENTBecause of the low incidence of eversion ankle
sprains and the thickness of the deltoid ligament
is rarely injured in isolation and when the injury
does not usually full thickness Usually
accompanied by lesions of the medial malleolus
and lateral displacement of the talus with
consequent widening of the ankle mortise
Ultrasound is useful for differentiating ligament
injury of the posterior tibial tendon injury
(TP) adjacent they have similar symptoms
The inability to visualize the deltoid ligament may
indicate tear but this is not considered a reliable
sign as its full ultrasound is not always possible
Partial medial ligament rupture
Thickened heterogeneous abnormal deltoid demonstrating hyperemia
Ultrasonogram showing a disrupted deltoid ligament with the probe in the coronal plane The white arrow indicates the medial malleolus the blue arrow indicates the talus and the red arrows indicate the disrupted deltoid ligament (A) Radiograph showing the same injury (B)
bullJOINT AND BONE DISORDERSUltrasound reliably detect spills mild (gt 2 ml) inside
of the ankle joint by exploring the front and rear
recess as well as areas of synovial proliferation and
may even display using the colour Doppler
hyperemic areas in arthritis patients
The intraarticular joints are displayed surrounded
fluid in one of the recesses of the ankle or subtalar
joint Sonographically diagnosed when changing position to perform flexion and extension Fracture of the lateral process of the talus is overlooked up to 50 of cases with plain radiography Ultrasound may suspect the presence of focal cortical disruption helping further to exclude concomitant ligament injury
Rheumatoid arthritis with synovial thickening (1) and erosion of the tibia (2)
Infectious arthritis with a pus filled anterior recess of the ankle
Arthritis and tenosynovitis of the ankle in a patient with rheumatoid arthritis
bullTUMOURSUltrasound can differentiate between a mass complex
and solid and a cystic in addition to verifying the
existence of accessory muscles (peroneus fourth
accessory flexor digitorum longus and accessory
soleus) As in any other location can be found
neoformative soft tissue tumors inflammatory
infectious etc
Ganglions of this location are more often symptomatic
and larger with multiple partitions
branched and lobed edges Differential diagnosis must
be made with tenosynovitis abscesses seromas and
varicosities
Neurogenic tumours are described as pathognomonic
homogeneous hypoechoic oval mass in continuity with
a nerve of origin
Ganglion cysts are non-malignant cystic masses that occur in association with musculoskeletal structures They are sometimes also simply referred to as ganglia or a ganglion but should not be confused with the anatomical term ganglion UltrasoundThe vast majority are anechoic to hypoechoic on ultrasound and have well defined margins Many demonstrate internal septations as well as acoustic enhancement A synovial cyst is a small fluid-filled sac or pouch that can develop over a tendon or joint creating a mass under the skin Synovial cyst is rare in ankle joint A synovial cyst may or may not be painful depending on their size and location
Ganglion cyst in the foot with bony erosion between navicular and cuneiform bones
Tarsal synovial cyst
Anechoic ganglion situated in the sinus tarsi fat between the talus and calcaneous
Plantar fasciitis (PF) refers to inflammation of the
plantar fascia of the foot It is considered the most common cause of heel pain
Clinical presentation Pain on the undersurface of the heel on weight bearing is the principal complaint It can be worse when weight is borne after a period of rest (eg in the morning) and eases with walking Passive dorsiflexion of the toes may exacerbates discomfort
UltrasoundOften the initial imaging modality of choice Ultrasound typically shows increased thickness of the fascia and a hypoechoic fascia
Thickened hypoechoic origin of the plantar fascia which has a convex superior margin
Complete avulsion of the plantar fascia from the calcaneal tubercle
Plantar fasciitis
bull LOCATING FOREIGN BODIES AND FRACTURES
As in any other location the ankle
area is also subsidiary host foreign
whose classification location and
existence can be defined perfectly by
ultrasound Being a focused study to
the area of interest and with great
resolution for surface structures can
be considered more resolute
examination to screen these cases
Osseous diseases and fractures | Sonography discovered Medial Malleolus Fracture
Ultrasound examination of left ankle A Longitudinal sonogram left ankle demonstrates a wooden foreign body B Transverse view left ankle Note the hypervascularity in the inflamed area C Corresponding X-ray of left ankle Note the swelling on the lateral aspect No foreign body is visible
Thank You
Medial AnkleTibialis Posterior tendonFlexor Digitorum tendonFlexor Hallucis Longus tendonDeltoid ligamentPosterior tibial nerve
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 amp Harry) If including the neurovascular bundle - Tom Dick And Very Nervous Harry
Deltoid Ligament scan plane Use plenty of gel and have the probe tip overlie the malleolar tip
Because of its obliquity you cannotreadily see all aspects of the ligament
Posterior AnkleAchilles tendonRetrocalcaneal (Kagers) fat-pad
Scan plane for the Achilles tendon Normal Achilles tendon longitudinal panorama
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 edema Guidance of injection aspiration or biopsy Relationship of normal anatomy and pathology to each other Some bony pathologyLIMITATIONSIt is recognised that ultrasound cannot adequately assess the deltoid ligament the ankle mortice and some inter-tarsal ligamentsEQUIPMENT SELECTION AND TECHNIQUEUse 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 TECHNIQUELATERAL 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 ANKLEPatient 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 mobilizing 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 calcaneumThe deltoid ligament Is poorly assessed with ultrasoundPosterior tibial nerve The neurovascular bundle is easily seen posterior to the medial malleolusPOSTERIOR 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 (Kagers) fat padThe calf muscles and plantaris tendon should also be assessed as clinically indicated
An ankle series should include the following minimum imagesPeroneus tendons - long trans + peroneus brevis insertionCalcaneo-fibular ligamentAnterior talo-fibula ligamentTibio-Fibula ligamentExtensor digitorum tendonExtensor hallucis longus tendonTibialis anterior tendonTibialis posterior tendonFlexor digitorum tendonFlexor hallucis longusAchilles tendon and retro calcaneal bursaDocument the normal anatomy Any pathology found in 2 planes(ligament tears or thickening synovial bulgingcysts joint effusion gross bony changes) including measurements and any vascularity
MAIN INDICATIONS OFTHE ANKLE ULTRASONOGRAPHIC STUDY
Tendon pathology of the different compartments
of the ankle
bull Evaluation of ligament injuries
bull Bone and joint disorders (synovitis chondral
and osteochondral lesions occult fractures)
bull Retroachilles and preachilles bursitis
bull Characterization of tumors (accessory muscles ganglia
neurogenic tumours soft tissue abscesses etc)
bull Localization of foreign bodies
ABNORMALITIES OF TENDONS
Tendon injuries include tenosynovitis tendinosis
rupture and instability
POSTERIOR COMPARTMENTACHILLES TENDINOPATHY
Can be classified as tendinosis and paratendinitis The isolated
paratendinitis shows intratendinous normal structure exist paratendinitis
spill shown irregularities in the edges of the tendon adhesions and
scarring associated paratendon and a heterogeneous aspect preachilles
fat pad In the tendinosis there is in swelling of the tendon usually
bilateral and textural heterogeneity intratendinous focal hypoechoic areas
TEAR OF ACHILLESThe rupture site is located generally between the 2 and 6 cm from the insertion into the calcaneous in the called critical zone of relative hypovascularityIn ultrasound complete rupture of the Achilles tendon is seen as a focal defect
between the broken ends of the tendon In the acute phase ends are contiguous but the defect may be filled by the anechoic or hypoechoic hematoma In most cases paratendon remains intact as a envelope straight echogenic contouring breakage As a sign associated can exist distortion of the fibrillar configuration and loss of parallelism of the tendon fibers Other signs are indicative fat herniation into the defect better visualization of the plantar tendon and the existence of a posterior acoustic shadowing at the site of the tear (useful sign to differentiate partial thickness tears)
Complete rupture of the Achilles tendon with focal defect between
the ends of the tendon and posterior acoustic shadowing at the
site of the tear useful sign to differentiate partial thickness tears
Patient with psoriasis which identifies tendinosis and Achilles tendon swelling
bilateral and textural heterogeneity with intratendinous focal hypoechoic areas
Ultrasound and radiological correlation calcified Achilles
enthesitis Calcaneal spur as associated finding
Discreetly thickened right Achilles tendon at its insertion combining linear hyperechoic
and hypoechoic areas on small breaks intrasubstance and calcifications of the enthesis
Fat herniation into the defect by complete tear of the Achilles tendon
Complete tear of the Achilles tendon with retraction
of ends and integrity thin plantaris tendon
Tendinosis versus partial tear of Achilles tendon
bullPREACHILLES AND RETROACHILLES BURSITIS
Although bursitis can occur in isolation often are
related and systemic inflammatory diseases
In the ultrasound examination the distended
retrocalcaneal and preachilles appears are a
hypoechoic structure shaped coma interposed
between the Achilles tendon and the posterosuperior
aspect of the calcaneous Care must be taken not to
confuse it with the fatty space Kager containing oval
lobules of hyperechoic fat When bursitis is a
manifestation of synovitis is appreciated
hypervascular area with Doppler ultrasound
In the retroachilles bursitis exists thickening and
collection of fluid in the subcutaneous tissue
superficial to the tendon retrocalcaneal portion
Bursitis preachilles with typical morphology appreciating accumulation of fluid
in a coma between the anterior portion of the Achilles tendon and the calcaneous
Bursitis preachiacutelea that associated synovitis showing hyperemia with increased Doppler flow
Rheumatoid arthritis with retrocalcaneal bursitis (1) and calcaneal erosions (2)
ACCESSORY NAVICULAR BONEIn the distal insertion site may exist TP 2 types of bones
accessories
Accessory navicular bone type I (os tibiale externum) size
between the 2 and 6 mm can be contained within the TP and
being positioned immediately proximal posteromedial to the
navicular bone It generally produces symptoms and should
not be confused with a tendon calcification or avulsion
fracture
Type II accessory navicular bone is an accessory
ossification centre of the navicular bone with size between
9 and 12 mm triangular shaped and articulated through a
synchondrosis of the posterior and medial navicular bone
It insertion site of some fibers of TP and is associated with a
syndrome of pain and increased incidence of tendon rupture
caused by abnormal overloads Osteoarthritic changes may
underlie this synchondrosis which mimic tendon pathology
Accessory navicular bone within the posterior tibial tendon as anatomical variant
ANTERIOR COMPARTMENTThe tendons of the anterior ankle compared
with the rest of the ankle tendons are rarely
affected by disease The anterior tibial tendon
is the most prone to abnormalities like
tendinopathy tenosynovitis and its place
between the most frequent rupture is extensor
retinaculum and insertion into the first
cuneiform and the base of the first metatarsal
Sometimes the retracted tendon stump causes
a nodule on the anteromedial aspect of the
distal portion of the leg making clinically
confused with a tumour or cyst
Distal insertion tendinopathy of the anterior tibial tendon with increased vascularity
Tenosynovitis of the anterior tibial tendon with effusion
Anterior tibial tendon tenosynovitis with intratendinous ruptures
Anterior tibial tendon rupture with retraction of the tendon
Tenosynovitis of the extensor digitorum tendons with a synovial effusion
Tenosynovitis of the extensor digitorum tendon with hypervascularized thickened tendon and synovium and synovial fluid
Rheumatoid arthritis with tenosynovitis of the extensor digitorum and peroneal tendons
Thickening of the extensor hallucis longus tendon caused by osteosynthesis material
Multicystic non vascularized intramuscular mass in the extensor digitorum brevis muscle
LATERAL COMPARTMENTTENOSYNOVITIS OF THE PERONEAL TENDONSThe main sign of ultrasound is the presence of liquid inside the
common synovial sheath whereas usually tendinous
morphology is preserved We must differentiate tenosynovitis of
a spill within the common peroneal sheath secondary to a tear of
calcaneofibular ligament (PCL) The ultrasound diagnosis is the detection of the tendons in a lateral plane relative to the distal portion of the lateral malleolus instead of behind it The dynamic exploration foot dorsiflexion as both eversion may help identify cases of intermittent subluxation In long-standing disease can be observed fusiform thickening
of the peroneal tendons at the tip of the malleolus The complete tears of the peroneus brevis tendon (PC) and peroneus longus (PL) are rare occurring in the area of the lateral malleolus or midfoot Seen in patients with ankle sprains or history of chronic instability especially if they suffer widespread diseases (RA DM) or treated with corticosteroids The peroneal tendon ruptures causing the inability to eversion of the foot and cavus foot varus
Important thickening of both peroneal tendons (longus and brevis) associated
with moderate amount of fluid and thickening of the synovial sheath
Discreet amount of fluid in the common sheath of the peroneal tendons
associated with disorganization and a heterogeneous appearance
peroneus brevis tendon related to longitudinal rupture
Peroneal tenosynovitis and osteosynthesis
Tenosynovitis of the peroneal tendons and an intratendinous rupture of the short peroneal tendon
Intratendinous rupture and cyst in the peroneus brevis tendon
Peroneus quartus with an accessory muscle next to the peroneus longus and brevis tendons
Tumor next to the peroneal tendons that proved to be a benign fibrous mass
MEDIAL COMPARTMENT
ANOMALIES POSTERIOR TIBIAL TENDON (TP)
It is the most frequently injured in this compartment with ruptures
in asymptomatic middle-aged obese women as a result of
widespread disease (RA seronegative Spondyloarthropathy) or
associated with bone fractures It causes a gradual collapse of the
medial longitudinal arch with hindfoot valgus deformity and
excessive forefoot pronation
The presence of small vessels in inflammatory diseases
intratendinosis can simulate a fissuration tendon confusion can be ignored using colour Doppler Another possible diagnostic difficulty is when the undamaged tendon flexor digitorum longus (FLD) moves back and simulates the TP unbroken but it is smaller and in this case we only see in the groove retromalleolar 1 only tendon
Ultrasound has also proven to be an effective resource for identifying alterations associated tendon tenosynovitis serosa and hypertrophicSubluxation and dislocation anteriorly and medial TP relative to internal
malleolus is rare and valued sonographically placing the foot in dorsiflexion with forced supination
Thickening moderate amount of fluid surrounding calcifications and
hyperemia affecting the sheath and the posterior tibial tendon related
to chronic tenosynovitis in patient affects rheumatoid arthritis
Thickening moderate amount of surrounding fluid and calcifications (arrow) affecting the
posterior tibial tendon related to chronic tenosynovitis in patient affects rheumatoid arthritis
Tenosynovitis of the posterior tibial tendon caused by a bony ridge at the insertion of the retinaculum The retinaculum is thickened and the tendon subluxates
Psoriatic arthritis Ankle Grayscale examination Posterior tibial tendon on longitudinal (a) and transverse (b) scan Marked tendon sheath widening with homogeneous anechoic aspect (asterisks) of the content indicating an exudative tenosynovitis Note as the normal fibrillar echotexture is conserved Hand Flexor tendons of second finger The volar longitudinal (c) and transverse scan (d) shows a tendon sheath widening with signs of synovial proliferation presence of intense power Doppler signal surrounding the tendon and micro interruption of the margin (arrow) e Wrist Extensor carpi ulnaris tendon (sixth compartment of the extensor tendons ecu) on lateral longitudinal (e) and transverse (f) scan Chronic tenosynovitis with clear areas of low of echogenicity and loss of the continuity of tendon fibrils indicative of partial tendon tear (arrows) Moreover note the presence of power Doppler signal within the interruption indicating still activity of the inflammatory process g Dactylitis Volar longitudinal scan using the ldquoextended viewrdquo technique showing proliferative tenosynovitis of the finger flexor tendon (circle) exudative synovitis of both proximal and distal interphalangeal joint (white asterisks) and edema of the peritendinous tissue (black asterisks) TP posterior tibial tendon mm medial malleolus DP distal phalanx mp middle phalanx cu cubital bone ft flexor tendons
Tenosynovitis of the posterior tibial (1) and flexor digitorum longus tendon (2)
Tibialis Posterior Tendon rupture
Tenosynovitis of the posterior tibial tendon the flexor digitorum tendon and flexor hallucis longus tendon
Tenosynovitis of the tendons on the medial side in the left ankle
bullLIGAMENT INJURIESThe ligament partial tear ligament shows a hypoechoic
areas swollen with internal focal or diffuse In the complete
ruptures within the substance of the divided ligament rift is
observed corresponding to the hematoma hypoechoic and
the free ends of the divided ligament can be and retracted
appreciated corrugated in contrast with normal
appearance straight
Grade I Mild stretching of the ligament without breakage
or instability
Grade II Partial tearing of the ligament
Grade III Complete tearing
Degrees depending on the severity of the injury and the
place of employment
LATERAL COMPARTMENTThese injuries occur secondary to inversion sprains with internal rotation of
the foot combined with ankle plantar flexion
The anterior talar fibular ligament tears (ATFL) usually occur as isolated
involvement (70) or associated with calcaneal fibular ligament (CFL) (20-40)
but the posterior talar fibular ligament (PTFL) affects only major trauma
involving ankle dislocation
ATFL breaks is associated with breakage of the joint capsule and synovial fluid
extravasation into the anterolateral soft ankle whereas the complete tearing of
CFL can communicate the ankle joint and synovial sheath peroneal tendons
Rupture of CFL is rarely associated with superior peroneal retinaculum tear
The CFL is tensioned during dorsiflexion pulling on peroneal tendons laterally
so that absence of its displacement is sign of a complete tear
Within a damaged ligament can also observe calcifications that often
correspond to fragments of avulsion bone
During the ultrasound can be performed forced maneuvers to detect to joint
laxity and ligament injuries The anterior drawer test is performed with the feet
hanging over the edge of the examination table while the forefoot is pulled
anteriorly when the foot is in plantar flexion and inversion This maneuver
helps differentiate partial tears (grade II) of the ATFL to complete (grade III)
where the anterior displacement of the talus on the tibia open a crack in the
substance becoming more visible the ligament injury
The sindesmosys sprains are up to 10 of ankle
injuries happening in eversion and pronation
movements (like the deltoid ligament injury) and
primarily affect the anterior tibiofibular ligament (ATFL)
the failure is frequently associated with fracture of the
fibula
According to the place of employment are 4 degrees
useful for prognostic evaluation and therapeutic strategy
choice
Grade I stretch or partial tear of the ATFL
Grade II complete tearing but only the ATFL
Grade III complete tear of the ATFL and partial CFL
Grade IV complete tear of the ATFL and CFL
The grade I and II injuries usually scarred without any
significant instability whereas grade III and IV injuries
can cause chronic pain and require surgical treatment
Thickened but continued ATFL right in relation to the partial rupture
Grade 111 sprain of right ATFL
Thickened anterior talofibular ligament with calcifications and a partial rupture
Thickened tibiofibular ligament after trauma
Anterior Talofibular Ligament Partial Tear and Elastography
Tibio fibular ligament rupture with bony avulsion
Complete rupture of right ATFL
Bony avulsion with radiographic evidence as visible calcification in a grade III sprain ATFL
Moderately thickened and hypoechoic ATFL
Discontinuity of the ATFL with fluid surrounding the torn ends (arrow)
Thickening and hypoechogenicity of the fibular end of the ligament seen here passing over the subtalar joint which contains a small of fluid
Complete disruption to the tibiofibular ligament with bony irregularity of particularly the tibial margin and fluid in the gap
MEDIAL COMPARTMENTBecause of the low incidence of eversion ankle
sprains and the thickness of the deltoid ligament
is rarely injured in isolation and when the injury
does not usually full thickness Usually
accompanied by lesions of the medial malleolus
and lateral displacement of the talus with
consequent widening of the ankle mortise
Ultrasound is useful for differentiating ligament
injury of the posterior tibial tendon injury
(TP) adjacent they have similar symptoms
The inability to visualize the deltoid ligament may
indicate tear but this is not considered a reliable
sign as its full ultrasound is not always possible
Partial medial ligament rupture
Thickened heterogeneous abnormal deltoid demonstrating hyperemia
Ultrasonogram showing a disrupted deltoid ligament with the probe in the coronal plane The white arrow indicates the medial malleolus the blue arrow indicates the talus and the red arrows indicate the disrupted deltoid ligament (A) Radiograph showing the same injury (B)
bullJOINT AND BONE DISORDERSUltrasound reliably detect spills mild (gt 2 ml) inside
of the ankle joint by exploring the front and rear
recess as well as areas of synovial proliferation and
may even display using the colour Doppler
hyperemic areas in arthritis patients
The intraarticular joints are displayed surrounded
fluid in one of the recesses of the ankle or subtalar
joint Sonographically diagnosed when changing position to perform flexion and extension Fracture of the lateral process of the talus is overlooked up to 50 of cases with plain radiography Ultrasound may suspect the presence of focal cortical disruption helping further to exclude concomitant ligament injury
Rheumatoid arthritis with synovial thickening (1) and erosion of the tibia (2)
Infectious arthritis with a pus filled anterior recess of the ankle
Arthritis and tenosynovitis of the ankle in a patient with rheumatoid arthritis
bullTUMOURSUltrasound can differentiate between a mass complex
and solid and a cystic in addition to verifying the
existence of accessory muscles (peroneus fourth
accessory flexor digitorum longus and accessory
soleus) As in any other location can be found
neoformative soft tissue tumors inflammatory
infectious etc
Ganglions of this location are more often symptomatic
and larger with multiple partitions
branched and lobed edges Differential diagnosis must
be made with tenosynovitis abscesses seromas and
varicosities
Neurogenic tumours are described as pathognomonic
homogeneous hypoechoic oval mass in continuity with
a nerve of origin
Ganglion cysts are non-malignant cystic masses that occur in association with musculoskeletal structures They are sometimes also simply referred to as ganglia or a ganglion but should not be confused with the anatomical term ganglion UltrasoundThe vast majority are anechoic to hypoechoic on ultrasound and have well defined margins Many demonstrate internal septations as well as acoustic enhancement A synovial cyst is a small fluid-filled sac or pouch that can develop over a tendon or joint creating a mass under the skin Synovial cyst is rare in ankle joint A synovial cyst may or may not be painful depending on their size and location
Ganglion cyst in the foot with bony erosion between navicular and cuneiform bones
Tarsal synovial cyst
Anechoic ganglion situated in the sinus tarsi fat between the talus and calcaneous
Plantar fasciitis (PF) refers to inflammation of the
plantar fascia of the foot It is considered the most common cause of heel pain
Clinical presentation Pain on the undersurface of the heel on weight bearing is the principal complaint It can be worse when weight is borne after a period of rest (eg in the morning) and eases with walking Passive dorsiflexion of the toes may exacerbates discomfort
UltrasoundOften the initial imaging modality of choice Ultrasound typically shows increased thickness of the fascia and a hypoechoic fascia
Thickened hypoechoic origin of the plantar fascia which has a convex superior margin
Complete avulsion of the plantar fascia from the calcaneal tubercle
Plantar fasciitis
bull LOCATING FOREIGN BODIES AND FRACTURES
As in any other location the ankle
area is also subsidiary host foreign
whose classification location and
existence can be defined perfectly by
ultrasound Being a focused study to
the area of interest and with great
resolution for surface structures can
be considered more resolute
examination to screen these cases
Osseous diseases and fractures | Sonography discovered Medial Malleolus Fracture
Ultrasound examination of left ankle A Longitudinal sonogram left ankle demonstrates a wooden foreign body B Transverse view left ankle Note the hypervascularity in the inflamed area C Corresponding X-ray of left ankle Note the swelling on the lateral aspect No foreign body is visible
Thank You
Deltoid Ligament scan plane Use plenty of gel and have the probe tip overlie the malleolar tip
Because of its obliquity you cannotreadily see all aspects of the ligament
Posterior AnkleAchilles tendonRetrocalcaneal (Kagers) fat-pad
Scan plane for the Achilles tendon Normal Achilles tendon longitudinal panorama
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 edema Guidance of injection aspiration or biopsy Relationship of normal anatomy and pathology to each other Some bony pathologyLIMITATIONSIt is recognised that ultrasound cannot adequately assess the deltoid ligament the ankle mortice and some inter-tarsal ligamentsEQUIPMENT SELECTION AND TECHNIQUEUse 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 TECHNIQUELATERAL 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 ANKLEPatient 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 mobilizing 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 calcaneumThe deltoid ligament Is poorly assessed with ultrasoundPosterior tibial nerve The neurovascular bundle is easily seen posterior to the medial malleolusPOSTERIOR 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 (Kagers) fat padThe calf muscles and plantaris tendon should also be assessed as clinically indicated
An ankle series should include the following minimum imagesPeroneus tendons - long trans + peroneus brevis insertionCalcaneo-fibular ligamentAnterior talo-fibula ligamentTibio-Fibula ligamentExtensor digitorum tendonExtensor hallucis longus tendonTibialis anterior tendonTibialis posterior tendonFlexor digitorum tendonFlexor hallucis longusAchilles tendon and retro calcaneal bursaDocument the normal anatomy Any pathology found in 2 planes(ligament tears or thickening synovial bulgingcysts joint effusion gross bony changes) including measurements and any vascularity
MAIN INDICATIONS OFTHE ANKLE ULTRASONOGRAPHIC STUDY
Tendon pathology of the different compartments
of the ankle
bull Evaluation of ligament injuries
bull Bone and joint disorders (synovitis chondral
and osteochondral lesions occult fractures)
bull Retroachilles and preachilles bursitis
bull Characterization of tumors (accessory muscles ganglia
neurogenic tumours soft tissue abscesses etc)
bull Localization of foreign bodies
ABNORMALITIES OF TENDONS
Tendon injuries include tenosynovitis tendinosis
rupture and instability
POSTERIOR COMPARTMENTACHILLES TENDINOPATHY
Can be classified as tendinosis and paratendinitis The isolated
paratendinitis shows intratendinous normal structure exist paratendinitis
spill shown irregularities in the edges of the tendon adhesions and
scarring associated paratendon and a heterogeneous aspect preachilles
fat pad In the tendinosis there is in swelling of the tendon usually
bilateral and textural heterogeneity intratendinous focal hypoechoic areas
TEAR OF ACHILLESThe rupture site is located generally between the 2 and 6 cm from the insertion into the calcaneous in the called critical zone of relative hypovascularityIn ultrasound complete rupture of the Achilles tendon is seen as a focal defect
between the broken ends of the tendon In the acute phase ends are contiguous but the defect may be filled by the anechoic or hypoechoic hematoma In most cases paratendon remains intact as a envelope straight echogenic contouring breakage As a sign associated can exist distortion of the fibrillar configuration and loss of parallelism of the tendon fibers Other signs are indicative fat herniation into the defect better visualization of the plantar tendon and the existence of a posterior acoustic shadowing at the site of the tear (useful sign to differentiate partial thickness tears)
Complete rupture of the Achilles tendon with focal defect between
the ends of the tendon and posterior acoustic shadowing at the
site of the tear useful sign to differentiate partial thickness tears
Patient with psoriasis which identifies tendinosis and Achilles tendon swelling
bilateral and textural heterogeneity with intratendinous focal hypoechoic areas
Ultrasound and radiological correlation calcified Achilles
enthesitis Calcaneal spur as associated finding
Discreetly thickened right Achilles tendon at its insertion combining linear hyperechoic
and hypoechoic areas on small breaks intrasubstance and calcifications of the enthesis
Fat herniation into the defect by complete tear of the Achilles tendon
Complete tear of the Achilles tendon with retraction
of ends and integrity thin plantaris tendon
Tendinosis versus partial tear of Achilles tendon
bullPREACHILLES AND RETROACHILLES BURSITIS
Although bursitis can occur in isolation often are
related and systemic inflammatory diseases
In the ultrasound examination the distended
retrocalcaneal and preachilles appears are a
hypoechoic structure shaped coma interposed
between the Achilles tendon and the posterosuperior
aspect of the calcaneous Care must be taken not to
confuse it with the fatty space Kager containing oval
lobules of hyperechoic fat When bursitis is a
manifestation of synovitis is appreciated
hypervascular area with Doppler ultrasound
In the retroachilles bursitis exists thickening and
collection of fluid in the subcutaneous tissue
superficial to the tendon retrocalcaneal portion
Bursitis preachilles with typical morphology appreciating accumulation of fluid
in a coma between the anterior portion of the Achilles tendon and the calcaneous
Bursitis preachiacutelea that associated synovitis showing hyperemia with increased Doppler flow
Rheumatoid arthritis with retrocalcaneal bursitis (1) and calcaneal erosions (2)
ACCESSORY NAVICULAR BONEIn the distal insertion site may exist TP 2 types of bones
accessories
Accessory navicular bone type I (os tibiale externum) size
between the 2 and 6 mm can be contained within the TP and
being positioned immediately proximal posteromedial to the
navicular bone It generally produces symptoms and should
not be confused with a tendon calcification or avulsion
fracture
Type II accessory navicular bone is an accessory
ossification centre of the navicular bone with size between
9 and 12 mm triangular shaped and articulated through a
synchondrosis of the posterior and medial navicular bone
It insertion site of some fibers of TP and is associated with a
syndrome of pain and increased incidence of tendon rupture
caused by abnormal overloads Osteoarthritic changes may
underlie this synchondrosis which mimic tendon pathology
Accessory navicular bone within the posterior tibial tendon as anatomical variant
ANTERIOR COMPARTMENTThe tendons of the anterior ankle compared
with the rest of the ankle tendons are rarely
affected by disease The anterior tibial tendon
is the most prone to abnormalities like
tendinopathy tenosynovitis and its place
between the most frequent rupture is extensor
retinaculum and insertion into the first
cuneiform and the base of the first metatarsal
Sometimes the retracted tendon stump causes
a nodule on the anteromedial aspect of the
distal portion of the leg making clinically
confused with a tumour or cyst
Distal insertion tendinopathy of the anterior tibial tendon with increased vascularity
Tenosynovitis of the anterior tibial tendon with effusion
Anterior tibial tendon tenosynovitis with intratendinous ruptures
Anterior tibial tendon rupture with retraction of the tendon
Tenosynovitis of the extensor digitorum tendons with a synovial effusion
Tenosynovitis of the extensor digitorum tendon with hypervascularized thickened tendon and synovium and synovial fluid
Rheumatoid arthritis with tenosynovitis of the extensor digitorum and peroneal tendons
Thickening of the extensor hallucis longus tendon caused by osteosynthesis material
Multicystic non vascularized intramuscular mass in the extensor digitorum brevis muscle
LATERAL COMPARTMENTTENOSYNOVITIS OF THE PERONEAL TENDONSThe main sign of ultrasound is the presence of liquid inside the
common synovial sheath whereas usually tendinous
morphology is preserved We must differentiate tenosynovitis of
a spill within the common peroneal sheath secondary to a tear of
calcaneofibular ligament (PCL) The ultrasound diagnosis is the detection of the tendons in a lateral plane relative to the distal portion of the lateral malleolus instead of behind it The dynamic exploration foot dorsiflexion as both eversion may help identify cases of intermittent subluxation In long-standing disease can be observed fusiform thickening
of the peroneal tendons at the tip of the malleolus The complete tears of the peroneus brevis tendon (PC) and peroneus longus (PL) are rare occurring in the area of the lateral malleolus or midfoot Seen in patients with ankle sprains or history of chronic instability especially if they suffer widespread diseases (RA DM) or treated with corticosteroids The peroneal tendon ruptures causing the inability to eversion of the foot and cavus foot varus
Important thickening of both peroneal tendons (longus and brevis) associated
with moderate amount of fluid and thickening of the synovial sheath
Discreet amount of fluid in the common sheath of the peroneal tendons
associated with disorganization and a heterogeneous appearance
peroneus brevis tendon related to longitudinal rupture
Peroneal tenosynovitis and osteosynthesis
Tenosynovitis of the peroneal tendons and an intratendinous rupture of the short peroneal tendon
Intratendinous rupture and cyst in the peroneus brevis tendon
Peroneus quartus with an accessory muscle next to the peroneus longus and brevis tendons
Tumor next to the peroneal tendons that proved to be a benign fibrous mass
MEDIAL COMPARTMENT
ANOMALIES POSTERIOR TIBIAL TENDON (TP)
It is the most frequently injured in this compartment with ruptures
in asymptomatic middle-aged obese women as a result of
widespread disease (RA seronegative Spondyloarthropathy) or
associated with bone fractures It causes a gradual collapse of the
medial longitudinal arch with hindfoot valgus deformity and
excessive forefoot pronation
The presence of small vessels in inflammatory diseases
intratendinosis can simulate a fissuration tendon confusion can be ignored using colour Doppler Another possible diagnostic difficulty is when the undamaged tendon flexor digitorum longus (FLD) moves back and simulates the TP unbroken but it is smaller and in this case we only see in the groove retromalleolar 1 only tendon
Ultrasound has also proven to be an effective resource for identifying alterations associated tendon tenosynovitis serosa and hypertrophicSubluxation and dislocation anteriorly and medial TP relative to internal
malleolus is rare and valued sonographically placing the foot in dorsiflexion with forced supination
Thickening moderate amount of fluid surrounding calcifications and
hyperemia affecting the sheath and the posterior tibial tendon related
to chronic tenosynovitis in patient affects rheumatoid arthritis
Thickening moderate amount of surrounding fluid and calcifications (arrow) affecting the
posterior tibial tendon related to chronic tenosynovitis in patient affects rheumatoid arthritis
Tenosynovitis of the posterior tibial tendon caused by a bony ridge at the insertion of the retinaculum The retinaculum is thickened and the tendon subluxates
Psoriatic arthritis Ankle Grayscale examination Posterior tibial tendon on longitudinal (a) and transverse (b) scan Marked tendon sheath widening with homogeneous anechoic aspect (asterisks) of the content indicating an exudative tenosynovitis Note as the normal fibrillar echotexture is conserved Hand Flexor tendons of second finger The volar longitudinal (c) and transverse scan (d) shows a tendon sheath widening with signs of synovial proliferation presence of intense power Doppler signal surrounding the tendon and micro interruption of the margin (arrow) e Wrist Extensor carpi ulnaris tendon (sixth compartment of the extensor tendons ecu) on lateral longitudinal (e) and transverse (f) scan Chronic tenosynovitis with clear areas of low of echogenicity and loss of the continuity of tendon fibrils indicative of partial tendon tear (arrows) Moreover note the presence of power Doppler signal within the interruption indicating still activity of the inflammatory process g Dactylitis Volar longitudinal scan using the ldquoextended viewrdquo technique showing proliferative tenosynovitis of the finger flexor tendon (circle) exudative synovitis of both proximal and distal interphalangeal joint (white asterisks) and edema of the peritendinous tissue (black asterisks) TP posterior tibial tendon mm medial malleolus DP distal phalanx mp middle phalanx cu cubital bone ft flexor tendons
Tenosynovitis of the posterior tibial (1) and flexor digitorum longus tendon (2)
Tibialis Posterior Tendon rupture
Tenosynovitis of the posterior tibial tendon the flexor digitorum tendon and flexor hallucis longus tendon
Tenosynovitis of the tendons on the medial side in the left ankle
bullLIGAMENT INJURIESThe ligament partial tear ligament shows a hypoechoic
areas swollen with internal focal or diffuse In the complete
ruptures within the substance of the divided ligament rift is
observed corresponding to the hematoma hypoechoic and
the free ends of the divided ligament can be and retracted
appreciated corrugated in contrast with normal
appearance straight
Grade I Mild stretching of the ligament without breakage
or instability
Grade II Partial tearing of the ligament
Grade III Complete tearing
Degrees depending on the severity of the injury and the
place of employment
LATERAL COMPARTMENTThese injuries occur secondary to inversion sprains with internal rotation of
the foot combined with ankle plantar flexion
The anterior talar fibular ligament tears (ATFL) usually occur as isolated
involvement (70) or associated with calcaneal fibular ligament (CFL) (20-40)
but the posterior talar fibular ligament (PTFL) affects only major trauma
involving ankle dislocation
ATFL breaks is associated with breakage of the joint capsule and synovial fluid
extravasation into the anterolateral soft ankle whereas the complete tearing of
CFL can communicate the ankle joint and synovial sheath peroneal tendons
Rupture of CFL is rarely associated with superior peroneal retinaculum tear
The CFL is tensioned during dorsiflexion pulling on peroneal tendons laterally
so that absence of its displacement is sign of a complete tear
Within a damaged ligament can also observe calcifications that often
correspond to fragments of avulsion bone
During the ultrasound can be performed forced maneuvers to detect to joint
laxity and ligament injuries The anterior drawer test is performed with the feet
hanging over the edge of the examination table while the forefoot is pulled
anteriorly when the foot is in plantar flexion and inversion This maneuver
helps differentiate partial tears (grade II) of the ATFL to complete (grade III)
where the anterior displacement of the talus on the tibia open a crack in the
substance becoming more visible the ligament injury
The sindesmosys sprains are up to 10 of ankle
injuries happening in eversion and pronation
movements (like the deltoid ligament injury) and
primarily affect the anterior tibiofibular ligament (ATFL)
the failure is frequently associated with fracture of the
fibula
According to the place of employment are 4 degrees
useful for prognostic evaluation and therapeutic strategy
choice
Grade I stretch or partial tear of the ATFL
Grade II complete tearing but only the ATFL
Grade III complete tear of the ATFL and partial CFL
Grade IV complete tear of the ATFL and CFL
The grade I and II injuries usually scarred without any
significant instability whereas grade III and IV injuries
can cause chronic pain and require surgical treatment
Thickened but continued ATFL right in relation to the partial rupture
Grade 111 sprain of right ATFL
Thickened anterior talofibular ligament with calcifications and a partial rupture
Thickened tibiofibular ligament after trauma
Anterior Talofibular Ligament Partial Tear and Elastography
Tibio fibular ligament rupture with bony avulsion
Complete rupture of right ATFL
Bony avulsion with radiographic evidence as visible calcification in a grade III sprain ATFL
Moderately thickened and hypoechoic ATFL
Discontinuity of the ATFL with fluid surrounding the torn ends (arrow)
Thickening and hypoechogenicity of the fibular end of the ligament seen here passing over the subtalar joint which contains a small of fluid
Complete disruption to the tibiofibular ligament with bony irregularity of particularly the tibial margin and fluid in the gap
MEDIAL COMPARTMENTBecause of the low incidence of eversion ankle
sprains and the thickness of the deltoid ligament
is rarely injured in isolation and when the injury
does not usually full thickness Usually
accompanied by lesions of the medial malleolus
and lateral displacement of the talus with
consequent widening of the ankle mortise
Ultrasound is useful for differentiating ligament
injury of the posterior tibial tendon injury
(TP) adjacent they have similar symptoms
The inability to visualize the deltoid ligament may
indicate tear but this is not considered a reliable
sign as its full ultrasound is not always possible
Partial medial ligament rupture
Thickened heterogeneous abnormal deltoid demonstrating hyperemia
Ultrasonogram showing a disrupted deltoid ligament with the probe in the coronal plane The white arrow indicates the medial malleolus the blue arrow indicates the talus and the red arrows indicate the disrupted deltoid ligament (A) Radiograph showing the same injury (B)
bullJOINT AND BONE DISORDERSUltrasound reliably detect spills mild (gt 2 ml) inside
of the ankle joint by exploring the front and rear
recess as well as areas of synovial proliferation and
may even display using the colour Doppler
hyperemic areas in arthritis patients
The intraarticular joints are displayed surrounded
fluid in one of the recesses of the ankle or subtalar
joint Sonographically diagnosed when changing position to perform flexion and extension Fracture of the lateral process of the talus is overlooked up to 50 of cases with plain radiography Ultrasound may suspect the presence of focal cortical disruption helping further to exclude concomitant ligament injury
Rheumatoid arthritis with synovial thickening (1) and erosion of the tibia (2)
Infectious arthritis with a pus filled anterior recess of the ankle
Arthritis and tenosynovitis of the ankle in a patient with rheumatoid arthritis
bullTUMOURSUltrasound can differentiate between a mass complex
and solid and a cystic in addition to verifying the
existence of accessory muscles (peroneus fourth
accessory flexor digitorum longus and accessory
soleus) As in any other location can be found
neoformative soft tissue tumors inflammatory
infectious etc
Ganglions of this location are more often symptomatic
and larger with multiple partitions
branched and lobed edges Differential diagnosis must
be made with tenosynovitis abscesses seromas and
varicosities
Neurogenic tumours are described as pathognomonic
homogeneous hypoechoic oval mass in continuity with
a nerve of origin
Ganglion cysts are non-malignant cystic masses that occur in association with musculoskeletal structures They are sometimes also simply referred to as ganglia or a ganglion but should not be confused with the anatomical term ganglion UltrasoundThe vast majority are anechoic to hypoechoic on ultrasound and have well defined margins Many demonstrate internal septations as well as acoustic enhancement A synovial cyst is a small fluid-filled sac or pouch that can develop over a tendon or joint creating a mass under the skin Synovial cyst is rare in ankle joint A synovial cyst may or may not be painful depending on their size and location
Ganglion cyst in the foot with bony erosion between navicular and cuneiform bones
Tarsal synovial cyst
Anechoic ganglion situated in the sinus tarsi fat between the talus and calcaneous
Plantar fasciitis (PF) refers to inflammation of the
plantar fascia of the foot It is considered the most common cause of heel pain
Clinical presentation Pain on the undersurface of the heel on weight bearing is the principal complaint It can be worse when weight is borne after a period of rest (eg in the morning) and eases with walking Passive dorsiflexion of the toes may exacerbates discomfort
UltrasoundOften the initial imaging modality of choice Ultrasound typically shows increased thickness of the fascia and a hypoechoic fascia
Thickened hypoechoic origin of the plantar fascia which has a convex superior margin
Complete avulsion of the plantar fascia from the calcaneal tubercle
Plantar fasciitis
bull LOCATING FOREIGN BODIES AND FRACTURES
As in any other location the ankle
area is also subsidiary host foreign
whose classification location and
existence can be defined perfectly by
ultrasound Being a focused study to
the area of interest and with great
resolution for surface structures can
be considered more resolute
examination to screen these cases
Osseous diseases and fractures | Sonography discovered Medial Malleolus Fracture
Ultrasound examination of left ankle A Longitudinal sonogram left ankle demonstrates a wooden foreign body B Transverse view left ankle Note the hypervascularity in the inflamed area C Corresponding X-ray of left ankle Note the swelling on the lateral aspect No foreign body is visible
Thank You
Posterior AnkleAchilles tendonRetrocalcaneal (Kagers) fat-pad
Scan plane for the Achilles tendon Normal Achilles tendon longitudinal panorama
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 edema Guidance of injection aspiration or biopsy Relationship of normal anatomy and pathology to each other Some bony pathologyLIMITATIONSIt is recognised that ultrasound cannot adequately assess the deltoid ligament the ankle mortice and some inter-tarsal ligamentsEQUIPMENT SELECTION AND TECHNIQUEUse 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 TECHNIQUELATERAL 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 ANKLEPatient 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 mobilizing 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 calcaneumThe deltoid ligament Is poorly assessed with ultrasoundPosterior tibial nerve The neurovascular bundle is easily seen posterior to the medial malleolusPOSTERIOR 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 (Kagers) fat padThe calf muscles and plantaris tendon should also be assessed as clinically indicated
An ankle series should include the following minimum imagesPeroneus tendons - long trans + peroneus brevis insertionCalcaneo-fibular ligamentAnterior talo-fibula ligamentTibio-Fibula ligamentExtensor digitorum tendonExtensor hallucis longus tendonTibialis anterior tendonTibialis posterior tendonFlexor digitorum tendonFlexor hallucis longusAchilles tendon and retro calcaneal bursaDocument the normal anatomy Any pathology found in 2 planes(ligament tears or thickening synovial bulgingcysts joint effusion gross bony changes) including measurements and any vascularity
MAIN INDICATIONS OFTHE ANKLE ULTRASONOGRAPHIC STUDY
Tendon pathology of the different compartments
of the ankle
bull Evaluation of ligament injuries
bull Bone and joint disorders (synovitis chondral
and osteochondral lesions occult fractures)
bull Retroachilles and preachilles bursitis
bull Characterization of tumors (accessory muscles ganglia
neurogenic tumours soft tissue abscesses etc)
bull Localization of foreign bodies
ABNORMALITIES OF TENDONS
Tendon injuries include tenosynovitis tendinosis
rupture and instability
POSTERIOR COMPARTMENTACHILLES TENDINOPATHY
Can be classified as tendinosis and paratendinitis The isolated
paratendinitis shows intratendinous normal structure exist paratendinitis
spill shown irregularities in the edges of the tendon adhesions and
scarring associated paratendon and a heterogeneous aspect preachilles
fat pad In the tendinosis there is in swelling of the tendon usually
bilateral and textural heterogeneity intratendinous focal hypoechoic areas
TEAR OF ACHILLESThe rupture site is located generally between the 2 and 6 cm from the insertion into the calcaneous in the called critical zone of relative hypovascularityIn ultrasound complete rupture of the Achilles tendon is seen as a focal defect
between the broken ends of the tendon In the acute phase ends are contiguous but the defect may be filled by the anechoic or hypoechoic hematoma In most cases paratendon remains intact as a envelope straight echogenic contouring breakage As a sign associated can exist distortion of the fibrillar configuration and loss of parallelism of the tendon fibers Other signs are indicative fat herniation into the defect better visualization of the plantar tendon and the existence of a posterior acoustic shadowing at the site of the tear (useful sign to differentiate partial thickness tears)
Complete rupture of the Achilles tendon with focal defect between
the ends of the tendon and posterior acoustic shadowing at the
site of the tear useful sign to differentiate partial thickness tears
Patient with psoriasis which identifies tendinosis and Achilles tendon swelling
bilateral and textural heterogeneity with intratendinous focal hypoechoic areas
Ultrasound and radiological correlation calcified Achilles
enthesitis Calcaneal spur as associated finding
Discreetly thickened right Achilles tendon at its insertion combining linear hyperechoic
and hypoechoic areas on small breaks intrasubstance and calcifications of the enthesis
Fat herniation into the defect by complete tear of the Achilles tendon
Complete tear of the Achilles tendon with retraction
of ends and integrity thin plantaris tendon
Tendinosis versus partial tear of Achilles tendon
bullPREACHILLES AND RETROACHILLES BURSITIS
Although bursitis can occur in isolation often are
related and systemic inflammatory diseases
In the ultrasound examination the distended
retrocalcaneal and preachilles appears are a
hypoechoic structure shaped coma interposed
between the Achilles tendon and the posterosuperior
aspect of the calcaneous Care must be taken not to
confuse it with the fatty space Kager containing oval
lobules of hyperechoic fat When bursitis is a
manifestation of synovitis is appreciated
hypervascular area with Doppler ultrasound
In the retroachilles bursitis exists thickening and
collection of fluid in the subcutaneous tissue
superficial to the tendon retrocalcaneal portion
Bursitis preachilles with typical morphology appreciating accumulation of fluid
in a coma between the anterior portion of the Achilles tendon and the calcaneous
Bursitis preachiacutelea that associated synovitis showing hyperemia with increased Doppler flow
Rheumatoid arthritis with retrocalcaneal bursitis (1) and calcaneal erosions (2)
ACCESSORY NAVICULAR BONEIn the distal insertion site may exist TP 2 types of bones
accessories
Accessory navicular bone type I (os tibiale externum) size
between the 2 and 6 mm can be contained within the TP and
being positioned immediately proximal posteromedial to the
navicular bone It generally produces symptoms and should
not be confused with a tendon calcification or avulsion
fracture
Type II accessory navicular bone is an accessory
ossification centre of the navicular bone with size between
9 and 12 mm triangular shaped and articulated through a
synchondrosis of the posterior and medial navicular bone
It insertion site of some fibers of TP and is associated with a
syndrome of pain and increased incidence of tendon rupture
caused by abnormal overloads Osteoarthritic changes may
underlie this synchondrosis which mimic tendon pathology
Accessory navicular bone within the posterior tibial tendon as anatomical variant
ANTERIOR COMPARTMENTThe tendons of the anterior ankle compared
with the rest of the ankle tendons are rarely
affected by disease The anterior tibial tendon
is the most prone to abnormalities like
tendinopathy tenosynovitis and its place
between the most frequent rupture is extensor
retinaculum and insertion into the first
cuneiform and the base of the first metatarsal
Sometimes the retracted tendon stump causes
a nodule on the anteromedial aspect of the
distal portion of the leg making clinically
confused with a tumour or cyst
Distal insertion tendinopathy of the anterior tibial tendon with increased vascularity
Tenosynovitis of the anterior tibial tendon with effusion
Anterior tibial tendon tenosynovitis with intratendinous ruptures
Anterior tibial tendon rupture with retraction of the tendon
Tenosynovitis of the extensor digitorum tendons with a synovial effusion
Tenosynovitis of the extensor digitorum tendon with hypervascularized thickened tendon and synovium and synovial fluid
Rheumatoid arthritis with tenosynovitis of the extensor digitorum and peroneal tendons
Thickening of the extensor hallucis longus tendon caused by osteosynthesis material
Multicystic non vascularized intramuscular mass in the extensor digitorum brevis muscle
LATERAL COMPARTMENTTENOSYNOVITIS OF THE PERONEAL TENDONSThe main sign of ultrasound is the presence of liquid inside the
common synovial sheath whereas usually tendinous
morphology is preserved We must differentiate tenosynovitis of
a spill within the common peroneal sheath secondary to a tear of
calcaneofibular ligament (PCL) The ultrasound diagnosis is the detection of the tendons in a lateral plane relative to the distal portion of the lateral malleolus instead of behind it The dynamic exploration foot dorsiflexion as both eversion may help identify cases of intermittent subluxation In long-standing disease can be observed fusiform thickening
of the peroneal tendons at the tip of the malleolus The complete tears of the peroneus brevis tendon (PC) and peroneus longus (PL) are rare occurring in the area of the lateral malleolus or midfoot Seen in patients with ankle sprains or history of chronic instability especially if they suffer widespread diseases (RA DM) or treated with corticosteroids The peroneal tendon ruptures causing the inability to eversion of the foot and cavus foot varus
Important thickening of both peroneal tendons (longus and brevis) associated
with moderate amount of fluid and thickening of the synovial sheath
Discreet amount of fluid in the common sheath of the peroneal tendons
associated with disorganization and a heterogeneous appearance
peroneus brevis tendon related to longitudinal rupture
Peroneal tenosynovitis and osteosynthesis
Tenosynovitis of the peroneal tendons and an intratendinous rupture of the short peroneal tendon
Intratendinous rupture and cyst in the peroneus brevis tendon
Peroneus quartus with an accessory muscle next to the peroneus longus and brevis tendons
Tumor next to the peroneal tendons that proved to be a benign fibrous mass
MEDIAL COMPARTMENT
ANOMALIES POSTERIOR TIBIAL TENDON (TP)
It is the most frequently injured in this compartment with ruptures
in asymptomatic middle-aged obese women as a result of
widespread disease (RA seronegative Spondyloarthropathy) or
associated with bone fractures It causes a gradual collapse of the
medial longitudinal arch with hindfoot valgus deformity and
excessive forefoot pronation
The presence of small vessels in inflammatory diseases
intratendinosis can simulate a fissuration tendon confusion can be ignored using colour Doppler Another possible diagnostic difficulty is when the undamaged tendon flexor digitorum longus (FLD) moves back and simulates the TP unbroken but it is smaller and in this case we only see in the groove retromalleolar 1 only tendon
Ultrasound has also proven to be an effective resource for identifying alterations associated tendon tenosynovitis serosa and hypertrophicSubluxation and dislocation anteriorly and medial TP relative to internal
malleolus is rare and valued sonographically placing the foot in dorsiflexion with forced supination
Thickening moderate amount of fluid surrounding calcifications and
hyperemia affecting the sheath and the posterior tibial tendon related
to chronic tenosynovitis in patient affects rheumatoid arthritis
Thickening moderate amount of surrounding fluid and calcifications (arrow) affecting the
posterior tibial tendon related to chronic tenosynovitis in patient affects rheumatoid arthritis
Tenosynovitis of the posterior tibial tendon caused by a bony ridge at the insertion of the retinaculum The retinaculum is thickened and the tendon subluxates
Psoriatic arthritis Ankle Grayscale examination Posterior tibial tendon on longitudinal (a) and transverse (b) scan Marked tendon sheath widening with homogeneous anechoic aspect (asterisks) of the content indicating an exudative tenosynovitis Note as the normal fibrillar echotexture is conserved Hand Flexor tendons of second finger The volar longitudinal (c) and transverse scan (d) shows a tendon sheath widening with signs of synovial proliferation presence of intense power Doppler signal surrounding the tendon and micro interruption of the margin (arrow) e Wrist Extensor carpi ulnaris tendon (sixth compartment of the extensor tendons ecu) on lateral longitudinal (e) and transverse (f) scan Chronic tenosynovitis with clear areas of low of echogenicity and loss of the continuity of tendon fibrils indicative of partial tendon tear (arrows) Moreover note the presence of power Doppler signal within the interruption indicating still activity of the inflammatory process g Dactylitis Volar longitudinal scan using the ldquoextended viewrdquo technique showing proliferative tenosynovitis of the finger flexor tendon (circle) exudative synovitis of both proximal and distal interphalangeal joint (white asterisks) and edema of the peritendinous tissue (black asterisks) TP posterior tibial tendon mm medial malleolus DP distal phalanx mp middle phalanx cu cubital bone ft flexor tendons
Tenosynovitis of the posterior tibial (1) and flexor digitorum longus tendon (2)
Tibialis Posterior Tendon rupture
Tenosynovitis of the posterior tibial tendon the flexor digitorum tendon and flexor hallucis longus tendon
Tenosynovitis of the tendons on the medial side in the left ankle
bullLIGAMENT INJURIESThe ligament partial tear ligament shows a hypoechoic
areas swollen with internal focal or diffuse In the complete
ruptures within the substance of the divided ligament rift is
observed corresponding to the hematoma hypoechoic and
the free ends of the divided ligament can be and retracted
appreciated corrugated in contrast with normal
appearance straight
Grade I Mild stretching of the ligament without breakage
or instability
Grade II Partial tearing of the ligament
Grade III Complete tearing
Degrees depending on the severity of the injury and the
place of employment
LATERAL COMPARTMENTThese injuries occur secondary to inversion sprains with internal rotation of
the foot combined with ankle plantar flexion
The anterior talar fibular ligament tears (ATFL) usually occur as isolated
involvement (70) or associated with calcaneal fibular ligament (CFL) (20-40)
but the posterior talar fibular ligament (PTFL) affects only major trauma
involving ankle dislocation
ATFL breaks is associated with breakage of the joint capsule and synovial fluid
extravasation into the anterolateral soft ankle whereas the complete tearing of
CFL can communicate the ankle joint and synovial sheath peroneal tendons
Rupture of CFL is rarely associated with superior peroneal retinaculum tear
The CFL is tensioned during dorsiflexion pulling on peroneal tendons laterally
so that absence of its displacement is sign of a complete tear
Within a damaged ligament can also observe calcifications that often
correspond to fragments of avulsion bone
During the ultrasound can be performed forced maneuvers to detect to joint
laxity and ligament injuries The anterior drawer test is performed with the feet
hanging over the edge of the examination table while the forefoot is pulled
anteriorly when the foot is in plantar flexion and inversion This maneuver
helps differentiate partial tears (grade II) of the ATFL to complete (grade III)
where the anterior displacement of the talus on the tibia open a crack in the
substance becoming more visible the ligament injury
The sindesmosys sprains are up to 10 of ankle
injuries happening in eversion and pronation
movements (like the deltoid ligament injury) and
primarily affect the anterior tibiofibular ligament (ATFL)
the failure is frequently associated with fracture of the
fibula
According to the place of employment are 4 degrees
useful for prognostic evaluation and therapeutic strategy
choice
Grade I stretch or partial tear of the ATFL
Grade II complete tearing but only the ATFL
Grade III complete tear of the ATFL and partial CFL
Grade IV complete tear of the ATFL and CFL
The grade I and II injuries usually scarred without any
significant instability whereas grade III and IV injuries
can cause chronic pain and require surgical treatment
Thickened but continued ATFL right in relation to the partial rupture
Grade 111 sprain of right ATFL
Thickened anterior talofibular ligament with calcifications and a partial rupture
Thickened tibiofibular ligament after trauma
Anterior Talofibular Ligament Partial Tear and Elastography
Tibio fibular ligament rupture with bony avulsion
Complete rupture of right ATFL
Bony avulsion with radiographic evidence as visible calcification in a grade III sprain ATFL
Moderately thickened and hypoechoic ATFL
Discontinuity of the ATFL with fluid surrounding the torn ends (arrow)
Thickening and hypoechogenicity of the fibular end of the ligament seen here passing over the subtalar joint which contains a small of fluid
Complete disruption to the tibiofibular ligament with bony irregularity of particularly the tibial margin and fluid in the gap
MEDIAL COMPARTMENTBecause of the low incidence of eversion ankle
sprains and the thickness of the deltoid ligament
is rarely injured in isolation and when the injury
does not usually full thickness Usually
accompanied by lesions of the medial malleolus
and lateral displacement of the talus with
consequent widening of the ankle mortise
Ultrasound is useful for differentiating ligament
injury of the posterior tibial tendon injury
(TP) adjacent they have similar symptoms
The inability to visualize the deltoid ligament may
indicate tear but this is not considered a reliable
sign as its full ultrasound is not always possible
Partial medial ligament rupture
Thickened heterogeneous abnormal deltoid demonstrating hyperemia
Ultrasonogram showing a disrupted deltoid ligament with the probe in the coronal plane The white arrow indicates the medial malleolus the blue arrow indicates the talus and the red arrows indicate the disrupted deltoid ligament (A) Radiograph showing the same injury (B)
bullJOINT AND BONE DISORDERSUltrasound reliably detect spills mild (gt 2 ml) inside
of the ankle joint by exploring the front and rear
recess as well as areas of synovial proliferation and
may even display using the colour Doppler
hyperemic areas in arthritis patients
The intraarticular joints are displayed surrounded
fluid in one of the recesses of the ankle or subtalar
joint Sonographically diagnosed when changing position to perform flexion and extension Fracture of the lateral process of the talus is overlooked up to 50 of cases with plain radiography Ultrasound may suspect the presence of focal cortical disruption helping further to exclude concomitant ligament injury
Rheumatoid arthritis with synovial thickening (1) and erosion of the tibia (2)
Infectious arthritis with a pus filled anterior recess of the ankle
Arthritis and tenosynovitis of the ankle in a patient with rheumatoid arthritis
bullTUMOURSUltrasound can differentiate between a mass complex
and solid and a cystic in addition to verifying the
existence of accessory muscles (peroneus fourth
accessory flexor digitorum longus and accessory
soleus) As in any other location can be found
neoformative soft tissue tumors inflammatory
infectious etc
Ganglions of this location are more often symptomatic
and larger with multiple partitions
branched and lobed edges Differential diagnosis must
be made with tenosynovitis abscesses seromas and
varicosities
Neurogenic tumours are described as pathognomonic
homogeneous hypoechoic oval mass in continuity with
a nerve of origin
Ganglion cysts are non-malignant cystic masses that occur in association with musculoskeletal structures They are sometimes also simply referred to as ganglia or a ganglion but should not be confused with the anatomical term ganglion UltrasoundThe vast majority are anechoic to hypoechoic on ultrasound and have well defined margins Many demonstrate internal septations as well as acoustic enhancement A synovial cyst is a small fluid-filled sac or pouch that can develop over a tendon or joint creating a mass under the skin Synovial cyst is rare in ankle joint A synovial cyst may or may not be painful depending on their size and location
Ganglion cyst in the foot with bony erosion between navicular and cuneiform bones
Tarsal synovial cyst
Anechoic ganglion situated in the sinus tarsi fat between the talus and calcaneous
Plantar fasciitis (PF) refers to inflammation of the
plantar fascia of the foot It is considered the most common cause of heel pain
Clinical presentation Pain on the undersurface of the heel on weight bearing is the principal complaint It can be worse when weight is borne after a period of rest (eg in the morning) and eases with walking Passive dorsiflexion of the toes may exacerbates discomfort
UltrasoundOften the initial imaging modality of choice Ultrasound typically shows increased thickness of the fascia and a hypoechoic fascia
Thickened hypoechoic origin of the plantar fascia which has a convex superior margin
Complete avulsion of the plantar fascia from the calcaneal tubercle
Plantar fasciitis
bull LOCATING FOREIGN BODIES AND FRACTURES
As in any other location the ankle
area is also subsidiary host foreign
whose classification location and
existence can be defined perfectly by
ultrasound Being a focused study to
the area of interest and with great
resolution for surface structures can
be considered more resolute
examination to screen these cases
Osseous diseases and fractures | Sonography discovered Medial Malleolus Fracture
Ultrasound examination of left ankle A Longitudinal sonogram left ankle demonstrates a wooden foreign body B Transverse view left ankle Note the hypervascularity in the inflamed area C Corresponding X-ray of left ankle Note the swelling on the lateral aspect No foreign body is visible
Thank You
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 edema Guidance of injection aspiration or biopsy Relationship of normal anatomy and pathology to each other Some bony pathologyLIMITATIONSIt is recognised that ultrasound cannot adequately assess the deltoid ligament the ankle mortice and some inter-tarsal ligamentsEQUIPMENT SELECTION AND TECHNIQUEUse 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 TECHNIQUELATERAL 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 ANKLEPatient 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 mobilizing 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 calcaneumThe deltoid ligament Is poorly assessed with ultrasoundPosterior tibial nerve The neurovascular bundle is easily seen posterior to the medial malleolusPOSTERIOR 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 (Kagers) fat padThe calf muscles and plantaris tendon should also be assessed as clinically indicated
An ankle series should include the following minimum imagesPeroneus tendons - long trans + peroneus brevis insertionCalcaneo-fibular ligamentAnterior talo-fibula ligamentTibio-Fibula ligamentExtensor digitorum tendonExtensor hallucis longus tendonTibialis anterior tendonTibialis posterior tendonFlexor digitorum tendonFlexor hallucis longusAchilles tendon and retro calcaneal bursaDocument the normal anatomy Any pathology found in 2 planes(ligament tears or thickening synovial bulgingcysts joint effusion gross bony changes) including measurements and any vascularity
MAIN INDICATIONS OFTHE ANKLE ULTRASONOGRAPHIC STUDY
Tendon pathology of the different compartments
of the ankle
bull Evaluation of ligament injuries
bull Bone and joint disorders (synovitis chondral
and osteochondral lesions occult fractures)
bull Retroachilles and preachilles bursitis
bull Characterization of tumors (accessory muscles ganglia
neurogenic tumours soft tissue abscesses etc)
bull Localization of foreign bodies
ABNORMALITIES OF TENDONS
Tendon injuries include tenosynovitis tendinosis
rupture and instability
POSTERIOR COMPARTMENTACHILLES TENDINOPATHY
Can be classified as tendinosis and paratendinitis The isolated
paratendinitis shows intratendinous normal structure exist paratendinitis
spill shown irregularities in the edges of the tendon adhesions and
scarring associated paratendon and a heterogeneous aspect preachilles
fat pad In the tendinosis there is in swelling of the tendon usually
bilateral and textural heterogeneity intratendinous focal hypoechoic areas
TEAR OF ACHILLESThe rupture site is located generally between the 2 and 6 cm from the insertion into the calcaneous in the called critical zone of relative hypovascularityIn ultrasound complete rupture of the Achilles tendon is seen as a focal defect
between the broken ends of the tendon In the acute phase ends are contiguous but the defect may be filled by the anechoic or hypoechoic hematoma In most cases paratendon remains intact as a envelope straight echogenic contouring breakage As a sign associated can exist distortion of the fibrillar configuration and loss of parallelism of the tendon fibers Other signs are indicative fat herniation into the defect better visualization of the plantar tendon and the existence of a posterior acoustic shadowing at the site of the tear (useful sign to differentiate partial thickness tears)
Complete rupture of the Achilles tendon with focal defect between
the ends of the tendon and posterior acoustic shadowing at the
site of the tear useful sign to differentiate partial thickness tears
Patient with psoriasis which identifies tendinosis and Achilles tendon swelling
bilateral and textural heterogeneity with intratendinous focal hypoechoic areas
Ultrasound and radiological correlation calcified Achilles
enthesitis Calcaneal spur as associated finding
Discreetly thickened right Achilles tendon at its insertion combining linear hyperechoic
and hypoechoic areas on small breaks intrasubstance and calcifications of the enthesis
Fat herniation into the defect by complete tear of the Achilles tendon
Complete tear of the Achilles tendon with retraction
of ends and integrity thin plantaris tendon
Tendinosis versus partial tear of Achilles tendon
bullPREACHILLES AND RETROACHILLES BURSITIS
Although bursitis can occur in isolation often are
related and systemic inflammatory diseases
In the ultrasound examination the distended
retrocalcaneal and preachilles appears are a
hypoechoic structure shaped coma interposed
between the Achilles tendon and the posterosuperior
aspect of the calcaneous Care must be taken not to
confuse it with the fatty space Kager containing oval
lobules of hyperechoic fat When bursitis is a
manifestation of synovitis is appreciated
hypervascular area with Doppler ultrasound
In the retroachilles bursitis exists thickening and
collection of fluid in the subcutaneous tissue
superficial to the tendon retrocalcaneal portion
Bursitis preachilles with typical morphology appreciating accumulation of fluid
in a coma between the anterior portion of the Achilles tendon and the calcaneous
Bursitis preachiacutelea that associated synovitis showing hyperemia with increased Doppler flow
Rheumatoid arthritis with retrocalcaneal bursitis (1) and calcaneal erosions (2)
ACCESSORY NAVICULAR BONEIn the distal insertion site may exist TP 2 types of bones
accessories
Accessory navicular bone type I (os tibiale externum) size
between the 2 and 6 mm can be contained within the TP and
being positioned immediately proximal posteromedial to the
navicular bone It generally produces symptoms and should
not be confused with a tendon calcification or avulsion
fracture
Type II accessory navicular bone is an accessory
ossification centre of the navicular bone with size between
9 and 12 mm triangular shaped and articulated through a
synchondrosis of the posterior and medial navicular bone
It insertion site of some fibers of TP and is associated with a
syndrome of pain and increased incidence of tendon rupture
caused by abnormal overloads Osteoarthritic changes may
underlie this synchondrosis which mimic tendon pathology
Accessory navicular bone within the posterior tibial tendon as anatomical variant
ANTERIOR COMPARTMENTThe tendons of the anterior ankle compared
with the rest of the ankle tendons are rarely
affected by disease The anterior tibial tendon
is the most prone to abnormalities like
tendinopathy tenosynovitis and its place
between the most frequent rupture is extensor
retinaculum and insertion into the first
cuneiform and the base of the first metatarsal
Sometimes the retracted tendon stump causes
a nodule on the anteromedial aspect of the
distal portion of the leg making clinically
confused with a tumour or cyst
Distal insertion tendinopathy of the anterior tibial tendon with increased vascularity
Tenosynovitis of the anterior tibial tendon with effusion
Anterior tibial tendon tenosynovitis with intratendinous ruptures
Anterior tibial tendon rupture with retraction of the tendon
Tenosynovitis of the extensor digitorum tendons with a synovial effusion
Tenosynovitis of the extensor digitorum tendon with hypervascularized thickened tendon and synovium and synovial fluid
Rheumatoid arthritis with tenosynovitis of the extensor digitorum and peroneal tendons
Thickening of the extensor hallucis longus tendon caused by osteosynthesis material
Multicystic non vascularized intramuscular mass in the extensor digitorum brevis muscle
LATERAL COMPARTMENTTENOSYNOVITIS OF THE PERONEAL TENDONSThe main sign of ultrasound is the presence of liquid inside the
common synovial sheath whereas usually tendinous
morphology is preserved We must differentiate tenosynovitis of
a spill within the common peroneal sheath secondary to a tear of
calcaneofibular ligament (PCL) The ultrasound diagnosis is the detection of the tendons in a lateral plane relative to the distal portion of the lateral malleolus instead of behind it The dynamic exploration foot dorsiflexion as both eversion may help identify cases of intermittent subluxation In long-standing disease can be observed fusiform thickening
of the peroneal tendons at the tip of the malleolus The complete tears of the peroneus brevis tendon (PC) and peroneus longus (PL) are rare occurring in the area of the lateral malleolus or midfoot Seen in patients with ankle sprains or history of chronic instability especially if they suffer widespread diseases (RA DM) or treated with corticosteroids The peroneal tendon ruptures causing the inability to eversion of the foot and cavus foot varus
Important thickening of both peroneal tendons (longus and brevis) associated
with moderate amount of fluid and thickening of the synovial sheath
Discreet amount of fluid in the common sheath of the peroneal tendons
associated with disorganization and a heterogeneous appearance
peroneus brevis tendon related to longitudinal rupture
Peroneal tenosynovitis and osteosynthesis
Tenosynovitis of the peroneal tendons and an intratendinous rupture of the short peroneal tendon
Intratendinous rupture and cyst in the peroneus brevis tendon
Peroneus quartus with an accessory muscle next to the peroneus longus and brevis tendons
Tumor next to the peroneal tendons that proved to be a benign fibrous mass
MEDIAL COMPARTMENT
ANOMALIES POSTERIOR TIBIAL TENDON (TP)
It is the most frequently injured in this compartment with ruptures
in asymptomatic middle-aged obese women as a result of
widespread disease (RA seronegative Spondyloarthropathy) or
associated with bone fractures It causes a gradual collapse of the
medial longitudinal arch with hindfoot valgus deformity and
excessive forefoot pronation
The presence of small vessels in inflammatory diseases
intratendinosis can simulate a fissuration tendon confusion can be ignored using colour Doppler Another possible diagnostic difficulty is when the undamaged tendon flexor digitorum longus (FLD) moves back and simulates the TP unbroken but it is smaller and in this case we only see in the groove retromalleolar 1 only tendon
Ultrasound has also proven to be an effective resource for identifying alterations associated tendon tenosynovitis serosa and hypertrophicSubluxation and dislocation anteriorly and medial TP relative to internal
malleolus is rare and valued sonographically placing the foot in dorsiflexion with forced supination
Thickening moderate amount of fluid surrounding calcifications and
hyperemia affecting the sheath and the posterior tibial tendon related
to chronic tenosynovitis in patient affects rheumatoid arthritis
Thickening moderate amount of surrounding fluid and calcifications (arrow) affecting the
posterior tibial tendon related to chronic tenosynovitis in patient affects rheumatoid arthritis
Tenosynovitis of the posterior tibial tendon caused by a bony ridge at the insertion of the retinaculum The retinaculum is thickened and the tendon subluxates
Psoriatic arthritis Ankle Grayscale examination Posterior tibial tendon on longitudinal (a) and transverse (b) scan Marked tendon sheath widening with homogeneous anechoic aspect (asterisks) of the content indicating an exudative tenosynovitis Note as the normal fibrillar echotexture is conserved Hand Flexor tendons of second finger The volar longitudinal (c) and transverse scan (d) shows a tendon sheath widening with signs of synovial proliferation presence of intense power Doppler signal surrounding the tendon and micro interruption of the margin (arrow) e Wrist Extensor carpi ulnaris tendon (sixth compartment of the extensor tendons ecu) on lateral longitudinal (e) and transverse (f) scan Chronic tenosynovitis with clear areas of low of echogenicity and loss of the continuity of tendon fibrils indicative of partial tendon tear (arrows) Moreover note the presence of power Doppler signal within the interruption indicating still activity of the inflammatory process g Dactylitis Volar longitudinal scan using the ldquoextended viewrdquo technique showing proliferative tenosynovitis of the finger flexor tendon (circle) exudative synovitis of both proximal and distal interphalangeal joint (white asterisks) and edema of the peritendinous tissue (black asterisks) TP posterior tibial tendon mm medial malleolus DP distal phalanx mp middle phalanx cu cubital bone ft flexor tendons
Tenosynovitis of the posterior tibial (1) and flexor digitorum longus tendon (2)
Tibialis Posterior Tendon rupture
Tenosynovitis of the posterior tibial tendon the flexor digitorum tendon and flexor hallucis longus tendon
Tenosynovitis of the tendons on the medial side in the left ankle
bullLIGAMENT INJURIESThe ligament partial tear ligament shows a hypoechoic
areas swollen with internal focal or diffuse In the complete
ruptures within the substance of the divided ligament rift is
observed corresponding to the hematoma hypoechoic and
the free ends of the divided ligament can be and retracted
appreciated corrugated in contrast with normal
appearance straight
Grade I Mild stretching of the ligament without breakage
or instability
Grade II Partial tearing of the ligament
Grade III Complete tearing
Degrees depending on the severity of the injury and the
place of employment
LATERAL COMPARTMENTThese injuries occur secondary to inversion sprains with internal rotation of
the foot combined with ankle plantar flexion
The anterior talar fibular ligament tears (ATFL) usually occur as isolated
involvement (70) or associated with calcaneal fibular ligament (CFL) (20-40)
but the posterior talar fibular ligament (PTFL) affects only major trauma
involving ankle dislocation
ATFL breaks is associated with breakage of the joint capsule and synovial fluid
extravasation into the anterolateral soft ankle whereas the complete tearing of
CFL can communicate the ankle joint and synovial sheath peroneal tendons
Rupture of CFL is rarely associated with superior peroneal retinaculum tear
The CFL is tensioned during dorsiflexion pulling on peroneal tendons laterally
so that absence of its displacement is sign of a complete tear
Within a damaged ligament can also observe calcifications that often
correspond to fragments of avulsion bone
During the ultrasound can be performed forced maneuvers to detect to joint
laxity and ligament injuries The anterior drawer test is performed with the feet
hanging over the edge of the examination table while the forefoot is pulled
anteriorly when the foot is in plantar flexion and inversion This maneuver
helps differentiate partial tears (grade II) of the ATFL to complete (grade III)
where the anterior displacement of the talus on the tibia open a crack in the
substance becoming more visible the ligament injury
The sindesmosys sprains are up to 10 of ankle
injuries happening in eversion and pronation
movements (like the deltoid ligament injury) and
primarily affect the anterior tibiofibular ligament (ATFL)
the failure is frequently associated with fracture of the
fibula
According to the place of employment are 4 degrees
useful for prognostic evaluation and therapeutic strategy
choice
Grade I stretch or partial tear of the ATFL
Grade II complete tearing but only the ATFL
Grade III complete tear of the ATFL and partial CFL
Grade IV complete tear of the ATFL and CFL
The grade I and II injuries usually scarred without any
significant instability whereas grade III and IV injuries
can cause chronic pain and require surgical treatment
Thickened but continued ATFL right in relation to the partial rupture
Grade 111 sprain of right ATFL
Thickened anterior talofibular ligament with calcifications and a partial rupture
Thickened tibiofibular ligament after trauma
Anterior Talofibular Ligament Partial Tear and Elastography
Tibio fibular ligament rupture with bony avulsion
Complete rupture of right ATFL
Bony avulsion with radiographic evidence as visible calcification in a grade III sprain ATFL
Moderately thickened and hypoechoic ATFL
Discontinuity of the ATFL with fluid surrounding the torn ends (arrow)
Thickening and hypoechogenicity of the fibular end of the ligament seen here passing over the subtalar joint which contains a small of fluid
Complete disruption to the tibiofibular ligament with bony irregularity of particularly the tibial margin and fluid in the gap
MEDIAL COMPARTMENTBecause of the low incidence of eversion ankle
sprains and the thickness of the deltoid ligament
is rarely injured in isolation and when the injury
does not usually full thickness Usually
accompanied by lesions of the medial malleolus
and lateral displacement of the talus with
consequent widening of the ankle mortise
Ultrasound is useful for differentiating ligament
injury of the posterior tibial tendon injury
(TP) adjacent they have similar symptoms
The inability to visualize the deltoid ligament may
indicate tear but this is not considered a reliable
sign as its full ultrasound is not always possible
Partial medial ligament rupture
Thickened heterogeneous abnormal deltoid demonstrating hyperemia
Ultrasonogram showing a disrupted deltoid ligament with the probe in the coronal plane The white arrow indicates the medial malleolus the blue arrow indicates the talus and the red arrows indicate the disrupted deltoid ligament (A) Radiograph showing the same injury (B)
bullJOINT AND BONE DISORDERSUltrasound reliably detect spills mild (gt 2 ml) inside
of the ankle joint by exploring the front and rear
recess as well as areas of synovial proliferation and
may even display using the colour Doppler
hyperemic areas in arthritis patients
The intraarticular joints are displayed surrounded
fluid in one of the recesses of the ankle or subtalar
joint Sonographically diagnosed when changing position to perform flexion and extension Fracture of the lateral process of the talus is overlooked up to 50 of cases with plain radiography Ultrasound may suspect the presence of focal cortical disruption helping further to exclude concomitant ligament injury
Rheumatoid arthritis with synovial thickening (1) and erosion of the tibia (2)
Infectious arthritis with a pus filled anterior recess of the ankle
Arthritis and tenosynovitis of the ankle in a patient with rheumatoid arthritis
bullTUMOURSUltrasound can differentiate between a mass complex
and solid and a cystic in addition to verifying the
existence of accessory muscles (peroneus fourth
accessory flexor digitorum longus and accessory
soleus) As in any other location can be found
neoformative soft tissue tumors inflammatory
infectious etc
Ganglions of this location are more often symptomatic
and larger with multiple partitions
branched and lobed edges Differential diagnosis must
be made with tenosynovitis abscesses seromas and
varicosities
Neurogenic tumours are described as pathognomonic
homogeneous hypoechoic oval mass in continuity with
a nerve of origin
Ganglion cysts are non-malignant cystic masses that occur in association with musculoskeletal structures They are sometimes also simply referred to as ganglia or a ganglion but should not be confused with the anatomical term ganglion UltrasoundThe vast majority are anechoic to hypoechoic on ultrasound and have well defined margins Many demonstrate internal septations as well as acoustic enhancement A synovial cyst is a small fluid-filled sac or pouch that can develop over a tendon or joint creating a mass under the skin Synovial cyst is rare in ankle joint A synovial cyst may or may not be painful depending on their size and location
Ganglion cyst in the foot with bony erosion between navicular and cuneiform bones
Tarsal synovial cyst
Anechoic ganglion situated in the sinus tarsi fat between the talus and calcaneous
Plantar fasciitis (PF) refers to inflammation of the
plantar fascia of the foot It is considered the most common cause of heel pain
Clinical presentation Pain on the undersurface of the heel on weight bearing is the principal complaint It can be worse when weight is borne after a period of rest (eg in the morning) and eases with walking Passive dorsiflexion of the toes may exacerbates discomfort
UltrasoundOften the initial imaging modality of choice Ultrasound typically shows increased thickness of the fascia and a hypoechoic fascia
Thickened hypoechoic origin of the plantar fascia which has a convex superior margin
Complete avulsion of the plantar fascia from the calcaneal tubercle
Plantar fasciitis
bull LOCATING FOREIGN BODIES AND FRACTURES
As in any other location the ankle
area is also subsidiary host foreign
whose classification location and
existence can be defined perfectly by
ultrasound Being a focused study to
the area of interest and with great
resolution for surface structures can
be considered more resolute
examination to screen these cases
Osseous diseases and fractures | Sonography discovered Medial Malleolus Fracture
Ultrasound examination of left ankle A Longitudinal sonogram left ankle demonstrates a wooden foreign body B Transverse view left ankle Note the hypervascularity in the inflamed area C Corresponding X-ray of left ankle Note the swelling on the lateral aspect No foreign body is visible
Thank You
SCANNING TECHNIQUELATERAL 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 ANKLEPatient 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 mobilizing 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 calcaneumThe deltoid ligament Is poorly assessed with ultrasoundPosterior tibial nerve The neurovascular bundle is easily seen posterior to the medial malleolusPOSTERIOR 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 (Kagers) fat padThe calf muscles and plantaris tendon should also be assessed as clinically indicated
An ankle series should include the following minimum imagesPeroneus tendons - long trans + peroneus brevis insertionCalcaneo-fibular ligamentAnterior talo-fibula ligamentTibio-Fibula ligamentExtensor digitorum tendonExtensor hallucis longus tendonTibialis anterior tendonTibialis posterior tendonFlexor digitorum tendonFlexor hallucis longusAchilles tendon and retro calcaneal bursaDocument the normal anatomy Any pathology found in 2 planes(ligament tears or thickening synovial bulgingcysts joint effusion gross bony changes) including measurements and any vascularity
MAIN INDICATIONS OFTHE ANKLE ULTRASONOGRAPHIC STUDY
Tendon pathology of the different compartments
of the ankle
bull Evaluation of ligament injuries
bull Bone and joint disorders (synovitis chondral
and osteochondral lesions occult fractures)
bull Retroachilles and preachilles bursitis
bull Characterization of tumors (accessory muscles ganglia
neurogenic tumours soft tissue abscesses etc)
bull Localization of foreign bodies
ABNORMALITIES OF TENDONS
Tendon injuries include tenosynovitis tendinosis
rupture and instability
POSTERIOR COMPARTMENTACHILLES TENDINOPATHY
Can be classified as tendinosis and paratendinitis The isolated
paratendinitis shows intratendinous normal structure exist paratendinitis
spill shown irregularities in the edges of the tendon adhesions and
scarring associated paratendon and a heterogeneous aspect preachilles
fat pad In the tendinosis there is in swelling of the tendon usually
bilateral and textural heterogeneity intratendinous focal hypoechoic areas
TEAR OF ACHILLESThe rupture site is located generally between the 2 and 6 cm from the insertion into the calcaneous in the called critical zone of relative hypovascularityIn ultrasound complete rupture of the Achilles tendon is seen as a focal defect
between the broken ends of the tendon In the acute phase ends are contiguous but the defect may be filled by the anechoic or hypoechoic hematoma In most cases paratendon remains intact as a envelope straight echogenic contouring breakage As a sign associated can exist distortion of the fibrillar configuration and loss of parallelism of the tendon fibers Other signs are indicative fat herniation into the defect better visualization of the plantar tendon and the existence of a posterior acoustic shadowing at the site of the tear (useful sign to differentiate partial thickness tears)
Complete rupture of the Achilles tendon with focal defect between
the ends of the tendon and posterior acoustic shadowing at the
site of the tear useful sign to differentiate partial thickness tears
Patient with psoriasis which identifies tendinosis and Achilles tendon swelling
bilateral and textural heterogeneity with intratendinous focal hypoechoic areas
Ultrasound and radiological correlation calcified Achilles
enthesitis Calcaneal spur as associated finding
Discreetly thickened right Achilles tendon at its insertion combining linear hyperechoic
and hypoechoic areas on small breaks intrasubstance and calcifications of the enthesis
Fat herniation into the defect by complete tear of the Achilles tendon
Complete tear of the Achilles tendon with retraction
of ends and integrity thin plantaris tendon
Tendinosis versus partial tear of Achilles tendon
bullPREACHILLES AND RETROACHILLES BURSITIS
Although bursitis can occur in isolation often are
related and systemic inflammatory diseases
In the ultrasound examination the distended
retrocalcaneal and preachilles appears are a
hypoechoic structure shaped coma interposed
between the Achilles tendon and the posterosuperior
aspect of the calcaneous Care must be taken not to
confuse it with the fatty space Kager containing oval
lobules of hyperechoic fat When bursitis is a
manifestation of synovitis is appreciated
hypervascular area with Doppler ultrasound
In the retroachilles bursitis exists thickening and
collection of fluid in the subcutaneous tissue
superficial to the tendon retrocalcaneal portion
Bursitis preachilles with typical morphology appreciating accumulation of fluid
in a coma between the anterior portion of the Achilles tendon and the calcaneous
Bursitis preachiacutelea that associated synovitis showing hyperemia with increased Doppler flow
Rheumatoid arthritis with retrocalcaneal bursitis (1) and calcaneal erosions (2)
ACCESSORY NAVICULAR BONEIn the distal insertion site may exist TP 2 types of bones
accessories
Accessory navicular bone type I (os tibiale externum) size
between the 2 and 6 mm can be contained within the TP and
being positioned immediately proximal posteromedial to the
navicular bone It generally produces symptoms and should
not be confused with a tendon calcification or avulsion
fracture
Type II accessory navicular bone is an accessory
ossification centre of the navicular bone with size between
9 and 12 mm triangular shaped and articulated through a
synchondrosis of the posterior and medial navicular bone
It insertion site of some fibers of TP and is associated with a
syndrome of pain and increased incidence of tendon rupture
caused by abnormal overloads Osteoarthritic changes may
underlie this synchondrosis which mimic tendon pathology
Accessory navicular bone within the posterior tibial tendon as anatomical variant
ANTERIOR COMPARTMENTThe tendons of the anterior ankle compared
with the rest of the ankle tendons are rarely
affected by disease The anterior tibial tendon
is the most prone to abnormalities like
tendinopathy tenosynovitis and its place
between the most frequent rupture is extensor
retinaculum and insertion into the first
cuneiform and the base of the first metatarsal
Sometimes the retracted tendon stump causes
a nodule on the anteromedial aspect of the
distal portion of the leg making clinically
confused with a tumour or cyst
Distal insertion tendinopathy of the anterior tibial tendon with increased vascularity
Tenosynovitis of the anterior tibial tendon with effusion
Anterior tibial tendon tenosynovitis with intratendinous ruptures
Anterior tibial tendon rupture with retraction of the tendon
Tenosynovitis of the extensor digitorum tendons with a synovial effusion
Tenosynovitis of the extensor digitorum tendon with hypervascularized thickened tendon and synovium and synovial fluid
Rheumatoid arthritis with tenosynovitis of the extensor digitorum and peroneal tendons
Thickening of the extensor hallucis longus tendon caused by osteosynthesis material
Multicystic non vascularized intramuscular mass in the extensor digitorum brevis muscle
LATERAL COMPARTMENTTENOSYNOVITIS OF THE PERONEAL TENDONSThe main sign of ultrasound is the presence of liquid inside the
common synovial sheath whereas usually tendinous
morphology is preserved We must differentiate tenosynovitis of
a spill within the common peroneal sheath secondary to a tear of
calcaneofibular ligament (PCL) The ultrasound diagnosis is the detection of the tendons in a lateral plane relative to the distal portion of the lateral malleolus instead of behind it The dynamic exploration foot dorsiflexion as both eversion may help identify cases of intermittent subluxation In long-standing disease can be observed fusiform thickening
of the peroneal tendons at the tip of the malleolus The complete tears of the peroneus brevis tendon (PC) and peroneus longus (PL) are rare occurring in the area of the lateral malleolus or midfoot Seen in patients with ankle sprains or history of chronic instability especially if they suffer widespread diseases (RA DM) or treated with corticosteroids The peroneal tendon ruptures causing the inability to eversion of the foot and cavus foot varus
Important thickening of both peroneal tendons (longus and brevis) associated
with moderate amount of fluid and thickening of the synovial sheath
Discreet amount of fluid in the common sheath of the peroneal tendons
associated with disorganization and a heterogeneous appearance
peroneus brevis tendon related to longitudinal rupture
Peroneal tenosynovitis and osteosynthesis
Tenosynovitis of the peroneal tendons and an intratendinous rupture of the short peroneal tendon
Intratendinous rupture and cyst in the peroneus brevis tendon
Peroneus quartus with an accessory muscle next to the peroneus longus and brevis tendons
Tumor next to the peroneal tendons that proved to be a benign fibrous mass
MEDIAL COMPARTMENT
ANOMALIES POSTERIOR TIBIAL TENDON (TP)
It is the most frequently injured in this compartment with ruptures
in asymptomatic middle-aged obese women as a result of
widespread disease (RA seronegative Spondyloarthropathy) or
associated with bone fractures It causes a gradual collapse of the
medial longitudinal arch with hindfoot valgus deformity and
excessive forefoot pronation
The presence of small vessels in inflammatory diseases
intratendinosis can simulate a fissuration tendon confusion can be ignored using colour Doppler Another possible diagnostic difficulty is when the undamaged tendon flexor digitorum longus (FLD) moves back and simulates the TP unbroken but it is smaller and in this case we only see in the groove retromalleolar 1 only tendon
Ultrasound has also proven to be an effective resource for identifying alterations associated tendon tenosynovitis serosa and hypertrophicSubluxation and dislocation anteriorly and medial TP relative to internal
malleolus is rare and valued sonographically placing the foot in dorsiflexion with forced supination
Thickening moderate amount of fluid surrounding calcifications and
hyperemia affecting the sheath and the posterior tibial tendon related
to chronic tenosynovitis in patient affects rheumatoid arthritis
Thickening moderate amount of surrounding fluid and calcifications (arrow) affecting the
posterior tibial tendon related to chronic tenosynovitis in patient affects rheumatoid arthritis
Tenosynovitis of the posterior tibial tendon caused by a bony ridge at the insertion of the retinaculum The retinaculum is thickened and the tendon subluxates
Psoriatic arthritis Ankle Grayscale examination Posterior tibial tendon on longitudinal (a) and transverse (b) scan Marked tendon sheath widening with homogeneous anechoic aspect (asterisks) of the content indicating an exudative tenosynovitis Note as the normal fibrillar echotexture is conserved Hand Flexor tendons of second finger The volar longitudinal (c) and transverse scan (d) shows a tendon sheath widening with signs of synovial proliferation presence of intense power Doppler signal surrounding the tendon and micro interruption of the margin (arrow) e Wrist Extensor carpi ulnaris tendon (sixth compartment of the extensor tendons ecu) on lateral longitudinal (e) and transverse (f) scan Chronic tenosynovitis with clear areas of low of echogenicity and loss of the continuity of tendon fibrils indicative of partial tendon tear (arrows) Moreover note the presence of power Doppler signal within the interruption indicating still activity of the inflammatory process g Dactylitis Volar longitudinal scan using the ldquoextended viewrdquo technique showing proliferative tenosynovitis of the finger flexor tendon (circle) exudative synovitis of both proximal and distal interphalangeal joint (white asterisks) and edema of the peritendinous tissue (black asterisks) TP posterior tibial tendon mm medial malleolus DP distal phalanx mp middle phalanx cu cubital bone ft flexor tendons
Tenosynovitis of the posterior tibial (1) and flexor digitorum longus tendon (2)
Tibialis Posterior Tendon rupture
Tenosynovitis of the posterior tibial tendon the flexor digitorum tendon and flexor hallucis longus tendon
Tenosynovitis of the tendons on the medial side in the left ankle
bullLIGAMENT INJURIESThe ligament partial tear ligament shows a hypoechoic
areas swollen with internal focal or diffuse In the complete
ruptures within the substance of the divided ligament rift is
observed corresponding to the hematoma hypoechoic and
the free ends of the divided ligament can be and retracted
appreciated corrugated in contrast with normal
appearance straight
Grade I Mild stretching of the ligament without breakage
or instability
Grade II Partial tearing of the ligament
Grade III Complete tearing
Degrees depending on the severity of the injury and the
place of employment
LATERAL COMPARTMENTThese injuries occur secondary to inversion sprains with internal rotation of
the foot combined with ankle plantar flexion
The anterior talar fibular ligament tears (ATFL) usually occur as isolated
involvement (70) or associated with calcaneal fibular ligament (CFL) (20-40)
but the posterior talar fibular ligament (PTFL) affects only major trauma
involving ankle dislocation
ATFL breaks is associated with breakage of the joint capsule and synovial fluid
extravasation into the anterolateral soft ankle whereas the complete tearing of
CFL can communicate the ankle joint and synovial sheath peroneal tendons
Rupture of CFL is rarely associated with superior peroneal retinaculum tear
The CFL is tensioned during dorsiflexion pulling on peroneal tendons laterally
so that absence of its displacement is sign of a complete tear
Within a damaged ligament can also observe calcifications that often
correspond to fragments of avulsion bone
During the ultrasound can be performed forced maneuvers to detect to joint
laxity and ligament injuries The anterior drawer test is performed with the feet
hanging over the edge of the examination table while the forefoot is pulled
anteriorly when the foot is in plantar flexion and inversion This maneuver
helps differentiate partial tears (grade II) of the ATFL to complete (grade III)
where the anterior displacement of the talus on the tibia open a crack in the
substance becoming more visible the ligament injury
The sindesmosys sprains are up to 10 of ankle
injuries happening in eversion and pronation
movements (like the deltoid ligament injury) and
primarily affect the anterior tibiofibular ligament (ATFL)
the failure is frequently associated with fracture of the
fibula
According to the place of employment are 4 degrees
useful for prognostic evaluation and therapeutic strategy
choice
Grade I stretch or partial tear of the ATFL
Grade II complete tearing but only the ATFL
Grade III complete tear of the ATFL and partial CFL
Grade IV complete tear of the ATFL and CFL
The grade I and II injuries usually scarred without any
significant instability whereas grade III and IV injuries
can cause chronic pain and require surgical treatment
Thickened but continued ATFL right in relation to the partial rupture
Grade 111 sprain of right ATFL
Thickened anterior talofibular ligament with calcifications and a partial rupture
Thickened tibiofibular ligament after trauma
Anterior Talofibular Ligament Partial Tear and Elastography
Tibio fibular ligament rupture with bony avulsion
Complete rupture of right ATFL
Bony avulsion with radiographic evidence as visible calcification in a grade III sprain ATFL
Moderately thickened and hypoechoic ATFL
Discontinuity of the ATFL with fluid surrounding the torn ends (arrow)
Thickening and hypoechogenicity of the fibular end of the ligament seen here passing over the subtalar joint which contains a small of fluid
Complete disruption to the tibiofibular ligament with bony irregularity of particularly the tibial margin and fluid in the gap
MEDIAL COMPARTMENTBecause of the low incidence of eversion ankle
sprains and the thickness of the deltoid ligament
is rarely injured in isolation and when the injury
does not usually full thickness Usually
accompanied by lesions of the medial malleolus
and lateral displacement of the talus with
consequent widening of the ankle mortise
Ultrasound is useful for differentiating ligament
injury of the posterior tibial tendon injury
(TP) adjacent they have similar symptoms
The inability to visualize the deltoid ligament may
indicate tear but this is not considered a reliable
sign as its full ultrasound is not always possible
Partial medial ligament rupture
Thickened heterogeneous abnormal deltoid demonstrating hyperemia
Ultrasonogram showing a disrupted deltoid ligament with the probe in the coronal plane The white arrow indicates the medial malleolus the blue arrow indicates the talus and the red arrows indicate the disrupted deltoid ligament (A) Radiograph showing the same injury (B)
bullJOINT AND BONE DISORDERSUltrasound reliably detect spills mild (gt 2 ml) inside
of the ankle joint by exploring the front and rear
recess as well as areas of synovial proliferation and
may even display using the colour Doppler
hyperemic areas in arthritis patients
The intraarticular joints are displayed surrounded
fluid in one of the recesses of the ankle or subtalar
joint Sonographically diagnosed when changing position to perform flexion and extension Fracture of the lateral process of the talus is overlooked up to 50 of cases with plain radiography Ultrasound may suspect the presence of focal cortical disruption helping further to exclude concomitant ligament injury
Rheumatoid arthritis with synovial thickening (1) and erosion of the tibia (2)
Infectious arthritis with a pus filled anterior recess of the ankle
Arthritis and tenosynovitis of the ankle in a patient with rheumatoid arthritis
bullTUMOURSUltrasound can differentiate between a mass complex
and solid and a cystic in addition to verifying the
existence of accessory muscles (peroneus fourth
accessory flexor digitorum longus and accessory
soleus) As in any other location can be found
neoformative soft tissue tumors inflammatory
infectious etc
Ganglions of this location are more often symptomatic
and larger with multiple partitions
branched and lobed edges Differential diagnosis must
be made with tenosynovitis abscesses seromas and
varicosities
Neurogenic tumours are described as pathognomonic
homogeneous hypoechoic oval mass in continuity with
a nerve of origin
Ganglion cysts are non-malignant cystic masses that occur in association with musculoskeletal structures They are sometimes also simply referred to as ganglia or a ganglion but should not be confused with the anatomical term ganglion UltrasoundThe vast majority are anechoic to hypoechoic on ultrasound and have well defined margins Many demonstrate internal septations as well as acoustic enhancement A synovial cyst is a small fluid-filled sac or pouch that can develop over a tendon or joint creating a mass under the skin Synovial cyst is rare in ankle joint A synovial cyst may or may not be painful depending on their size and location
Ganglion cyst in the foot with bony erosion between navicular and cuneiform bones
Tarsal synovial cyst
Anechoic ganglion situated in the sinus tarsi fat between the talus and calcaneous
Plantar fasciitis (PF) refers to inflammation of the
plantar fascia of the foot It is considered the most common cause of heel pain
Clinical presentation Pain on the undersurface of the heel on weight bearing is the principal complaint It can be worse when weight is borne after a period of rest (eg in the morning) and eases with walking Passive dorsiflexion of the toes may exacerbates discomfort
UltrasoundOften the initial imaging modality of choice Ultrasound typically shows increased thickness of the fascia and a hypoechoic fascia
Thickened hypoechoic origin of the plantar fascia which has a convex superior margin
Complete avulsion of the plantar fascia from the calcaneal tubercle
Plantar fasciitis
bull LOCATING FOREIGN BODIES AND FRACTURES
As in any other location the ankle
area is also subsidiary host foreign
whose classification location and
existence can be defined perfectly by
ultrasound Being a focused study to
the area of interest and with great
resolution for surface structures can
be considered more resolute
examination to screen these cases
Osseous diseases and fractures | Sonography discovered Medial Malleolus Fracture
Ultrasound examination of left ankle A Longitudinal sonogram left ankle demonstrates a wooden foreign body B Transverse view left ankle Note the hypervascularity in the inflamed area C Corresponding X-ray of left ankle Note the swelling on the lateral aspect No foreign body is visible
Thank You
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 calcaneumThe deltoid ligament Is poorly assessed with ultrasoundPosterior tibial nerve The neurovascular bundle is easily seen posterior to the medial malleolusPOSTERIOR 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 (Kagers) fat padThe calf muscles and plantaris tendon should also be assessed as clinically indicated
An ankle series should include the following minimum imagesPeroneus tendons - long trans + peroneus brevis insertionCalcaneo-fibular ligamentAnterior talo-fibula ligamentTibio-Fibula ligamentExtensor digitorum tendonExtensor hallucis longus tendonTibialis anterior tendonTibialis posterior tendonFlexor digitorum tendonFlexor hallucis longusAchilles tendon and retro calcaneal bursaDocument the normal anatomy Any pathology found in 2 planes(ligament tears or thickening synovial bulgingcysts joint effusion gross bony changes) including measurements and any vascularity
MAIN INDICATIONS OFTHE ANKLE ULTRASONOGRAPHIC STUDY
Tendon pathology of the different compartments
of the ankle
bull Evaluation of ligament injuries
bull Bone and joint disorders (synovitis chondral
and osteochondral lesions occult fractures)
bull Retroachilles and preachilles bursitis
bull Characterization of tumors (accessory muscles ganglia
neurogenic tumours soft tissue abscesses etc)
bull Localization of foreign bodies
ABNORMALITIES OF TENDONS
Tendon injuries include tenosynovitis tendinosis
rupture and instability
POSTERIOR COMPARTMENTACHILLES TENDINOPATHY
Can be classified as tendinosis and paratendinitis The isolated
paratendinitis shows intratendinous normal structure exist paratendinitis
spill shown irregularities in the edges of the tendon adhesions and
scarring associated paratendon and a heterogeneous aspect preachilles
fat pad In the tendinosis there is in swelling of the tendon usually
bilateral and textural heterogeneity intratendinous focal hypoechoic areas
TEAR OF ACHILLESThe rupture site is located generally between the 2 and 6 cm from the insertion into the calcaneous in the called critical zone of relative hypovascularityIn ultrasound complete rupture of the Achilles tendon is seen as a focal defect
between the broken ends of the tendon In the acute phase ends are contiguous but the defect may be filled by the anechoic or hypoechoic hematoma In most cases paratendon remains intact as a envelope straight echogenic contouring breakage As a sign associated can exist distortion of the fibrillar configuration and loss of parallelism of the tendon fibers Other signs are indicative fat herniation into the defect better visualization of the plantar tendon and the existence of a posterior acoustic shadowing at the site of the tear (useful sign to differentiate partial thickness tears)
Complete rupture of the Achilles tendon with focal defect between
the ends of the tendon and posterior acoustic shadowing at the
site of the tear useful sign to differentiate partial thickness tears
Patient with psoriasis which identifies tendinosis and Achilles tendon swelling
bilateral and textural heterogeneity with intratendinous focal hypoechoic areas
Ultrasound and radiological correlation calcified Achilles
enthesitis Calcaneal spur as associated finding
Discreetly thickened right Achilles tendon at its insertion combining linear hyperechoic
and hypoechoic areas on small breaks intrasubstance and calcifications of the enthesis
Fat herniation into the defect by complete tear of the Achilles tendon
Complete tear of the Achilles tendon with retraction
of ends and integrity thin plantaris tendon
Tendinosis versus partial tear of Achilles tendon
bullPREACHILLES AND RETROACHILLES BURSITIS
Although bursitis can occur in isolation often are
related and systemic inflammatory diseases
In the ultrasound examination the distended
retrocalcaneal and preachilles appears are a
hypoechoic structure shaped coma interposed
between the Achilles tendon and the posterosuperior
aspect of the calcaneous Care must be taken not to
confuse it with the fatty space Kager containing oval
lobules of hyperechoic fat When bursitis is a
manifestation of synovitis is appreciated
hypervascular area with Doppler ultrasound
In the retroachilles bursitis exists thickening and
collection of fluid in the subcutaneous tissue
superficial to the tendon retrocalcaneal portion
Bursitis preachilles with typical morphology appreciating accumulation of fluid
in a coma between the anterior portion of the Achilles tendon and the calcaneous
Bursitis preachiacutelea that associated synovitis showing hyperemia with increased Doppler flow
Rheumatoid arthritis with retrocalcaneal bursitis (1) and calcaneal erosions (2)
ACCESSORY NAVICULAR BONEIn the distal insertion site may exist TP 2 types of bones
accessories
Accessory navicular bone type I (os tibiale externum) size
between the 2 and 6 mm can be contained within the TP and
being positioned immediately proximal posteromedial to the
navicular bone It generally produces symptoms and should
not be confused with a tendon calcification or avulsion
fracture
Type II accessory navicular bone is an accessory
ossification centre of the navicular bone with size between
9 and 12 mm triangular shaped and articulated through a
synchondrosis of the posterior and medial navicular bone
It insertion site of some fibers of TP and is associated with a
syndrome of pain and increased incidence of tendon rupture
caused by abnormal overloads Osteoarthritic changes may
underlie this synchondrosis which mimic tendon pathology
Accessory navicular bone within the posterior tibial tendon as anatomical variant
ANTERIOR COMPARTMENTThe tendons of the anterior ankle compared
with the rest of the ankle tendons are rarely
affected by disease The anterior tibial tendon
is the most prone to abnormalities like
tendinopathy tenosynovitis and its place
between the most frequent rupture is extensor
retinaculum and insertion into the first
cuneiform and the base of the first metatarsal
Sometimes the retracted tendon stump causes
a nodule on the anteromedial aspect of the
distal portion of the leg making clinically
confused with a tumour or cyst
Distal insertion tendinopathy of the anterior tibial tendon with increased vascularity
Tenosynovitis of the anterior tibial tendon with effusion
Anterior tibial tendon tenosynovitis with intratendinous ruptures
Anterior tibial tendon rupture with retraction of the tendon
Tenosynovitis of the extensor digitorum tendons with a synovial effusion
Tenosynovitis of the extensor digitorum tendon with hypervascularized thickened tendon and synovium and synovial fluid
Rheumatoid arthritis with tenosynovitis of the extensor digitorum and peroneal tendons
Thickening of the extensor hallucis longus tendon caused by osteosynthesis material
Multicystic non vascularized intramuscular mass in the extensor digitorum brevis muscle
LATERAL COMPARTMENTTENOSYNOVITIS OF THE PERONEAL TENDONSThe main sign of ultrasound is the presence of liquid inside the
common synovial sheath whereas usually tendinous
morphology is preserved We must differentiate tenosynovitis of
a spill within the common peroneal sheath secondary to a tear of
calcaneofibular ligament (PCL) The ultrasound diagnosis is the detection of the tendons in a lateral plane relative to the distal portion of the lateral malleolus instead of behind it The dynamic exploration foot dorsiflexion as both eversion may help identify cases of intermittent subluxation In long-standing disease can be observed fusiform thickening
of the peroneal tendons at the tip of the malleolus The complete tears of the peroneus brevis tendon (PC) and peroneus longus (PL) are rare occurring in the area of the lateral malleolus or midfoot Seen in patients with ankle sprains or history of chronic instability especially if they suffer widespread diseases (RA DM) or treated with corticosteroids The peroneal tendon ruptures causing the inability to eversion of the foot and cavus foot varus
Important thickening of both peroneal tendons (longus and brevis) associated
with moderate amount of fluid and thickening of the synovial sheath
Discreet amount of fluid in the common sheath of the peroneal tendons
associated with disorganization and a heterogeneous appearance
peroneus brevis tendon related to longitudinal rupture
Peroneal tenosynovitis and osteosynthesis
Tenosynovitis of the peroneal tendons and an intratendinous rupture of the short peroneal tendon
Intratendinous rupture and cyst in the peroneus brevis tendon
Peroneus quartus with an accessory muscle next to the peroneus longus and brevis tendons
Tumor next to the peroneal tendons that proved to be a benign fibrous mass
MEDIAL COMPARTMENT
ANOMALIES POSTERIOR TIBIAL TENDON (TP)
It is the most frequently injured in this compartment with ruptures
in asymptomatic middle-aged obese women as a result of
widespread disease (RA seronegative Spondyloarthropathy) or
associated with bone fractures It causes a gradual collapse of the
medial longitudinal arch with hindfoot valgus deformity and
excessive forefoot pronation
The presence of small vessels in inflammatory diseases
intratendinosis can simulate a fissuration tendon confusion can be ignored using colour Doppler Another possible diagnostic difficulty is when the undamaged tendon flexor digitorum longus (FLD) moves back and simulates the TP unbroken but it is smaller and in this case we only see in the groove retromalleolar 1 only tendon
Ultrasound has also proven to be an effective resource for identifying alterations associated tendon tenosynovitis serosa and hypertrophicSubluxation and dislocation anteriorly and medial TP relative to internal
malleolus is rare and valued sonographically placing the foot in dorsiflexion with forced supination
Thickening moderate amount of fluid surrounding calcifications and
hyperemia affecting the sheath and the posterior tibial tendon related
to chronic tenosynovitis in patient affects rheumatoid arthritis
Thickening moderate amount of surrounding fluid and calcifications (arrow) affecting the
posterior tibial tendon related to chronic tenosynovitis in patient affects rheumatoid arthritis
Tenosynovitis of the posterior tibial tendon caused by a bony ridge at the insertion of the retinaculum The retinaculum is thickened and the tendon subluxates
Psoriatic arthritis Ankle Grayscale examination Posterior tibial tendon on longitudinal (a) and transverse (b) scan Marked tendon sheath widening with homogeneous anechoic aspect (asterisks) of the content indicating an exudative tenosynovitis Note as the normal fibrillar echotexture is conserved Hand Flexor tendons of second finger The volar longitudinal (c) and transverse scan (d) shows a tendon sheath widening with signs of synovial proliferation presence of intense power Doppler signal surrounding the tendon and micro interruption of the margin (arrow) e Wrist Extensor carpi ulnaris tendon (sixth compartment of the extensor tendons ecu) on lateral longitudinal (e) and transverse (f) scan Chronic tenosynovitis with clear areas of low of echogenicity and loss of the continuity of tendon fibrils indicative of partial tendon tear (arrows) Moreover note the presence of power Doppler signal within the interruption indicating still activity of the inflammatory process g Dactylitis Volar longitudinal scan using the ldquoextended viewrdquo technique showing proliferative tenosynovitis of the finger flexor tendon (circle) exudative synovitis of both proximal and distal interphalangeal joint (white asterisks) and edema of the peritendinous tissue (black asterisks) TP posterior tibial tendon mm medial malleolus DP distal phalanx mp middle phalanx cu cubital bone ft flexor tendons
Tenosynovitis of the posterior tibial (1) and flexor digitorum longus tendon (2)
Tibialis Posterior Tendon rupture
Tenosynovitis of the posterior tibial tendon the flexor digitorum tendon and flexor hallucis longus tendon
Tenosynovitis of the tendons on the medial side in the left ankle
bullLIGAMENT INJURIESThe ligament partial tear ligament shows a hypoechoic
areas swollen with internal focal or diffuse In the complete
ruptures within the substance of the divided ligament rift is
observed corresponding to the hematoma hypoechoic and
the free ends of the divided ligament can be and retracted
appreciated corrugated in contrast with normal
appearance straight
Grade I Mild stretching of the ligament without breakage
or instability
Grade II Partial tearing of the ligament
Grade III Complete tearing
Degrees depending on the severity of the injury and the
place of employment
LATERAL COMPARTMENTThese injuries occur secondary to inversion sprains with internal rotation of
the foot combined with ankle plantar flexion
The anterior talar fibular ligament tears (ATFL) usually occur as isolated
involvement (70) or associated with calcaneal fibular ligament (CFL) (20-40)
but the posterior talar fibular ligament (PTFL) affects only major trauma
involving ankle dislocation
ATFL breaks is associated with breakage of the joint capsule and synovial fluid
extravasation into the anterolateral soft ankle whereas the complete tearing of
CFL can communicate the ankle joint and synovial sheath peroneal tendons
Rupture of CFL is rarely associated with superior peroneal retinaculum tear
The CFL is tensioned during dorsiflexion pulling on peroneal tendons laterally
so that absence of its displacement is sign of a complete tear
Within a damaged ligament can also observe calcifications that often
correspond to fragments of avulsion bone
During the ultrasound can be performed forced maneuvers to detect to joint
laxity and ligament injuries The anterior drawer test is performed with the feet
hanging over the edge of the examination table while the forefoot is pulled
anteriorly when the foot is in plantar flexion and inversion This maneuver
helps differentiate partial tears (grade II) of the ATFL to complete (grade III)
where the anterior displacement of the talus on the tibia open a crack in the
substance becoming more visible the ligament injury
The sindesmosys sprains are up to 10 of ankle
injuries happening in eversion and pronation
movements (like the deltoid ligament injury) and
primarily affect the anterior tibiofibular ligament (ATFL)
the failure is frequently associated with fracture of the
fibula
According to the place of employment are 4 degrees
useful for prognostic evaluation and therapeutic strategy
choice
Grade I stretch or partial tear of the ATFL
Grade II complete tearing but only the ATFL
Grade III complete tear of the ATFL and partial CFL
Grade IV complete tear of the ATFL and CFL
The grade I and II injuries usually scarred without any
significant instability whereas grade III and IV injuries
can cause chronic pain and require surgical treatment
Thickened but continued ATFL right in relation to the partial rupture
Grade 111 sprain of right ATFL
Thickened anterior talofibular ligament with calcifications and a partial rupture
Thickened tibiofibular ligament after trauma
Anterior Talofibular Ligament Partial Tear and Elastography
Tibio fibular ligament rupture with bony avulsion
Complete rupture of right ATFL
Bony avulsion with radiographic evidence as visible calcification in a grade III sprain ATFL
Moderately thickened and hypoechoic ATFL
Discontinuity of the ATFL with fluid surrounding the torn ends (arrow)
Thickening and hypoechogenicity of the fibular end of the ligament seen here passing over the subtalar joint which contains a small of fluid
Complete disruption to the tibiofibular ligament with bony irregularity of particularly the tibial margin and fluid in the gap
MEDIAL COMPARTMENTBecause of the low incidence of eversion ankle
sprains and the thickness of the deltoid ligament
is rarely injured in isolation and when the injury
does not usually full thickness Usually
accompanied by lesions of the medial malleolus
and lateral displacement of the talus with
consequent widening of the ankle mortise
Ultrasound is useful for differentiating ligament
injury of the posterior tibial tendon injury
(TP) adjacent they have similar symptoms
The inability to visualize the deltoid ligament may
indicate tear but this is not considered a reliable
sign as its full ultrasound is not always possible
Partial medial ligament rupture
Thickened heterogeneous abnormal deltoid demonstrating hyperemia
Ultrasonogram showing a disrupted deltoid ligament with the probe in the coronal plane The white arrow indicates the medial malleolus the blue arrow indicates the talus and the red arrows indicate the disrupted deltoid ligament (A) Radiograph showing the same injury (B)
bullJOINT AND BONE DISORDERSUltrasound reliably detect spills mild (gt 2 ml) inside
of the ankle joint by exploring the front and rear
recess as well as areas of synovial proliferation and
may even display using the colour Doppler
hyperemic areas in arthritis patients
The intraarticular joints are displayed surrounded
fluid in one of the recesses of the ankle or subtalar
joint Sonographically diagnosed when changing position to perform flexion and extension Fracture of the lateral process of the talus is overlooked up to 50 of cases with plain radiography Ultrasound may suspect the presence of focal cortical disruption helping further to exclude concomitant ligament injury
Rheumatoid arthritis with synovial thickening (1) and erosion of the tibia (2)
Infectious arthritis with a pus filled anterior recess of the ankle
Arthritis and tenosynovitis of the ankle in a patient with rheumatoid arthritis
bullTUMOURSUltrasound can differentiate between a mass complex
and solid and a cystic in addition to verifying the
existence of accessory muscles (peroneus fourth
accessory flexor digitorum longus and accessory
soleus) As in any other location can be found
neoformative soft tissue tumors inflammatory
infectious etc
Ganglions of this location are more often symptomatic
and larger with multiple partitions
branched and lobed edges Differential diagnosis must
be made with tenosynovitis abscesses seromas and
varicosities
Neurogenic tumours are described as pathognomonic
homogeneous hypoechoic oval mass in continuity with
a nerve of origin
Ganglion cysts are non-malignant cystic masses that occur in association with musculoskeletal structures They are sometimes also simply referred to as ganglia or a ganglion but should not be confused with the anatomical term ganglion UltrasoundThe vast majority are anechoic to hypoechoic on ultrasound and have well defined margins Many demonstrate internal septations as well as acoustic enhancement A synovial cyst is a small fluid-filled sac or pouch that can develop over a tendon or joint creating a mass under the skin Synovial cyst is rare in ankle joint A synovial cyst may or may not be painful depending on their size and location
Ganglion cyst in the foot with bony erosion between navicular and cuneiform bones
Tarsal synovial cyst
Anechoic ganglion situated in the sinus tarsi fat between the talus and calcaneous
Plantar fasciitis (PF) refers to inflammation of the
plantar fascia of the foot It is considered the most common cause of heel pain
Clinical presentation Pain on the undersurface of the heel on weight bearing is the principal complaint It can be worse when weight is borne after a period of rest (eg in the morning) and eases with walking Passive dorsiflexion of the toes may exacerbates discomfort
UltrasoundOften the initial imaging modality of choice Ultrasound typically shows increased thickness of the fascia and a hypoechoic fascia
Thickened hypoechoic origin of the plantar fascia which has a convex superior margin
Complete avulsion of the plantar fascia from the calcaneal tubercle
Plantar fasciitis
bull LOCATING FOREIGN BODIES AND FRACTURES
As in any other location the ankle
area is also subsidiary host foreign
whose classification location and
existence can be defined perfectly by
ultrasound Being a focused study to
the area of interest and with great
resolution for surface structures can
be considered more resolute
examination to screen these cases
Osseous diseases and fractures | Sonography discovered Medial Malleolus Fracture
Ultrasound examination of left ankle A Longitudinal sonogram left ankle demonstrates a wooden foreign body B Transverse view left ankle Note the hypervascularity in the inflamed area C Corresponding X-ray of left ankle Note the swelling on the lateral aspect No foreign body is visible
Thank You
An ankle series should include the following minimum imagesPeroneus tendons - long trans + peroneus brevis insertionCalcaneo-fibular ligamentAnterior talo-fibula ligamentTibio-Fibula ligamentExtensor digitorum tendonExtensor hallucis longus tendonTibialis anterior tendonTibialis posterior tendonFlexor digitorum tendonFlexor hallucis longusAchilles tendon and retro calcaneal bursaDocument the normal anatomy Any pathology found in 2 planes(ligament tears or thickening synovial bulgingcysts joint effusion gross bony changes) including measurements and any vascularity
MAIN INDICATIONS OFTHE ANKLE ULTRASONOGRAPHIC STUDY
Tendon pathology of the different compartments
of the ankle
bull Evaluation of ligament injuries
bull Bone and joint disorders (synovitis chondral
and osteochondral lesions occult fractures)
bull Retroachilles and preachilles bursitis
bull Characterization of tumors (accessory muscles ganglia
neurogenic tumours soft tissue abscesses etc)
bull Localization of foreign bodies
ABNORMALITIES OF TENDONS
Tendon injuries include tenosynovitis tendinosis
rupture and instability
POSTERIOR COMPARTMENTACHILLES TENDINOPATHY
Can be classified as tendinosis and paratendinitis The isolated
paratendinitis shows intratendinous normal structure exist paratendinitis
spill shown irregularities in the edges of the tendon adhesions and
scarring associated paratendon and a heterogeneous aspect preachilles
fat pad In the tendinosis there is in swelling of the tendon usually
bilateral and textural heterogeneity intratendinous focal hypoechoic areas
TEAR OF ACHILLESThe rupture site is located generally between the 2 and 6 cm from the insertion into the calcaneous in the called critical zone of relative hypovascularityIn ultrasound complete rupture of the Achilles tendon is seen as a focal defect
between the broken ends of the tendon In the acute phase ends are contiguous but the defect may be filled by the anechoic or hypoechoic hematoma In most cases paratendon remains intact as a envelope straight echogenic contouring breakage As a sign associated can exist distortion of the fibrillar configuration and loss of parallelism of the tendon fibers Other signs are indicative fat herniation into the defect better visualization of the plantar tendon and the existence of a posterior acoustic shadowing at the site of the tear (useful sign to differentiate partial thickness tears)
Complete rupture of the Achilles tendon with focal defect between
the ends of the tendon and posterior acoustic shadowing at the
site of the tear useful sign to differentiate partial thickness tears
Patient with psoriasis which identifies tendinosis and Achilles tendon swelling
bilateral and textural heterogeneity with intratendinous focal hypoechoic areas
Ultrasound and radiological correlation calcified Achilles
enthesitis Calcaneal spur as associated finding
Discreetly thickened right Achilles tendon at its insertion combining linear hyperechoic
and hypoechoic areas on small breaks intrasubstance and calcifications of the enthesis
Fat herniation into the defect by complete tear of the Achilles tendon
Complete tear of the Achilles tendon with retraction
of ends and integrity thin plantaris tendon
Tendinosis versus partial tear of Achilles tendon
bullPREACHILLES AND RETROACHILLES BURSITIS
Although bursitis can occur in isolation often are
related and systemic inflammatory diseases
In the ultrasound examination the distended
retrocalcaneal and preachilles appears are a
hypoechoic structure shaped coma interposed
between the Achilles tendon and the posterosuperior
aspect of the calcaneous Care must be taken not to
confuse it with the fatty space Kager containing oval
lobules of hyperechoic fat When bursitis is a
manifestation of synovitis is appreciated
hypervascular area with Doppler ultrasound
In the retroachilles bursitis exists thickening and
collection of fluid in the subcutaneous tissue
superficial to the tendon retrocalcaneal portion
Bursitis preachilles with typical morphology appreciating accumulation of fluid
in a coma between the anterior portion of the Achilles tendon and the calcaneous
Bursitis preachiacutelea that associated synovitis showing hyperemia with increased Doppler flow
Rheumatoid arthritis with retrocalcaneal bursitis (1) and calcaneal erosions (2)
ACCESSORY NAVICULAR BONEIn the distal insertion site may exist TP 2 types of bones
accessories
Accessory navicular bone type I (os tibiale externum) size
between the 2 and 6 mm can be contained within the TP and
being positioned immediately proximal posteromedial to the
navicular bone It generally produces symptoms and should
not be confused with a tendon calcification or avulsion
fracture
Type II accessory navicular bone is an accessory
ossification centre of the navicular bone with size between
9 and 12 mm triangular shaped and articulated through a
synchondrosis of the posterior and medial navicular bone
It insertion site of some fibers of TP and is associated with a
syndrome of pain and increased incidence of tendon rupture
caused by abnormal overloads Osteoarthritic changes may
underlie this synchondrosis which mimic tendon pathology
Accessory navicular bone within the posterior tibial tendon as anatomical variant
ANTERIOR COMPARTMENTThe tendons of the anterior ankle compared
with the rest of the ankle tendons are rarely
affected by disease The anterior tibial tendon
is the most prone to abnormalities like
tendinopathy tenosynovitis and its place
between the most frequent rupture is extensor
retinaculum and insertion into the first
cuneiform and the base of the first metatarsal
Sometimes the retracted tendon stump causes
a nodule on the anteromedial aspect of the
distal portion of the leg making clinically
confused with a tumour or cyst
Distal insertion tendinopathy of the anterior tibial tendon with increased vascularity
Tenosynovitis of the anterior tibial tendon with effusion
Anterior tibial tendon tenosynovitis with intratendinous ruptures
Anterior tibial tendon rupture with retraction of the tendon
Tenosynovitis of the extensor digitorum tendons with a synovial effusion
Tenosynovitis of the extensor digitorum tendon with hypervascularized thickened tendon and synovium and synovial fluid
Rheumatoid arthritis with tenosynovitis of the extensor digitorum and peroneal tendons
Thickening of the extensor hallucis longus tendon caused by osteosynthesis material
Multicystic non vascularized intramuscular mass in the extensor digitorum brevis muscle
LATERAL COMPARTMENTTENOSYNOVITIS OF THE PERONEAL TENDONSThe main sign of ultrasound is the presence of liquid inside the
common synovial sheath whereas usually tendinous
morphology is preserved We must differentiate tenosynovitis of
a spill within the common peroneal sheath secondary to a tear of
calcaneofibular ligament (PCL) The ultrasound diagnosis is the detection of the tendons in a lateral plane relative to the distal portion of the lateral malleolus instead of behind it The dynamic exploration foot dorsiflexion as both eversion may help identify cases of intermittent subluxation In long-standing disease can be observed fusiform thickening
of the peroneal tendons at the tip of the malleolus The complete tears of the peroneus brevis tendon (PC) and peroneus longus (PL) are rare occurring in the area of the lateral malleolus or midfoot Seen in patients with ankle sprains or history of chronic instability especially if they suffer widespread diseases (RA DM) or treated with corticosteroids The peroneal tendon ruptures causing the inability to eversion of the foot and cavus foot varus
Important thickening of both peroneal tendons (longus and brevis) associated
with moderate amount of fluid and thickening of the synovial sheath
Discreet amount of fluid in the common sheath of the peroneal tendons
associated with disorganization and a heterogeneous appearance
peroneus brevis tendon related to longitudinal rupture
Peroneal tenosynovitis and osteosynthesis
Tenosynovitis of the peroneal tendons and an intratendinous rupture of the short peroneal tendon
Intratendinous rupture and cyst in the peroneus brevis tendon
Peroneus quartus with an accessory muscle next to the peroneus longus and brevis tendons
Tumor next to the peroneal tendons that proved to be a benign fibrous mass
MEDIAL COMPARTMENT
ANOMALIES POSTERIOR TIBIAL TENDON (TP)
It is the most frequently injured in this compartment with ruptures
in asymptomatic middle-aged obese women as a result of
widespread disease (RA seronegative Spondyloarthropathy) or
associated with bone fractures It causes a gradual collapse of the
medial longitudinal arch with hindfoot valgus deformity and
excessive forefoot pronation
The presence of small vessels in inflammatory diseases
intratendinosis can simulate a fissuration tendon confusion can be ignored using colour Doppler Another possible diagnostic difficulty is when the undamaged tendon flexor digitorum longus (FLD) moves back and simulates the TP unbroken but it is smaller and in this case we only see in the groove retromalleolar 1 only tendon
Ultrasound has also proven to be an effective resource for identifying alterations associated tendon tenosynovitis serosa and hypertrophicSubluxation and dislocation anteriorly and medial TP relative to internal
malleolus is rare and valued sonographically placing the foot in dorsiflexion with forced supination
Thickening moderate amount of fluid surrounding calcifications and
hyperemia affecting the sheath and the posterior tibial tendon related
to chronic tenosynovitis in patient affects rheumatoid arthritis
Thickening moderate amount of surrounding fluid and calcifications (arrow) affecting the
posterior tibial tendon related to chronic tenosynovitis in patient affects rheumatoid arthritis
Tenosynovitis of the posterior tibial tendon caused by a bony ridge at the insertion of the retinaculum The retinaculum is thickened and the tendon subluxates
Psoriatic arthritis Ankle Grayscale examination Posterior tibial tendon on longitudinal (a) and transverse (b) scan Marked tendon sheath widening with homogeneous anechoic aspect (asterisks) of the content indicating an exudative tenosynovitis Note as the normal fibrillar echotexture is conserved Hand Flexor tendons of second finger The volar longitudinal (c) and transverse scan (d) shows a tendon sheath widening with signs of synovial proliferation presence of intense power Doppler signal surrounding the tendon and micro interruption of the margin (arrow) e Wrist Extensor carpi ulnaris tendon (sixth compartment of the extensor tendons ecu) on lateral longitudinal (e) and transverse (f) scan Chronic tenosynovitis with clear areas of low of echogenicity and loss of the continuity of tendon fibrils indicative of partial tendon tear (arrows) Moreover note the presence of power Doppler signal within the interruption indicating still activity of the inflammatory process g Dactylitis Volar longitudinal scan using the ldquoextended viewrdquo technique showing proliferative tenosynovitis of the finger flexor tendon (circle) exudative synovitis of both proximal and distal interphalangeal joint (white asterisks) and edema of the peritendinous tissue (black asterisks) TP posterior tibial tendon mm medial malleolus DP distal phalanx mp middle phalanx cu cubital bone ft flexor tendons
Tenosynovitis of the posterior tibial (1) and flexor digitorum longus tendon (2)
Tibialis Posterior Tendon rupture
Tenosynovitis of the posterior tibial tendon the flexor digitorum tendon and flexor hallucis longus tendon
Tenosynovitis of the tendons on the medial side in the left ankle
bullLIGAMENT INJURIESThe ligament partial tear ligament shows a hypoechoic
areas swollen with internal focal or diffuse In the complete
ruptures within the substance of the divided ligament rift is
observed corresponding to the hematoma hypoechoic and
the free ends of the divided ligament can be and retracted
appreciated corrugated in contrast with normal
appearance straight
Grade I Mild stretching of the ligament without breakage
or instability
Grade II Partial tearing of the ligament
Grade III Complete tearing
Degrees depending on the severity of the injury and the
place of employment
LATERAL COMPARTMENTThese injuries occur secondary to inversion sprains with internal rotation of
the foot combined with ankle plantar flexion
The anterior talar fibular ligament tears (ATFL) usually occur as isolated
involvement (70) or associated with calcaneal fibular ligament (CFL) (20-40)
but the posterior talar fibular ligament (PTFL) affects only major trauma
involving ankle dislocation
ATFL breaks is associated with breakage of the joint capsule and synovial fluid
extravasation into the anterolateral soft ankle whereas the complete tearing of
CFL can communicate the ankle joint and synovial sheath peroneal tendons
Rupture of CFL is rarely associated with superior peroneal retinaculum tear
The CFL is tensioned during dorsiflexion pulling on peroneal tendons laterally
so that absence of its displacement is sign of a complete tear
Within a damaged ligament can also observe calcifications that often
correspond to fragments of avulsion bone
During the ultrasound can be performed forced maneuvers to detect to joint
laxity and ligament injuries The anterior drawer test is performed with the feet
hanging over the edge of the examination table while the forefoot is pulled
anteriorly when the foot is in plantar flexion and inversion This maneuver
helps differentiate partial tears (grade II) of the ATFL to complete (grade III)
where the anterior displacement of the talus on the tibia open a crack in the
substance becoming more visible the ligament injury
The sindesmosys sprains are up to 10 of ankle
injuries happening in eversion and pronation
movements (like the deltoid ligament injury) and
primarily affect the anterior tibiofibular ligament (ATFL)
the failure is frequently associated with fracture of the
fibula
According to the place of employment are 4 degrees
useful for prognostic evaluation and therapeutic strategy
choice
Grade I stretch or partial tear of the ATFL
Grade II complete tearing but only the ATFL
Grade III complete tear of the ATFL and partial CFL
Grade IV complete tear of the ATFL and CFL
The grade I and II injuries usually scarred without any
significant instability whereas grade III and IV injuries
can cause chronic pain and require surgical treatment
Thickened but continued ATFL right in relation to the partial rupture
Grade 111 sprain of right ATFL
Thickened anterior talofibular ligament with calcifications and a partial rupture
Thickened tibiofibular ligament after trauma
Anterior Talofibular Ligament Partial Tear and Elastography
Tibio fibular ligament rupture with bony avulsion
Complete rupture of right ATFL
Bony avulsion with radiographic evidence as visible calcification in a grade III sprain ATFL
Moderately thickened and hypoechoic ATFL
Discontinuity of the ATFL with fluid surrounding the torn ends (arrow)
Thickening and hypoechogenicity of the fibular end of the ligament seen here passing over the subtalar joint which contains a small of fluid
Complete disruption to the tibiofibular ligament with bony irregularity of particularly the tibial margin and fluid in the gap
MEDIAL COMPARTMENTBecause of the low incidence of eversion ankle
sprains and the thickness of the deltoid ligament
is rarely injured in isolation and when the injury
does not usually full thickness Usually
accompanied by lesions of the medial malleolus
and lateral displacement of the talus with
consequent widening of the ankle mortise
Ultrasound is useful for differentiating ligament
injury of the posterior tibial tendon injury
(TP) adjacent they have similar symptoms
The inability to visualize the deltoid ligament may
indicate tear but this is not considered a reliable
sign as its full ultrasound is not always possible
Partial medial ligament rupture
Thickened heterogeneous abnormal deltoid demonstrating hyperemia
Ultrasonogram showing a disrupted deltoid ligament with the probe in the coronal plane The white arrow indicates the medial malleolus the blue arrow indicates the talus and the red arrows indicate the disrupted deltoid ligament (A) Radiograph showing the same injury (B)
bullJOINT AND BONE DISORDERSUltrasound reliably detect spills mild (gt 2 ml) inside
of the ankle joint by exploring the front and rear
recess as well as areas of synovial proliferation and
may even display using the colour Doppler
hyperemic areas in arthritis patients
The intraarticular joints are displayed surrounded
fluid in one of the recesses of the ankle or subtalar
joint Sonographically diagnosed when changing position to perform flexion and extension Fracture of the lateral process of the talus is overlooked up to 50 of cases with plain radiography Ultrasound may suspect the presence of focal cortical disruption helping further to exclude concomitant ligament injury
Rheumatoid arthritis with synovial thickening (1) and erosion of the tibia (2)
Infectious arthritis with a pus filled anterior recess of the ankle
Arthritis and tenosynovitis of the ankle in a patient with rheumatoid arthritis
bullTUMOURSUltrasound can differentiate between a mass complex
and solid and a cystic in addition to verifying the
existence of accessory muscles (peroneus fourth
accessory flexor digitorum longus and accessory
soleus) As in any other location can be found
neoformative soft tissue tumors inflammatory
infectious etc
Ganglions of this location are more often symptomatic
and larger with multiple partitions
branched and lobed edges Differential diagnosis must
be made with tenosynovitis abscesses seromas and
varicosities
Neurogenic tumours are described as pathognomonic
homogeneous hypoechoic oval mass in continuity with
a nerve of origin
Ganglion cysts are non-malignant cystic masses that occur in association with musculoskeletal structures They are sometimes also simply referred to as ganglia or a ganglion but should not be confused with the anatomical term ganglion UltrasoundThe vast majority are anechoic to hypoechoic on ultrasound and have well defined margins Many demonstrate internal septations as well as acoustic enhancement A synovial cyst is a small fluid-filled sac or pouch that can develop over a tendon or joint creating a mass under the skin Synovial cyst is rare in ankle joint A synovial cyst may or may not be painful depending on their size and location
Ganglion cyst in the foot with bony erosion between navicular and cuneiform bones
Tarsal synovial cyst
Anechoic ganglion situated in the sinus tarsi fat between the talus and calcaneous
Plantar fasciitis (PF) refers to inflammation of the
plantar fascia of the foot It is considered the most common cause of heel pain
Clinical presentation Pain on the undersurface of the heel on weight bearing is the principal complaint It can be worse when weight is borne after a period of rest (eg in the morning) and eases with walking Passive dorsiflexion of the toes may exacerbates discomfort
UltrasoundOften the initial imaging modality of choice Ultrasound typically shows increased thickness of the fascia and a hypoechoic fascia
Thickened hypoechoic origin of the plantar fascia which has a convex superior margin
Complete avulsion of the plantar fascia from the calcaneal tubercle
Plantar fasciitis
bull LOCATING FOREIGN BODIES AND FRACTURES
As in any other location the ankle
area is also subsidiary host foreign
whose classification location and
existence can be defined perfectly by
ultrasound Being a focused study to
the area of interest and with great
resolution for surface structures can
be considered more resolute
examination to screen these cases
Osseous diseases and fractures | Sonography discovered Medial Malleolus Fracture
Ultrasound examination of left ankle A Longitudinal sonogram left ankle demonstrates a wooden foreign body B Transverse view left ankle Note the hypervascularity in the inflamed area C Corresponding X-ray of left ankle Note the swelling on the lateral aspect No foreign body is visible
Thank You
MAIN INDICATIONS OFTHE ANKLE ULTRASONOGRAPHIC STUDY
Tendon pathology of the different compartments
of the ankle
bull Evaluation of ligament injuries
bull Bone and joint disorders (synovitis chondral
and osteochondral lesions occult fractures)
bull Retroachilles and preachilles bursitis
bull Characterization of tumors (accessory muscles ganglia
neurogenic tumours soft tissue abscesses etc)
bull Localization of foreign bodies
ABNORMALITIES OF TENDONS
Tendon injuries include tenosynovitis tendinosis
rupture and instability
POSTERIOR COMPARTMENTACHILLES TENDINOPATHY
Can be classified as tendinosis and paratendinitis The isolated
paratendinitis shows intratendinous normal structure exist paratendinitis
spill shown irregularities in the edges of the tendon adhesions and
scarring associated paratendon and a heterogeneous aspect preachilles
fat pad In the tendinosis there is in swelling of the tendon usually
bilateral and textural heterogeneity intratendinous focal hypoechoic areas
TEAR OF ACHILLESThe rupture site is located generally between the 2 and 6 cm from the insertion into the calcaneous in the called critical zone of relative hypovascularityIn ultrasound complete rupture of the Achilles tendon is seen as a focal defect
between the broken ends of the tendon In the acute phase ends are contiguous but the defect may be filled by the anechoic or hypoechoic hematoma In most cases paratendon remains intact as a envelope straight echogenic contouring breakage As a sign associated can exist distortion of the fibrillar configuration and loss of parallelism of the tendon fibers Other signs are indicative fat herniation into the defect better visualization of the plantar tendon and the existence of a posterior acoustic shadowing at the site of the tear (useful sign to differentiate partial thickness tears)
Complete rupture of the Achilles tendon with focal defect between
the ends of the tendon and posterior acoustic shadowing at the
site of the tear useful sign to differentiate partial thickness tears
Patient with psoriasis which identifies tendinosis and Achilles tendon swelling
bilateral and textural heterogeneity with intratendinous focal hypoechoic areas
Ultrasound and radiological correlation calcified Achilles
enthesitis Calcaneal spur as associated finding
Discreetly thickened right Achilles tendon at its insertion combining linear hyperechoic
and hypoechoic areas on small breaks intrasubstance and calcifications of the enthesis
Fat herniation into the defect by complete tear of the Achilles tendon
Complete tear of the Achilles tendon with retraction
of ends and integrity thin plantaris tendon
Tendinosis versus partial tear of Achilles tendon
bullPREACHILLES AND RETROACHILLES BURSITIS
Although bursitis can occur in isolation often are
related and systemic inflammatory diseases
In the ultrasound examination the distended
retrocalcaneal and preachilles appears are a
hypoechoic structure shaped coma interposed
between the Achilles tendon and the posterosuperior
aspect of the calcaneous Care must be taken not to
confuse it with the fatty space Kager containing oval
lobules of hyperechoic fat When bursitis is a
manifestation of synovitis is appreciated
hypervascular area with Doppler ultrasound
In the retroachilles bursitis exists thickening and
collection of fluid in the subcutaneous tissue
superficial to the tendon retrocalcaneal portion
Bursitis preachilles with typical morphology appreciating accumulation of fluid
in a coma between the anterior portion of the Achilles tendon and the calcaneous
Bursitis preachiacutelea that associated synovitis showing hyperemia with increased Doppler flow
Rheumatoid arthritis with retrocalcaneal bursitis (1) and calcaneal erosions (2)
ACCESSORY NAVICULAR BONEIn the distal insertion site may exist TP 2 types of bones
accessories
Accessory navicular bone type I (os tibiale externum) size
between the 2 and 6 mm can be contained within the TP and
being positioned immediately proximal posteromedial to the
navicular bone It generally produces symptoms and should
not be confused with a tendon calcification or avulsion
fracture
Type II accessory navicular bone is an accessory
ossification centre of the navicular bone with size between
9 and 12 mm triangular shaped and articulated through a
synchondrosis of the posterior and medial navicular bone
It insertion site of some fibers of TP and is associated with a
syndrome of pain and increased incidence of tendon rupture
caused by abnormal overloads Osteoarthritic changes may
underlie this synchondrosis which mimic tendon pathology
Accessory navicular bone within the posterior tibial tendon as anatomical variant
ANTERIOR COMPARTMENTThe tendons of the anterior ankle compared
with the rest of the ankle tendons are rarely
affected by disease The anterior tibial tendon
is the most prone to abnormalities like
tendinopathy tenosynovitis and its place
between the most frequent rupture is extensor
retinaculum and insertion into the first
cuneiform and the base of the first metatarsal
Sometimes the retracted tendon stump causes
a nodule on the anteromedial aspect of the
distal portion of the leg making clinically
confused with a tumour or cyst
Distal insertion tendinopathy of the anterior tibial tendon with increased vascularity
Tenosynovitis of the anterior tibial tendon with effusion
Anterior tibial tendon tenosynovitis with intratendinous ruptures
Anterior tibial tendon rupture with retraction of the tendon
Tenosynovitis of the extensor digitorum tendons with a synovial effusion
Tenosynovitis of the extensor digitorum tendon with hypervascularized thickened tendon and synovium and synovial fluid
Rheumatoid arthritis with tenosynovitis of the extensor digitorum and peroneal tendons
Thickening of the extensor hallucis longus tendon caused by osteosynthesis material
Multicystic non vascularized intramuscular mass in the extensor digitorum brevis muscle
LATERAL COMPARTMENTTENOSYNOVITIS OF THE PERONEAL TENDONSThe main sign of ultrasound is the presence of liquid inside the
common synovial sheath whereas usually tendinous
morphology is preserved We must differentiate tenosynovitis of
a spill within the common peroneal sheath secondary to a tear of
calcaneofibular ligament (PCL) The ultrasound diagnosis is the detection of the tendons in a lateral plane relative to the distal portion of the lateral malleolus instead of behind it The dynamic exploration foot dorsiflexion as both eversion may help identify cases of intermittent subluxation In long-standing disease can be observed fusiform thickening
of the peroneal tendons at the tip of the malleolus The complete tears of the peroneus brevis tendon (PC) and peroneus longus (PL) are rare occurring in the area of the lateral malleolus or midfoot Seen in patients with ankle sprains or history of chronic instability especially if they suffer widespread diseases (RA DM) or treated with corticosteroids The peroneal tendon ruptures causing the inability to eversion of the foot and cavus foot varus
Important thickening of both peroneal tendons (longus and brevis) associated
with moderate amount of fluid and thickening of the synovial sheath
Discreet amount of fluid in the common sheath of the peroneal tendons
associated with disorganization and a heterogeneous appearance
peroneus brevis tendon related to longitudinal rupture
Peroneal tenosynovitis and osteosynthesis
Tenosynovitis of the peroneal tendons and an intratendinous rupture of the short peroneal tendon
Intratendinous rupture and cyst in the peroneus brevis tendon
Peroneus quartus with an accessory muscle next to the peroneus longus and brevis tendons
Tumor next to the peroneal tendons that proved to be a benign fibrous mass
MEDIAL COMPARTMENT
ANOMALIES POSTERIOR TIBIAL TENDON (TP)
It is the most frequently injured in this compartment with ruptures
in asymptomatic middle-aged obese women as a result of
widespread disease (RA seronegative Spondyloarthropathy) or
associated with bone fractures It causes a gradual collapse of the
medial longitudinal arch with hindfoot valgus deformity and
excessive forefoot pronation
The presence of small vessels in inflammatory diseases
intratendinosis can simulate a fissuration tendon confusion can be ignored using colour Doppler Another possible diagnostic difficulty is when the undamaged tendon flexor digitorum longus (FLD) moves back and simulates the TP unbroken but it is smaller and in this case we only see in the groove retromalleolar 1 only tendon
Ultrasound has also proven to be an effective resource for identifying alterations associated tendon tenosynovitis serosa and hypertrophicSubluxation and dislocation anteriorly and medial TP relative to internal
malleolus is rare and valued sonographically placing the foot in dorsiflexion with forced supination
Thickening moderate amount of fluid surrounding calcifications and
hyperemia affecting the sheath and the posterior tibial tendon related
to chronic tenosynovitis in patient affects rheumatoid arthritis
Thickening moderate amount of surrounding fluid and calcifications (arrow) affecting the
posterior tibial tendon related to chronic tenosynovitis in patient affects rheumatoid arthritis
Tenosynovitis of the posterior tibial tendon caused by a bony ridge at the insertion of the retinaculum The retinaculum is thickened and the tendon subluxates
Psoriatic arthritis Ankle Grayscale examination Posterior tibial tendon on longitudinal (a) and transverse (b) scan Marked tendon sheath widening with homogeneous anechoic aspect (asterisks) of the content indicating an exudative tenosynovitis Note as the normal fibrillar echotexture is conserved Hand Flexor tendons of second finger The volar longitudinal (c) and transverse scan (d) shows a tendon sheath widening with signs of synovial proliferation presence of intense power Doppler signal surrounding the tendon and micro interruption of the margin (arrow) e Wrist Extensor carpi ulnaris tendon (sixth compartment of the extensor tendons ecu) on lateral longitudinal (e) and transverse (f) scan Chronic tenosynovitis with clear areas of low of echogenicity and loss of the continuity of tendon fibrils indicative of partial tendon tear (arrows) Moreover note the presence of power Doppler signal within the interruption indicating still activity of the inflammatory process g Dactylitis Volar longitudinal scan using the ldquoextended viewrdquo technique showing proliferative tenosynovitis of the finger flexor tendon (circle) exudative synovitis of both proximal and distal interphalangeal joint (white asterisks) and edema of the peritendinous tissue (black asterisks) TP posterior tibial tendon mm medial malleolus DP distal phalanx mp middle phalanx cu cubital bone ft flexor tendons
Tenosynovitis of the posterior tibial (1) and flexor digitorum longus tendon (2)
Tibialis Posterior Tendon rupture
Tenosynovitis of the posterior tibial tendon the flexor digitorum tendon and flexor hallucis longus tendon
Tenosynovitis of the tendons on the medial side in the left ankle
bullLIGAMENT INJURIESThe ligament partial tear ligament shows a hypoechoic
areas swollen with internal focal or diffuse In the complete
ruptures within the substance of the divided ligament rift is
observed corresponding to the hematoma hypoechoic and
the free ends of the divided ligament can be and retracted
appreciated corrugated in contrast with normal
appearance straight
Grade I Mild stretching of the ligament without breakage
or instability
Grade II Partial tearing of the ligament
Grade III Complete tearing
Degrees depending on the severity of the injury and the
place of employment
LATERAL COMPARTMENTThese injuries occur secondary to inversion sprains with internal rotation of
the foot combined with ankle plantar flexion
The anterior talar fibular ligament tears (ATFL) usually occur as isolated
involvement (70) or associated with calcaneal fibular ligament (CFL) (20-40)
but the posterior talar fibular ligament (PTFL) affects only major trauma
involving ankle dislocation
ATFL breaks is associated with breakage of the joint capsule and synovial fluid
extravasation into the anterolateral soft ankle whereas the complete tearing of
CFL can communicate the ankle joint and synovial sheath peroneal tendons
Rupture of CFL is rarely associated with superior peroneal retinaculum tear
The CFL is tensioned during dorsiflexion pulling on peroneal tendons laterally
so that absence of its displacement is sign of a complete tear
Within a damaged ligament can also observe calcifications that often
correspond to fragments of avulsion bone
During the ultrasound can be performed forced maneuvers to detect to joint
laxity and ligament injuries The anterior drawer test is performed with the feet
hanging over the edge of the examination table while the forefoot is pulled
anteriorly when the foot is in plantar flexion and inversion This maneuver
helps differentiate partial tears (grade II) of the ATFL to complete (grade III)
where the anterior displacement of the talus on the tibia open a crack in the
substance becoming more visible the ligament injury
The sindesmosys sprains are up to 10 of ankle
injuries happening in eversion and pronation
movements (like the deltoid ligament injury) and
primarily affect the anterior tibiofibular ligament (ATFL)
the failure is frequently associated with fracture of the
fibula
According to the place of employment are 4 degrees
useful for prognostic evaluation and therapeutic strategy
choice
Grade I stretch or partial tear of the ATFL
Grade II complete tearing but only the ATFL
Grade III complete tear of the ATFL and partial CFL
Grade IV complete tear of the ATFL and CFL
The grade I and II injuries usually scarred without any
significant instability whereas grade III and IV injuries
can cause chronic pain and require surgical treatment
Thickened but continued ATFL right in relation to the partial rupture
Grade 111 sprain of right ATFL
Thickened anterior talofibular ligament with calcifications and a partial rupture
Thickened tibiofibular ligament after trauma
Anterior Talofibular Ligament Partial Tear and Elastography
Tibio fibular ligament rupture with bony avulsion
Complete rupture of right ATFL
Bony avulsion with radiographic evidence as visible calcification in a grade III sprain ATFL
Moderately thickened and hypoechoic ATFL
Discontinuity of the ATFL with fluid surrounding the torn ends (arrow)
Thickening and hypoechogenicity of the fibular end of the ligament seen here passing over the subtalar joint which contains a small of fluid
Complete disruption to the tibiofibular ligament with bony irregularity of particularly the tibial margin and fluid in the gap
MEDIAL COMPARTMENTBecause of the low incidence of eversion ankle
sprains and the thickness of the deltoid ligament
is rarely injured in isolation and when the injury
does not usually full thickness Usually
accompanied by lesions of the medial malleolus
and lateral displacement of the talus with
consequent widening of the ankle mortise
Ultrasound is useful for differentiating ligament
injury of the posterior tibial tendon injury
(TP) adjacent they have similar symptoms
The inability to visualize the deltoid ligament may
indicate tear but this is not considered a reliable
sign as its full ultrasound is not always possible
Partial medial ligament rupture
Thickened heterogeneous abnormal deltoid demonstrating hyperemia
Ultrasonogram showing a disrupted deltoid ligament with the probe in the coronal plane The white arrow indicates the medial malleolus the blue arrow indicates the talus and the red arrows indicate the disrupted deltoid ligament (A) Radiograph showing the same injury (B)
bullJOINT AND BONE DISORDERSUltrasound reliably detect spills mild (gt 2 ml) inside
of the ankle joint by exploring the front and rear
recess as well as areas of synovial proliferation and
may even display using the colour Doppler
hyperemic areas in arthritis patients
The intraarticular joints are displayed surrounded
fluid in one of the recesses of the ankle or subtalar
joint Sonographically diagnosed when changing position to perform flexion and extension Fracture of the lateral process of the talus is overlooked up to 50 of cases with plain radiography Ultrasound may suspect the presence of focal cortical disruption helping further to exclude concomitant ligament injury
Rheumatoid arthritis with synovial thickening (1) and erosion of the tibia (2)
Infectious arthritis with a pus filled anterior recess of the ankle
Arthritis and tenosynovitis of the ankle in a patient with rheumatoid arthritis
bullTUMOURSUltrasound can differentiate between a mass complex
and solid and a cystic in addition to verifying the
existence of accessory muscles (peroneus fourth
accessory flexor digitorum longus and accessory
soleus) As in any other location can be found
neoformative soft tissue tumors inflammatory
infectious etc
Ganglions of this location are more often symptomatic
and larger with multiple partitions
branched and lobed edges Differential diagnosis must
be made with tenosynovitis abscesses seromas and
varicosities
Neurogenic tumours are described as pathognomonic
homogeneous hypoechoic oval mass in continuity with
a nerve of origin
Ganglion cysts are non-malignant cystic masses that occur in association with musculoskeletal structures They are sometimes also simply referred to as ganglia or a ganglion but should not be confused with the anatomical term ganglion UltrasoundThe vast majority are anechoic to hypoechoic on ultrasound and have well defined margins Many demonstrate internal septations as well as acoustic enhancement A synovial cyst is a small fluid-filled sac or pouch that can develop over a tendon or joint creating a mass under the skin Synovial cyst is rare in ankle joint A synovial cyst may or may not be painful depending on their size and location
Ganglion cyst in the foot with bony erosion between navicular and cuneiform bones
Tarsal synovial cyst
Anechoic ganglion situated in the sinus tarsi fat between the talus and calcaneous
Plantar fasciitis (PF) refers to inflammation of the
plantar fascia of the foot It is considered the most common cause of heel pain
Clinical presentation Pain on the undersurface of the heel on weight bearing is the principal complaint It can be worse when weight is borne after a period of rest (eg in the morning) and eases with walking Passive dorsiflexion of the toes may exacerbates discomfort
UltrasoundOften the initial imaging modality of choice Ultrasound typically shows increased thickness of the fascia and a hypoechoic fascia
Thickened hypoechoic origin of the plantar fascia which has a convex superior margin
Complete avulsion of the plantar fascia from the calcaneal tubercle
Plantar fasciitis
bull LOCATING FOREIGN BODIES AND FRACTURES
As in any other location the ankle
area is also subsidiary host foreign
whose classification location and
existence can be defined perfectly by
ultrasound Being a focused study to
the area of interest and with great
resolution for surface structures can
be considered more resolute
examination to screen these cases
Osseous diseases and fractures | Sonography discovered Medial Malleolus Fracture
Ultrasound examination of left ankle A Longitudinal sonogram left ankle demonstrates a wooden foreign body B Transverse view left ankle Note the hypervascularity in the inflamed area C Corresponding X-ray of left ankle Note the swelling on the lateral aspect No foreign body is visible
Thank You
POSTERIOR COMPARTMENTACHILLES TENDINOPATHY
Can be classified as tendinosis and paratendinitis The isolated
paratendinitis shows intratendinous normal structure exist paratendinitis
spill shown irregularities in the edges of the tendon adhesions and
scarring associated paratendon and a heterogeneous aspect preachilles
fat pad In the tendinosis there is in swelling of the tendon usually
bilateral and textural heterogeneity intratendinous focal hypoechoic areas
TEAR OF ACHILLESThe rupture site is located generally between the 2 and 6 cm from the insertion into the calcaneous in the called critical zone of relative hypovascularityIn ultrasound complete rupture of the Achilles tendon is seen as a focal defect
between the broken ends of the tendon In the acute phase ends are contiguous but the defect may be filled by the anechoic or hypoechoic hematoma In most cases paratendon remains intact as a envelope straight echogenic contouring breakage As a sign associated can exist distortion of the fibrillar configuration and loss of parallelism of the tendon fibers Other signs are indicative fat herniation into the defect better visualization of the plantar tendon and the existence of a posterior acoustic shadowing at the site of the tear (useful sign to differentiate partial thickness tears)
Complete rupture of the Achilles tendon with focal defect between
the ends of the tendon and posterior acoustic shadowing at the
site of the tear useful sign to differentiate partial thickness tears
Patient with psoriasis which identifies tendinosis and Achilles tendon swelling
bilateral and textural heterogeneity with intratendinous focal hypoechoic areas
Ultrasound and radiological correlation calcified Achilles
enthesitis Calcaneal spur as associated finding
Discreetly thickened right Achilles tendon at its insertion combining linear hyperechoic
and hypoechoic areas on small breaks intrasubstance and calcifications of the enthesis
Fat herniation into the defect by complete tear of the Achilles tendon
Complete tear of the Achilles tendon with retraction
of ends and integrity thin plantaris tendon
Tendinosis versus partial tear of Achilles tendon
bullPREACHILLES AND RETROACHILLES BURSITIS
Although bursitis can occur in isolation often are
related and systemic inflammatory diseases
In the ultrasound examination the distended
retrocalcaneal and preachilles appears are a
hypoechoic structure shaped coma interposed
between the Achilles tendon and the posterosuperior
aspect of the calcaneous Care must be taken not to
confuse it with the fatty space Kager containing oval
lobules of hyperechoic fat When bursitis is a
manifestation of synovitis is appreciated
hypervascular area with Doppler ultrasound
In the retroachilles bursitis exists thickening and
collection of fluid in the subcutaneous tissue
superficial to the tendon retrocalcaneal portion
Bursitis preachilles with typical morphology appreciating accumulation of fluid
in a coma between the anterior portion of the Achilles tendon and the calcaneous
Bursitis preachiacutelea that associated synovitis showing hyperemia with increased Doppler flow
Rheumatoid arthritis with retrocalcaneal bursitis (1) and calcaneal erosions (2)
ACCESSORY NAVICULAR BONEIn the distal insertion site may exist TP 2 types of bones
accessories
Accessory navicular bone type I (os tibiale externum) size
between the 2 and 6 mm can be contained within the TP and
being positioned immediately proximal posteromedial to the
navicular bone It generally produces symptoms and should
not be confused with a tendon calcification or avulsion
fracture
Type II accessory navicular bone is an accessory
ossification centre of the navicular bone with size between
9 and 12 mm triangular shaped and articulated through a
synchondrosis of the posterior and medial navicular bone
It insertion site of some fibers of TP and is associated with a
syndrome of pain and increased incidence of tendon rupture
caused by abnormal overloads Osteoarthritic changes may
underlie this synchondrosis which mimic tendon pathology
Accessory navicular bone within the posterior tibial tendon as anatomical variant
ANTERIOR COMPARTMENTThe tendons of the anterior ankle compared
with the rest of the ankle tendons are rarely
affected by disease The anterior tibial tendon
is the most prone to abnormalities like
tendinopathy tenosynovitis and its place
between the most frequent rupture is extensor
retinaculum and insertion into the first
cuneiform and the base of the first metatarsal
Sometimes the retracted tendon stump causes
a nodule on the anteromedial aspect of the
distal portion of the leg making clinically
confused with a tumour or cyst
Distal insertion tendinopathy of the anterior tibial tendon with increased vascularity
Tenosynovitis of the anterior tibial tendon with effusion
Anterior tibial tendon tenosynovitis with intratendinous ruptures
Anterior tibial tendon rupture with retraction of the tendon
Tenosynovitis of the extensor digitorum tendons with a synovial effusion
Tenosynovitis of the extensor digitorum tendon with hypervascularized thickened tendon and synovium and synovial fluid
Rheumatoid arthritis with tenosynovitis of the extensor digitorum and peroneal tendons
Thickening of the extensor hallucis longus tendon caused by osteosynthesis material
Multicystic non vascularized intramuscular mass in the extensor digitorum brevis muscle
LATERAL COMPARTMENTTENOSYNOVITIS OF THE PERONEAL TENDONSThe main sign of ultrasound is the presence of liquid inside the
common synovial sheath whereas usually tendinous
morphology is preserved We must differentiate tenosynovitis of
a spill within the common peroneal sheath secondary to a tear of
calcaneofibular ligament (PCL) The ultrasound diagnosis is the detection of the tendons in a lateral plane relative to the distal portion of the lateral malleolus instead of behind it The dynamic exploration foot dorsiflexion as both eversion may help identify cases of intermittent subluxation In long-standing disease can be observed fusiform thickening
of the peroneal tendons at the tip of the malleolus The complete tears of the peroneus brevis tendon (PC) and peroneus longus (PL) are rare occurring in the area of the lateral malleolus or midfoot Seen in patients with ankle sprains or history of chronic instability especially if they suffer widespread diseases (RA DM) or treated with corticosteroids The peroneal tendon ruptures causing the inability to eversion of the foot and cavus foot varus
Important thickening of both peroneal tendons (longus and brevis) associated
with moderate amount of fluid and thickening of the synovial sheath
Discreet amount of fluid in the common sheath of the peroneal tendons
associated with disorganization and a heterogeneous appearance
peroneus brevis tendon related to longitudinal rupture
Peroneal tenosynovitis and osteosynthesis
Tenosynovitis of the peroneal tendons and an intratendinous rupture of the short peroneal tendon
Intratendinous rupture and cyst in the peroneus brevis tendon
Peroneus quartus with an accessory muscle next to the peroneus longus and brevis tendons
Tumor next to the peroneal tendons that proved to be a benign fibrous mass
MEDIAL COMPARTMENT
ANOMALIES POSTERIOR TIBIAL TENDON (TP)
It is the most frequently injured in this compartment with ruptures
in asymptomatic middle-aged obese women as a result of
widespread disease (RA seronegative Spondyloarthropathy) or
associated with bone fractures It causes a gradual collapse of the
medial longitudinal arch with hindfoot valgus deformity and
excessive forefoot pronation
The presence of small vessels in inflammatory diseases
intratendinosis can simulate a fissuration tendon confusion can be ignored using colour Doppler Another possible diagnostic difficulty is when the undamaged tendon flexor digitorum longus (FLD) moves back and simulates the TP unbroken but it is smaller and in this case we only see in the groove retromalleolar 1 only tendon
Ultrasound has also proven to be an effective resource for identifying alterations associated tendon tenosynovitis serosa and hypertrophicSubluxation and dislocation anteriorly and medial TP relative to internal
malleolus is rare and valued sonographically placing the foot in dorsiflexion with forced supination
Thickening moderate amount of fluid surrounding calcifications and
hyperemia affecting the sheath and the posterior tibial tendon related
to chronic tenosynovitis in patient affects rheumatoid arthritis
Thickening moderate amount of surrounding fluid and calcifications (arrow) affecting the
posterior tibial tendon related to chronic tenosynovitis in patient affects rheumatoid arthritis
Tenosynovitis of the posterior tibial tendon caused by a bony ridge at the insertion of the retinaculum The retinaculum is thickened and the tendon subluxates
Psoriatic arthritis Ankle Grayscale examination Posterior tibial tendon on longitudinal (a) and transverse (b) scan Marked tendon sheath widening with homogeneous anechoic aspect (asterisks) of the content indicating an exudative tenosynovitis Note as the normal fibrillar echotexture is conserved Hand Flexor tendons of second finger The volar longitudinal (c) and transverse scan (d) shows a tendon sheath widening with signs of synovial proliferation presence of intense power Doppler signal surrounding the tendon and micro interruption of the margin (arrow) e Wrist Extensor carpi ulnaris tendon (sixth compartment of the extensor tendons ecu) on lateral longitudinal (e) and transverse (f) scan Chronic tenosynovitis with clear areas of low of echogenicity and loss of the continuity of tendon fibrils indicative of partial tendon tear (arrows) Moreover note the presence of power Doppler signal within the interruption indicating still activity of the inflammatory process g Dactylitis Volar longitudinal scan using the ldquoextended viewrdquo technique showing proliferative tenosynovitis of the finger flexor tendon (circle) exudative synovitis of both proximal and distal interphalangeal joint (white asterisks) and edema of the peritendinous tissue (black asterisks) TP posterior tibial tendon mm medial malleolus DP distal phalanx mp middle phalanx cu cubital bone ft flexor tendons
Tenosynovitis of the posterior tibial (1) and flexor digitorum longus tendon (2)
Tibialis Posterior Tendon rupture
Tenosynovitis of the posterior tibial tendon the flexor digitorum tendon and flexor hallucis longus tendon
Tenosynovitis of the tendons on the medial side in the left ankle
bullLIGAMENT INJURIESThe ligament partial tear ligament shows a hypoechoic
areas swollen with internal focal or diffuse In the complete
ruptures within the substance of the divided ligament rift is
observed corresponding to the hematoma hypoechoic and
the free ends of the divided ligament can be and retracted
appreciated corrugated in contrast with normal
appearance straight
Grade I Mild stretching of the ligament without breakage
or instability
Grade II Partial tearing of the ligament
Grade III Complete tearing
Degrees depending on the severity of the injury and the
place of employment
LATERAL COMPARTMENTThese injuries occur secondary to inversion sprains with internal rotation of
the foot combined with ankle plantar flexion
The anterior talar fibular ligament tears (ATFL) usually occur as isolated
involvement (70) or associated with calcaneal fibular ligament (CFL) (20-40)
but the posterior talar fibular ligament (PTFL) affects only major trauma
involving ankle dislocation
ATFL breaks is associated with breakage of the joint capsule and synovial fluid
extravasation into the anterolateral soft ankle whereas the complete tearing of
CFL can communicate the ankle joint and synovial sheath peroneal tendons
Rupture of CFL is rarely associated with superior peroneal retinaculum tear
The CFL is tensioned during dorsiflexion pulling on peroneal tendons laterally
so that absence of its displacement is sign of a complete tear
Within a damaged ligament can also observe calcifications that often
correspond to fragments of avulsion bone
During the ultrasound can be performed forced maneuvers to detect to joint
laxity and ligament injuries The anterior drawer test is performed with the feet
hanging over the edge of the examination table while the forefoot is pulled
anteriorly when the foot is in plantar flexion and inversion This maneuver
helps differentiate partial tears (grade II) of the ATFL to complete (grade III)
where the anterior displacement of the talus on the tibia open a crack in the
substance becoming more visible the ligament injury
The sindesmosys sprains are up to 10 of ankle
injuries happening in eversion and pronation
movements (like the deltoid ligament injury) and
primarily affect the anterior tibiofibular ligament (ATFL)
the failure is frequently associated with fracture of the
fibula
According to the place of employment are 4 degrees
useful for prognostic evaluation and therapeutic strategy
choice
Grade I stretch or partial tear of the ATFL
Grade II complete tearing but only the ATFL
Grade III complete tear of the ATFL and partial CFL
Grade IV complete tear of the ATFL and CFL
The grade I and II injuries usually scarred without any
significant instability whereas grade III and IV injuries
can cause chronic pain and require surgical treatment
Thickened but continued ATFL right in relation to the partial rupture
Grade 111 sprain of right ATFL
Thickened anterior talofibular ligament with calcifications and a partial rupture
Thickened tibiofibular ligament after trauma
Anterior Talofibular Ligament Partial Tear and Elastography
Tibio fibular ligament rupture with bony avulsion
Complete rupture of right ATFL
Bony avulsion with radiographic evidence as visible calcification in a grade III sprain ATFL
Moderately thickened and hypoechoic ATFL
Discontinuity of the ATFL with fluid surrounding the torn ends (arrow)
Thickening and hypoechogenicity of the fibular end of the ligament seen here passing over the subtalar joint which contains a small of fluid
Complete disruption to the tibiofibular ligament with bony irregularity of particularly the tibial margin and fluid in the gap
MEDIAL COMPARTMENTBecause of the low incidence of eversion ankle
sprains and the thickness of the deltoid ligament
is rarely injured in isolation and when the injury
does not usually full thickness Usually
accompanied by lesions of the medial malleolus
and lateral displacement of the talus with
consequent widening of the ankle mortise
Ultrasound is useful for differentiating ligament
injury of the posterior tibial tendon injury
(TP) adjacent they have similar symptoms
The inability to visualize the deltoid ligament may
indicate tear but this is not considered a reliable
sign as its full ultrasound is not always possible
Partial medial ligament rupture
Thickened heterogeneous abnormal deltoid demonstrating hyperemia
Ultrasonogram showing a disrupted deltoid ligament with the probe in the coronal plane The white arrow indicates the medial malleolus the blue arrow indicates the talus and the red arrows indicate the disrupted deltoid ligament (A) Radiograph showing the same injury (B)
bullJOINT AND BONE DISORDERSUltrasound reliably detect spills mild (gt 2 ml) inside
of the ankle joint by exploring the front and rear
recess as well as areas of synovial proliferation and
may even display using the colour Doppler
hyperemic areas in arthritis patients
The intraarticular joints are displayed surrounded
fluid in one of the recesses of the ankle or subtalar
joint Sonographically diagnosed when changing position to perform flexion and extension Fracture of the lateral process of the talus is overlooked up to 50 of cases with plain radiography Ultrasound may suspect the presence of focal cortical disruption helping further to exclude concomitant ligament injury
Rheumatoid arthritis with synovial thickening (1) and erosion of the tibia (2)
Infectious arthritis with a pus filled anterior recess of the ankle
Arthritis and tenosynovitis of the ankle in a patient with rheumatoid arthritis
bullTUMOURSUltrasound can differentiate between a mass complex
and solid and a cystic in addition to verifying the
existence of accessory muscles (peroneus fourth
accessory flexor digitorum longus and accessory
soleus) As in any other location can be found
neoformative soft tissue tumors inflammatory
infectious etc
Ganglions of this location are more often symptomatic
and larger with multiple partitions
branched and lobed edges Differential diagnosis must
be made with tenosynovitis abscesses seromas and
varicosities
Neurogenic tumours are described as pathognomonic
homogeneous hypoechoic oval mass in continuity with
a nerve of origin
Ganglion cysts are non-malignant cystic masses that occur in association with musculoskeletal structures They are sometimes also simply referred to as ganglia or a ganglion but should not be confused with the anatomical term ganglion UltrasoundThe vast majority are anechoic to hypoechoic on ultrasound and have well defined margins Many demonstrate internal septations as well as acoustic enhancement A synovial cyst is a small fluid-filled sac or pouch that can develop over a tendon or joint creating a mass under the skin Synovial cyst is rare in ankle joint A synovial cyst may or may not be painful depending on their size and location
Ganglion cyst in the foot with bony erosion between navicular and cuneiform bones
Tarsal synovial cyst
Anechoic ganglion situated in the sinus tarsi fat between the talus and calcaneous
Plantar fasciitis (PF) refers to inflammation of the
plantar fascia of the foot It is considered the most common cause of heel pain
Clinical presentation Pain on the undersurface of the heel on weight bearing is the principal complaint It can be worse when weight is borne after a period of rest (eg in the morning) and eases with walking Passive dorsiflexion of the toes may exacerbates discomfort
UltrasoundOften the initial imaging modality of choice Ultrasound typically shows increased thickness of the fascia and a hypoechoic fascia
Thickened hypoechoic origin of the plantar fascia which has a convex superior margin
Complete avulsion of the plantar fascia from the calcaneal tubercle
Plantar fasciitis
bull LOCATING FOREIGN BODIES AND FRACTURES
As in any other location the ankle
area is also subsidiary host foreign
whose classification location and
existence can be defined perfectly by
ultrasound Being a focused study to
the area of interest and with great
resolution for surface structures can
be considered more resolute
examination to screen these cases
Osseous diseases and fractures | Sonography discovered Medial Malleolus Fracture
Ultrasound examination of left ankle A Longitudinal sonogram left ankle demonstrates a wooden foreign body B Transverse view left ankle Note the hypervascularity in the inflamed area C Corresponding X-ray of left ankle Note the swelling on the lateral aspect No foreign body is visible
Thank You
Complete rupture of the Achilles tendon with focal defect between
the ends of the tendon and posterior acoustic shadowing at the
site of the tear useful sign to differentiate partial thickness tears
Patient with psoriasis which identifies tendinosis and Achilles tendon swelling
bilateral and textural heterogeneity with intratendinous focal hypoechoic areas
Ultrasound and radiological correlation calcified Achilles
enthesitis Calcaneal spur as associated finding
Discreetly thickened right Achilles tendon at its insertion combining linear hyperechoic
and hypoechoic areas on small breaks intrasubstance and calcifications of the enthesis
Fat herniation into the defect by complete tear of the Achilles tendon
Complete tear of the Achilles tendon with retraction
of ends and integrity thin plantaris tendon
Tendinosis versus partial tear of Achilles tendon
bullPREACHILLES AND RETROACHILLES BURSITIS
Although bursitis can occur in isolation often are
related and systemic inflammatory diseases
In the ultrasound examination the distended
retrocalcaneal and preachilles appears are a
hypoechoic structure shaped coma interposed
between the Achilles tendon and the posterosuperior
aspect of the calcaneous Care must be taken not to
confuse it with the fatty space Kager containing oval
lobules of hyperechoic fat When bursitis is a
manifestation of synovitis is appreciated
hypervascular area with Doppler ultrasound
In the retroachilles bursitis exists thickening and
collection of fluid in the subcutaneous tissue
superficial to the tendon retrocalcaneal portion
Bursitis preachilles with typical morphology appreciating accumulation of fluid
in a coma between the anterior portion of the Achilles tendon and the calcaneous
Bursitis preachiacutelea that associated synovitis showing hyperemia with increased Doppler flow
Rheumatoid arthritis with retrocalcaneal bursitis (1) and calcaneal erosions (2)
ACCESSORY NAVICULAR BONEIn the distal insertion site may exist TP 2 types of bones
accessories
Accessory navicular bone type I (os tibiale externum) size
between the 2 and 6 mm can be contained within the TP and
being positioned immediately proximal posteromedial to the
navicular bone It generally produces symptoms and should
not be confused with a tendon calcification or avulsion
fracture
Type II accessory navicular bone is an accessory
ossification centre of the navicular bone with size between
9 and 12 mm triangular shaped and articulated through a
synchondrosis of the posterior and medial navicular bone
It insertion site of some fibers of TP and is associated with a
syndrome of pain and increased incidence of tendon rupture
caused by abnormal overloads Osteoarthritic changes may
underlie this synchondrosis which mimic tendon pathology
Accessory navicular bone within the posterior tibial tendon as anatomical variant
ANTERIOR COMPARTMENTThe tendons of the anterior ankle compared
with the rest of the ankle tendons are rarely
affected by disease The anterior tibial tendon
is the most prone to abnormalities like
tendinopathy tenosynovitis and its place
between the most frequent rupture is extensor
retinaculum and insertion into the first
cuneiform and the base of the first metatarsal
Sometimes the retracted tendon stump causes
a nodule on the anteromedial aspect of the
distal portion of the leg making clinically
confused with a tumour or cyst
Distal insertion tendinopathy of the anterior tibial tendon with increased vascularity
Tenosynovitis of the anterior tibial tendon with effusion
Anterior tibial tendon tenosynovitis with intratendinous ruptures
Anterior tibial tendon rupture with retraction of the tendon
Tenosynovitis of the extensor digitorum tendons with a synovial effusion
Tenosynovitis of the extensor digitorum tendon with hypervascularized thickened tendon and synovium and synovial fluid
Rheumatoid arthritis with tenosynovitis of the extensor digitorum and peroneal tendons
Thickening of the extensor hallucis longus tendon caused by osteosynthesis material
Multicystic non vascularized intramuscular mass in the extensor digitorum brevis muscle
LATERAL COMPARTMENTTENOSYNOVITIS OF THE PERONEAL TENDONSThe main sign of ultrasound is the presence of liquid inside the
common synovial sheath whereas usually tendinous
morphology is preserved We must differentiate tenosynovitis of
a spill within the common peroneal sheath secondary to a tear of
calcaneofibular ligament (PCL) The ultrasound diagnosis is the detection of the tendons in a lateral plane relative to the distal portion of the lateral malleolus instead of behind it The dynamic exploration foot dorsiflexion as both eversion may help identify cases of intermittent subluxation In long-standing disease can be observed fusiform thickening
of the peroneal tendons at the tip of the malleolus The complete tears of the peroneus brevis tendon (PC) and peroneus longus (PL) are rare occurring in the area of the lateral malleolus or midfoot Seen in patients with ankle sprains or history of chronic instability especially if they suffer widespread diseases (RA DM) or treated with corticosteroids The peroneal tendon ruptures causing the inability to eversion of the foot and cavus foot varus
Important thickening of both peroneal tendons (longus and brevis) associated
with moderate amount of fluid and thickening of the synovial sheath
Discreet amount of fluid in the common sheath of the peroneal tendons
associated with disorganization and a heterogeneous appearance
peroneus brevis tendon related to longitudinal rupture
Peroneal tenosynovitis and osteosynthesis
Tenosynovitis of the peroneal tendons and an intratendinous rupture of the short peroneal tendon
Intratendinous rupture and cyst in the peroneus brevis tendon
Peroneus quartus with an accessory muscle next to the peroneus longus and brevis tendons
Tumor next to the peroneal tendons that proved to be a benign fibrous mass
MEDIAL COMPARTMENT
ANOMALIES POSTERIOR TIBIAL TENDON (TP)
It is the most frequently injured in this compartment with ruptures
in asymptomatic middle-aged obese women as a result of
widespread disease (RA seronegative Spondyloarthropathy) or
associated with bone fractures It causes a gradual collapse of the
medial longitudinal arch with hindfoot valgus deformity and
excessive forefoot pronation
The presence of small vessels in inflammatory diseases
intratendinosis can simulate a fissuration tendon confusion can be ignored using colour Doppler Another possible diagnostic difficulty is when the undamaged tendon flexor digitorum longus (FLD) moves back and simulates the TP unbroken but it is smaller and in this case we only see in the groove retromalleolar 1 only tendon
Ultrasound has also proven to be an effective resource for identifying alterations associated tendon tenosynovitis serosa and hypertrophicSubluxation and dislocation anteriorly and medial TP relative to internal
malleolus is rare and valued sonographically placing the foot in dorsiflexion with forced supination
Thickening moderate amount of fluid surrounding calcifications and
hyperemia affecting the sheath and the posterior tibial tendon related
to chronic tenosynovitis in patient affects rheumatoid arthritis
Thickening moderate amount of surrounding fluid and calcifications (arrow) affecting the
posterior tibial tendon related to chronic tenosynovitis in patient affects rheumatoid arthritis
Tenosynovitis of the posterior tibial tendon caused by a bony ridge at the insertion of the retinaculum The retinaculum is thickened and the tendon subluxates
Psoriatic arthritis Ankle Grayscale examination Posterior tibial tendon on longitudinal (a) and transverse (b) scan Marked tendon sheath widening with homogeneous anechoic aspect (asterisks) of the content indicating an exudative tenosynovitis Note as the normal fibrillar echotexture is conserved Hand Flexor tendons of second finger The volar longitudinal (c) and transverse scan (d) shows a tendon sheath widening with signs of synovial proliferation presence of intense power Doppler signal surrounding the tendon and micro interruption of the margin (arrow) e Wrist Extensor carpi ulnaris tendon (sixth compartment of the extensor tendons ecu) on lateral longitudinal (e) and transverse (f) scan Chronic tenosynovitis with clear areas of low of echogenicity and loss of the continuity of tendon fibrils indicative of partial tendon tear (arrows) Moreover note the presence of power Doppler signal within the interruption indicating still activity of the inflammatory process g Dactylitis Volar longitudinal scan using the ldquoextended viewrdquo technique showing proliferative tenosynovitis of the finger flexor tendon (circle) exudative synovitis of both proximal and distal interphalangeal joint (white asterisks) and edema of the peritendinous tissue (black asterisks) TP posterior tibial tendon mm medial malleolus DP distal phalanx mp middle phalanx cu cubital bone ft flexor tendons
Tenosynovitis of the posterior tibial (1) and flexor digitorum longus tendon (2)
Tibialis Posterior Tendon rupture
Tenosynovitis of the posterior tibial tendon the flexor digitorum tendon and flexor hallucis longus tendon
Tenosynovitis of the tendons on the medial side in the left ankle
bullLIGAMENT INJURIESThe ligament partial tear ligament shows a hypoechoic
areas swollen with internal focal or diffuse In the complete
ruptures within the substance of the divided ligament rift is
observed corresponding to the hematoma hypoechoic and
the free ends of the divided ligament can be and retracted
appreciated corrugated in contrast with normal
appearance straight
Grade I Mild stretching of the ligament without breakage
or instability
Grade II Partial tearing of the ligament
Grade III Complete tearing
Degrees depending on the severity of the injury and the
place of employment
LATERAL COMPARTMENTThese injuries occur secondary to inversion sprains with internal rotation of
the foot combined with ankle plantar flexion
The anterior talar fibular ligament tears (ATFL) usually occur as isolated
involvement (70) or associated with calcaneal fibular ligament (CFL) (20-40)
but the posterior talar fibular ligament (PTFL) affects only major trauma
involving ankle dislocation
ATFL breaks is associated with breakage of the joint capsule and synovial fluid
extravasation into the anterolateral soft ankle whereas the complete tearing of
CFL can communicate the ankle joint and synovial sheath peroneal tendons
Rupture of CFL is rarely associated with superior peroneal retinaculum tear
The CFL is tensioned during dorsiflexion pulling on peroneal tendons laterally
so that absence of its displacement is sign of a complete tear
Within a damaged ligament can also observe calcifications that often
correspond to fragments of avulsion bone
During the ultrasound can be performed forced maneuvers to detect to joint
laxity and ligament injuries The anterior drawer test is performed with the feet
hanging over the edge of the examination table while the forefoot is pulled
anteriorly when the foot is in plantar flexion and inversion This maneuver
helps differentiate partial tears (grade II) of the ATFL to complete (grade III)
where the anterior displacement of the talus on the tibia open a crack in the
substance becoming more visible the ligament injury
The sindesmosys sprains are up to 10 of ankle
injuries happening in eversion and pronation
movements (like the deltoid ligament injury) and
primarily affect the anterior tibiofibular ligament (ATFL)
the failure is frequently associated with fracture of the
fibula
According to the place of employment are 4 degrees
useful for prognostic evaluation and therapeutic strategy
choice
Grade I stretch or partial tear of the ATFL
Grade II complete tearing but only the ATFL
Grade III complete tear of the ATFL and partial CFL
Grade IV complete tear of the ATFL and CFL
The grade I and II injuries usually scarred without any
significant instability whereas grade III and IV injuries
can cause chronic pain and require surgical treatment
Thickened but continued ATFL right in relation to the partial rupture
Grade 111 sprain of right ATFL
Thickened anterior talofibular ligament with calcifications and a partial rupture
Thickened tibiofibular ligament after trauma
Anterior Talofibular Ligament Partial Tear and Elastography
Tibio fibular ligament rupture with bony avulsion
Complete rupture of right ATFL
Bony avulsion with radiographic evidence as visible calcification in a grade III sprain ATFL
Moderately thickened and hypoechoic ATFL
Discontinuity of the ATFL with fluid surrounding the torn ends (arrow)
Thickening and hypoechogenicity of the fibular end of the ligament seen here passing over the subtalar joint which contains a small of fluid
Complete disruption to the tibiofibular ligament with bony irregularity of particularly the tibial margin and fluid in the gap
MEDIAL COMPARTMENTBecause of the low incidence of eversion ankle
sprains and the thickness of the deltoid ligament
is rarely injured in isolation and when the injury
does not usually full thickness Usually
accompanied by lesions of the medial malleolus
and lateral displacement of the talus with
consequent widening of the ankle mortise
Ultrasound is useful for differentiating ligament
injury of the posterior tibial tendon injury
(TP) adjacent they have similar symptoms
The inability to visualize the deltoid ligament may
indicate tear but this is not considered a reliable
sign as its full ultrasound is not always possible
Partial medial ligament rupture
Thickened heterogeneous abnormal deltoid demonstrating hyperemia
Ultrasonogram showing a disrupted deltoid ligament with the probe in the coronal plane The white arrow indicates the medial malleolus the blue arrow indicates the talus and the red arrows indicate the disrupted deltoid ligament (A) Radiograph showing the same injury (B)
bullJOINT AND BONE DISORDERSUltrasound reliably detect spills mild (gt 2 ml) inside
of the ankle joint by exploring the front and rear
recess as well as areas of synovial proliferation and
may even display using the colour Doppler
hyperemic areas in arthritis patients
The intraarticular joints are displayed surrounded
fluid in one of the recesses of the ankle or subtalar
joint Sonographically diagnosed when changing position to perform flexion and extension Fracture of the lateral process of the talus is overlooked up to 50 of cases with plain radiography Ultrasound may suspect the presence of focal cortical disruption helping further to exclude concomitant ligament injury
Rheumatoid arthritis with synovial thickening (1) and erosion of the tibia (2)
Infectious arthritis with a pus filled anterior recess of the ankle
Arthritis and tenosynovitis of the ankle in a patient with rheumatoid arthritis
bullTUMOURSUltrasound can differentiate between a mass complex
and solid and a cystic in addition to verifying the
existence of accessory muscles (peroneus fourth
accessory flexor digitorum longus and accessory
soleus) As in any other location can be found
neoformative soft tissue tumors inflammatory
infectious etc
Ganglions of this location are more often symptomatic
and larger with multiple partitions
branched and lobed edges Differential diagnosis must
be made with tenosynovitis abscesses seromas and
varicosities
Neurogenic tumours are described as pathognomonic
homogeneous hypoechoic oval mass in continuity with
a nerve of origin
Ganglion cysts are non-malignant cystic masses that occur in association with musculoskeletal structures They are sometimes also simply referred to as ganglia or a ganglion but should not be confused with the anatomical term ganglion UltrasoundThe vast majority are anechoic to hypoechoic on ultrasound and have well defined margins Many demonstrate internal septations as well as acoustic enhancement A synovial cyst is a small fluid-filled sac or pouch that can develop over a tendon or joint creating a mass under the skin Synovial cyst is rare in ankle joint A synovial cyst may or may not be painful depending on their size and location
Ganglion cyst in the foot with bony erosion between navicular and cuneiform bones
Tarsal synovial cyst
Anechoic ganglion situated in the sinus tarsi fat between the talus and calcaneous
Plantar fasciitis (PF) refers to inflammation of the
plantar fascia of the foot It is considered the most common cause of heel pain
Clinical presentation Pain on the undersurface of the heel on weight bearing is the principal complaint It can be worse when weight is borne after a period of rest (eg in the morning) and eases with walking Passive dorsiflexion of the toes may exacerbates discomfort
UltrasoundOften the initial imaging modality of choice Ultrasound typically shows increased thickness of the fascia and a hypoechoic fascia
Thickened hypoechoic origin of the plantar fascia which has a convex superior margin
Complete avulsion of the plantar fascia from the calcaneal tubercle
Plantar fasciitis
bull LOCATING FOREIGN BODIES AND FRACTURES
As in any other location the ankle
area is also subsidiary host foreign
whose classification location and
existence can be defined perfectly by
ultrasound Being a focused study to
the area of interest and with great
resolution for surface structures can
be considered more resolute
examination to screen these cases
Osseous diseases and fractures | Sonography discovered Medial Malleolus Fracture
Ultrasound examination of left ankle A Longitudinal sonogram left ankle demonstrates a wooden foreign body B Transverse view left ankle Note the hypervascularity in the inflamed area C Corresponding X-ray of left ankle Note the swelling on the lateral aspect No foreign body is visible
Thank You
Patient with psoriasis which identifies tendinosis and Achilles tendon swelling
bilateral and textural heterogeneity with intratendinous focal hypoechoic areas
Ultrasound and radiological correlation calcified Achilles
enthesitis Calcaneal spur as associated finding
Discreetly thickened right Achilles tendon at its insertion combining linear hyperechoic
and hypoechoic areas on small breaks intrasubstance and calcifications of the enthesis
Fat herniation into the defect by complete tear of the Achilles tendon
Complete tear of the Achilles tendon with retraction
of ends and integrity thin plantaris tendon
Tendinosis versus partial tear of Achilles tendon
bullPREACHILLES AND RETROACHILLES BURSITIS
Although bursitis can occur in isolation often are
related and systemic inflammatory diseases
In the ultrasound examination the distended
retrocalcaneal and preachilles appears are a
hypoechoic structure shaped coma interposed
between the Achilles tendon and the posterosuperior
aspect of the calcaneous Care must be taken not to
confuse it with the fatty space Kager containing oval
lobules of hyperechoic fat When bursitis is a
manifestation of synovitis is appreciated
hypervascular area with Doppler ultrasound
In the retroachilles bursitis exists thickening and
collection of fluid in the subcutaneous tissue
superficial to the tendon retrocalcaneal portion
Bursitis preachilles with typical morphology appreciating accumulation of fluid
in a coma between the anterior portion of the Achilles tendon and the calcaneous
Bursitis preachiacutelea that associated synovitis showing hyperemia with increased Doppler flow
Rheumatoid arthritis with retrocalcaneal bursitis (1) and calcaneal erosions (2)
ACCESSORY NAVICULAR BONEIn the distal insertion site may exist TP 2 types of bones
accessories
Accessory navicular bone type I (os tibiale externum) size
between the 2 and 6 mm can be contained within the TP and
being positioned immediately proximal posteromedial to the
navicular bone It generally produces symptoms and should
not be confused with a tendon calcification or avulsion
fracture
Type II accessory navicular bone is an accessory
ossification centre of the navicular bone with size between
9 and 12 mm triangular shaped and articulated through a
synchondrosis of the posterior and medial navicular bone
It insertion site of some fibers of TP and is associated with a
syndrome of pain and increased incidence of tendon rupture
caused by abnormal overloads Osteoarthritic changes may
underlie this synchondrosis which mimic tendon pathology
Accessory navicular bone within the posterior tibial tendon as anatomical variant
ANTERIOR COMPARTMENTThe tendons of the anterior ankle compared
with the rest of the ankle tendons are rarely
affected by disease The anterior tibial tendon
is the most prone to abnormalities like
tendinopathy tenosynovitis and its place
between the most frequent rupture is extensor
retinaculum and insertion into the first
cuneiform and the base of the first metatarsal
Sometimes the retracted tendon stump causes
a nodule on the anteromedial aspect of the
distal portion of the leg making clinically
confused with a tumour or cyst
Distal insertion tendinopathy of the anterior tibial tendon with increased vascularity
Tenosynovitis of the anterior tibial tendon with effusion
Anterior tibial tendon tenosynovitis with intratendinous ruptures
Anterior tibial tendon rupture with retraction of the tendon
Tenosynovitis of the extensor digitorum tendons with a synovial effusion
Tenosynovitis of the extensor digitorum tendon with hypervascularized thickened tendon and synovium and synovial fluid
Rheumatoid arthritis with tenosynovitis of the extensor digitorum and peroneal tendons
Thickening of the extensor hallucis longus tendon caused by osteosynthesis material
Multicystic non vascularized intramuscular mass in the extensor digitorum brevis muscle
LATERAL COMPARTMENTTENOSYNOVITIS OF THE PERONEAL TENDONSThe main sign of ultrasound is the presence of liquid inside the
common synovial sheath whereas usually tendinous
morphology is preserved We must differentiate tenosynovitis of
a spill within the common peroneal sheath secondary to a tear of
calcaneofibular ligament (PCL) The ultrasound diagnosis is the detection of the tendons in a lateral plane relative to the distal portion of the lateral malleolus instead of behind it The dynamic exploration foot dorsiflexion as both eversion may help identify cases of intermittent subluxation In long-standing disease can be observed fusiform thickening
of the peroneal tendons at the tip of the malleolus The complete tears of the peroneus brevis tendon (PC) and peroneus longus (PL) are rare occurring in the area of the lateral malleolus or midfoot Seen in patients with ankle sprains or history of chronic instability especially if they suffer widespread diseases (RA DM) or treated with corticosteroids The peroneal tendon ruptures causing the inability to eversion of the foot and cavus foot varus
Important thickening of both peroneal tendons (longus and brevis) associated
with moderate amount of fluid and thickening of the synovial sheath
Discreet amount of fluid in the common sheath of the peroneal tendons
associated with disorganization and a heterogeneous appearance
peroneus brevis tendon related to longitudinal rupture
Peroneal tenosynovitis and osteosynthesis
Tenosynovitis of the peroneal tendons and an intratendinous rupture of the short peroneal tendon
Intratendinous rupture and cyst in the peroneus brevis tendon
Peroneus quartus with an accessory muscle next to the peroneus longus and brevis tendons
Tumor next to the peroneal tendons that proved to be a benign fibrous mass
MEDIAL COMPARTMENT
ANOMALIES POSTERIOR TIBIAL TENDON (TP)
It is the most frequently injured in this compartment with ruptures
in asymptomatic middle-aged obese women as a result of
widespread disease (RA seronegative Spondyloarthropathy) or
associated with bone fractures It causes a gradual collapse of the
medial longitudinal arch with hindfoot valgus deformity and
excessive forefoot pronation
The presence of small vessels in inflammatory diseases
intratendinosis can simulate a fissuration tendon confusion can be ignored using colour Doppler Another possible diagnostic difficulty is when the undamaged tendon flexor digitorum longus (FLD) moves back and simulates the TP unbroken but it is smaller and in this case we only see in the groove retromalleolar 1 only tendon
Ultrasound has also proven to be an effective resource for identifying alterations associated tendon tenosynovitis serosa and hypertrophicSubluxation and dislocation anteriorly and medial TP relative to internal
malleolus is rare and valued sonographically placing the foot in dorsiflexion with forced supination
Thickening moderate amount of fluid surrounding calcifications and
hyperemia affecting the sheath and the posterior tibial tendon related
to chronic tenosynovitis in patient affects rheumatoid arthritis
Thickening moderate amount of surrounding fluid and calcifications (arrow) affecting the
posterior tibial tendon related to chronic tenosynovitis in patient affects rheumatoid arthritis
Tenosynovitis of the posterior tibial tendon caused by a bony ridge at the insertion of the retinaculum The retinaculum is thickened and the tendon subluxates
Psoriatic arthritis Ankle Grayscale examination Posterior tibial tendon on longitudinal (a) and transverse (b) scan Marked tendon sheath widening with homogeneous anechoic aspect (asterisks) of the content indicating an exudative tenosynovitis Note as the normal fibrillar echotexture is conserved Hand Flexor tendons of second finger The volar longitudinal (c) and transverse scan (d) shows a tendon sheath widening with signs of synovial proliferation presence of intense power Doppler signal surrounding the tendon and micro interruption of the margin (arrow) e Wrist Extensor carpi ulnaris tendon (sixth compartment of the extensor tendons ecu) on lateral longitudinal (e) and transverse (f) scan Chronic tenosynovitis with clear areas of low of echogenicity and loss of the continuity of tendon fibrils indicative of partial tendon tear (arrows) Moreover note the presence of power Doppler signal within the interruption indicating still activity of the inflammatory process g Dactylitis Volar longitudinal scan using the ldquoextended viewrdquo technique showing proliferative tenosynovitis of the finger flexor tendon (circle) exudative synovitis of both proximal and distal interphalangeal joint (white asterisks) and edema of the peritendinous tissue (black asterisks) TP posterior tibial tendon mm medial malleolus DP distal phalanx mp middle phalanx cu cubital bone ft flexor tendons
Tenosynovitis of the posterior tibial (1) and flexor digitorum longus tendon (2)
Tibialis Posterior Tendon rupture
Tenosynovitis of the posterior tibial tendon the flexor digitorum tendon and flexor hallucis longus tendon
Tenosynovitis of the tendons on the medial side in the left ankle
bullLIGAMENT INJURIESThe ligament partial tear ligament shows a hypoechoic
areas swollen with internal focal or diffuse In the complete
ruptures within the substance of the divided ligament rift is
observed corresponding to the hematoma hypoechoic and
the free ends of the divided ligament can be and retracted
appreciated corrugated in contrast with normal
appearance straight
Grade I Mild stretching of the ligament without breakage
or instability
Grade II Partial tearing of the ligament
Grade III Complete tearing
Degrees depending on the severity of the injury and the
place of employment
LATERAL COMPARTMENTThese injuries occur secondary to inversion sprains with internal rotation of
the foot combined with ankle plantar flexion
The anterior talar fibular ligament tears (ATFL) usually occur as isolated
involvement (70) or associated with calcaneal fibular ligament (CFL) (20-40)
but the posterior talar fibular ligament (PTFL) affects only major trauma
involving ankle dislocation
ATFL breaks is associated with breakage of the joint capsule and synovial fluid
extravasation into the anterolateral soft ankle whereas the complete tearing of
CFL can communicate the ankle joint and synovial sheath peroneal tendons
Rupture of CFL is rarely associated with superior peroneal retinaculum tear
The CFL is tensioned during dorsiflexion pulling on peroneal tendons laterally
so that absence of its displacement is sign of a complete tear
Within a damaged ligament can also observe calcifications that often
correspond to fragments of avulsion bone
During the ultrasound can be performed forced maneuvers to detect to joint
laxity and ligament injuries The anterior drawer test is performed with the feet
hanging over the edge of the examination table while the forefoot is pulled
anteriorly when the foot is in plantar flexion and inversion This maneuver
helps differentiate partial tears (grade II) of the ATFL to complete (grade III)
where the anterior displacement of the talus on the tibia open a crack in the
substance becoming more visible the ligament injury
The sindesmosys sprains are up to 10 of ankle
injuries happening in eversion and pronation
movements (like the deltoid ligament injury) and
primarily affect the anterior tibiofibular ligament (ATFL)
the failure is frequently associated with fracture of the
fibula
According to the place of employment are 4 degrees
useful for prognostic evaluation and therapeutic strategy
choice
Grade I stretch or partial tear of the ATFL
Grade II complete tearing but only the ATFL
Grade III complete tear of the ATFL and partial CFL
Grade IV complete tear of the ATFL and CFL
The grade I and II injuries usually scarred without any
significant instability whereas grade III and IV injuries
can cause chronic pain and require surgical treatment
Thickened but continued ATFL right in relation to the partial rupture
Grade 111 sprain of right ATFL
Thickened anterior talofibular ligament with calcifications and a partial rupture
Thickened tibiofibular ligament after trauma
Anterior Talofibular Ligament Partial Tear and Elastography
Tibio fibular ligament rupture with bony avulsion
Complete rupture of right ATFL
Bony avulsion with radiographic evidence as visible calcification in a grade III sprain ATFL
Moderately thickened and hypoechoic ATFL
Discontinuity of the ATFL with fluid surrounding the torn ends (arrow)
Thickening and hypoechogenicity of the fibular end of the ligament seen here passing over the subtalar joint which contains a small of fluid
Complete disruption to the tibiofibular ligament with bony irregularity of particularly the tibial margin and fluid in the gap
MEDIAL COMPARTMENTBecause of the low incidence of eversion ankle
sprains and the thickness of the deltoid ligament
is rarely injured in isolation and when the injury
does not usually full thickness Usually
accompanied by lesions of the medial malleolus
and lateral displacement of the talus with
consequent widening of the ankle mortise
Ultrasound is useful for differentiating ligament
injury of the posterior tibial tendon injury
(TP) adjacent they have similar symptoms
The inability to visualize the deltoid ligament may
indicate tear but this is not considered a reliable
sign as its full ultrasound is not always possible
Partial medial ligament rupture
Thickened heterogeneous abnormal deltoid demonstrating hyperemia
Ultrasonogram showing a disrupted deltoid ligament with the probe in the coronal plane The white arrow indicates the medial malleolus the blue arrow indicates the talus and the red arrows indicate the disrupted deltoid ligament (A) Radiograph showing the same injury (B)
bullJOINT AND BONE DISORDERSUltrasound reliably detect spills mild (gt 2 ml) inside
of the ankle joint by exploring the front and rear
recess as well as areas of synovial proliferation and
may even display using the colour Doppler
hyperemic areas in arthritis patients
The intraarticular joints are displayed surrounded
fluid in one of the recesses of the ankle or subtalar
joint Sonographically diagnosed when changing position to perform flexion and extension Fracture of the lateral process of the talus is overlooked up to 50 of cases with plain radiography Ultrasound may suspect the presence of focal cortical disruption helping further to exclude concomitant ligament injury
Rheumatoid arthritis with synovial thickening (1) and erosion of the tibia (2)
Infectious arthritis with a pus filled anterior recess of the ankle
Arthritis and tenosynovitis of the ankle in a patient with rheumatoid arthritis
bullTUMOURSUltrasound can differentiate between a mass complex
and solid and a cystic in addition to verifying the
existence of accessory muscles (peroneus fourth
accessory flexor digitorum longus and accessory
soleus) As in any other location can be found
neoformative soft tissue tumors inflammatory
infectious etc
Ganglions of this location are more often symptomatic
and larger with multiple partitions
branched and lobed edges Differential diagnosis must
be made with tenosynovitis abscesses seromas and
varicosities
Neurogenic tumours are described as pathognomonic
homogeneous hypoechoic oval mass in continuity with
a nerve of origin
Ganglion cysts are non-malignant cystic masses that occur in association with musculoskeletal structures They are sometimes also simply referred to as ganglia or a ganglion but should not be confused with the anatomical term ganglion UltrasoundThe vast majority are anechoic to hypoechoic on ultrasound and have well defined margins Many demonstrate internal septations as well as acoustic enhancement A synovial cyst is a small fluid-filled sac or pouch that can develop over a tendon or joint creating a mass under the skin Synovial cyst is rare in ankle joint A synovial cyst may or may not be painful depending on their size and location
Ganglion cyst in the foot with bony erosion between navicular and cuneiform bones
Tarsal synovial cyst
Anechoic ganglion situated in the sinus tarsi fat between the talus and calcaneous
Plantar fasciitis (PF) refers to inflammation of the
plantar fascia of the foot It is considered the most common cause of heel pain
Clinical presentation Pain on the undersurface of the heel on weight bearing is the principal complaint It can be worse when weight is borne after a period of rest (eg in the morning) and eases with walking Passive dorsiflexion of the toes may exacerbates discomfort
UltrasoundOften the initial imaging modality of choice Ultrasound typically shows increased thickness of the fascia and a hypoechoic fascia
Thickened hypoechoic origin of the plantar fascia which has a convex superior margin
Complete avulsion of the plantar fascia from the calcaneal tubercle
Plantar fasciitis
bull LOCATING FOREIGN BODIES AND FRACTURES
As in any other location the ankle
area is also subsidiary host foreign
whose classification location and
existence can be defined perfectly by
ultrasound Being a focused study to
the area of interest and with great
resolution for surface structures can
be considered more resolute
examination to screen these cases
Osseous diseases and fractures | Sonography discovered Medial Malleolus Fracture
Ultrasound examination of left ankle A Longitudinal sonogram left ankle demonstrates a wooden foreign body B Transverse view left ankle Note the hypervascularity in the inflamed area C Corresponding X-ray of left ankle Note the swelling on the lateral aspect No foreign body is visible
Thank You
Ultrasound and radiological correlation calcified Achilles
enthesitis Calcaneal spur as associated finding
Discreetly thickened right Achilles tendon at its insertion combining linear hyperechoic
and hypoechoic areas on small breaks intrasubstance and calcifications of the enthesis
Fat herniation into the defect by complete tear of the Achilles tendon
Complete tear of the Achilles tendon with retraction
of ends and integrity thin plantaris tendon
Tendinosis versus partial tear of Achilles tendon
bullPREACHILLES AND RETROACHILLES BURSITIS
Although bursitis can occur in isolation often are
related and systemic inflammatory diseases
In the ultrasound examination the distended
retrocalcaneal and preachilles appears are a
hypoechoic structure shaped coma interposed
between the Achilles tendon and the posterosuperior
aspect of the calcaneous Care must be taken not to
confuse it with the fatty space Kager containing oval
lobules of hyperechoic fat When bursitis is a
manifestation of synovitis is appreciated
hypervascular area with Doppler ultrasound
In the retroachilles bursitis exists thickening and
collection of fluid in the subcutaneous tissue
superficial to the tendon retrocalcaneal portion
Bursitis preachilles with typical morphology appreciating accumulation of fluid
in a coma between the anterior portion of the Achilles tendon and the calcaneous
Bursitis preachiacutelea that associated synovitis showing hyperemia with increased Doppler flow
Rheumatoid arthritis with retrocalcaneal bursitis (1) and calcaneal erosions (2)
ACCESSORY NAVICULAR BONEIn the distal insertion site may exist TP 2 types of bones
accessories
Accessory navicular bone type I (os tibiale externum) size
between the 2 and 6 mm can be contained within the TP and
being positioned immediately proximal posteromedial to the
navicular bone It generally produces symptoms and should
not be confused with a tendon calcification or avulsion
fracture
Type II accessory navicular bone is an accessory
ossification centre of the navicular bone with size between
9 and 12 mm triangular shaped and articulated through a
synchondrosis of the posterior and medial navicular bone
It insertion site of some fibers of TP and is associated with a
syndrome of pain and increased incidence of tendon rupture
caused by abnormal overloads Osteoarthritic changes may
underlie this synchondrosis which mimic tendon pathology
Accessory navicular bone within the posterior tibial tendon as anatomical variant
ANTERIOR COMPARTMENTThe tendons of the anterior ankle compared
with the rest of the ankle tendons are rarely
affected by disease The anterior tibial tendon
is the most prone to abnormalities like
tendinopathy tenosynovitis and its place
between the most frequent rupture is extensor
retinaculum and insertion into the first
cuneiform and the base of the first metatarsal
Sometimes the retracted tendon stump causes
a nodule on the anteromedial aspect of the
distal portion of the leg making clinically
confused with a tumour or cyst
Distal insertion tendinopathy of the anterior tibial tendon with increased vascularity
Tenosynovitis of the anterior tibial tendon with effusion
Anterior tibial tendon tenosynovitis with intratendinous ruptures
Anterior tibial tendon rupture with retraction of the tendon
Tenosynovitis of the extensor digitorum tendons with a synovial effusion
Tenosynovitis of the extensor digitorum tendon with hypervascularized thickened tendon and synovium and synovial fluid
Rheumatoid arthritis with tenosynovitis of the extensor digitorum and peroneal tendons
Thickening of the extensor hallucis longus tendon caused by osteosynthesis material
Multicystic non vascularized intramuscular mass in the extensor digitorum brevis muscle
LATERAL COMPARTMENTTENOSYNOVITIS OF THE PERONEAL TENDONSThe main sign of ultrasound is the presence of liquid inside the
common synovial sheath whereas usually tendinous
morphology is preserved We must differentiate tenosynovitis of
a spill within the common peroneal sheath secondary to a tear of
calcaneofibular ligament (PCL) The ultrasound diagnosis is the detection of the tendons in a lateral plane relative to the distal portion of the lateral malleolus instead of behind it The dynamic exploration foot dorsiflexion as both eversion may help identify cases of intermittent subluxation In long-standing disease can be observed fusiform thickening
of the peroneal tendons at the tip of the malleolus The complete tears of the peroneus brevis tendon (PC) and peroneus longus (PL) are rare occurring in the area of the lateral malleolus or midfoot Seen in patients with ankle sprains or history of chronic instability especially if they suffer widespread diseases (RA DM) or treated with corticosteroids The peroneal tendon ruptures causing the inability to eversion of the foot and cavus foot varus
Important thickening of both peroneal tendons (longus and brevis) associated
with moderate amount of fluid and thickening of the synovial sheath
Discreet amount of fluid in the common sheath of the peroneal tendons
associated with disorganization and a heterogeneous appearance
peroneus brevis tendon related to longitudinal rupture
Peroneal tenosynovitis and osteosynthesis
Tenosynovitis of the peroneal tendons and an intratendinous rupture of the short peroneal tendon
Intratendinous rupture and cyst in the peroneus brevis tendon
Peroneus quartus with an accessory muscle next to the peroneus longus and brevis tendons
Tumor next to the peroneal tendons that proved to be a benign fibrous mass
MEDIAL COMPARTMENT
ANOMALIES POSTERIOR TIBIAL TENDON (TP)
It is the most frequently injured in this compartment with ruptures
in asymptomatic middle-aged obese women as a result of
widespread disease (RA seronegative Spondyloarthropathy) or
associated with bone fractures It causes a gradual collapse of the
medial longitudinal arch with hindfoot valgus deformity and
excessive forefoot pronation
The presence of small vessels in inflammatory diseases
intratendinosis can simulate a fissuration tendon confusion can be ignored using colour Doppler Another possible diagnostic difficulty is when the undamaged tendon flexor digitorum longus (FLD) moves back and simulates the TP unbroken but it is smaller and in this case we only see in the groove retromalleolar 1 only tendon
Ultrasound has also proven to be an effective resource for identifying alterations associated tendon tenosynovitis serosa and hypertrophicSubluxation and dislocation anteriorly and medial TP relative to internal
malleolus is rare and valued sonographically placing the foot in dorsiflexion with forced supination
Thickening moderate amount of fluid surrounding calcifications and
hyperemia affecting the sheath and the posterior tibial tendon related
to chronic tenosynovitis in patient affects rheumatoid arthritis
Thickening moderate amount of surrounding fluid and calcifications (arrow) affecting the
posterior tibial tendon related to chronic tenosynovitis in patient affects rheumatoid arthritis
Tenosynovitis of the posterior tibial tendon caused by a bony ridge at the insertion of the retinaculum The retinaculum is thickened and the tendon subluxates
Psoriatic arthritis Ankle Grayscale examination Posterior tibial tendon on longitudinal (a) and transverse (b) scan Marked tendon sheath widening with homogeneous anechoic aspect (asterisks) of the content indicating an exudative tenosynovitis Note as the normal fibrillar echotexture is conserved Hand Flexor tendons of second finger The volar longitudinal (c) and transverse scan (d) shows a tendon sheath widening with signs of synovial proliferation presence of intense power Doppler signal surrounding the tendon and micro interruption of the margin (arrow) e Wrist Extensor carpi ulnaris tendon (sixth compartment of the extensor tendons ecu) on lateral longitudinal (e) and transverse (f) scan Chronic tenosynovitis with clear areas of low of echogenicity and loss of the continuity of tendon fibrils indicative of partial tendon tear (arrows) Moreover note the presence of power Doppler signal within the interruption indicating still activity of the inflammatory process g Dactylitis Volar longitudinal scan using the ldquoextended viewrdquo technique showing proliferative tenosynovitis of the finger flexor tendon (circle) exudative synovitis of both proximal and distal interphalangeal joint (white asterisks) and edema of the peritendinous tissue (black asterisks) TP posterior tibial tendon mm medial malleolus DP distal phalanx mp middle phalanx cu cubital bone ft flexor tendons
Tenosynovitis of the posterior tibial (1) and flexor digitorum longus tendon (2)
Tibialis Posterior Tendon rupture
Tenosynovitis of the posterior tibial tendon the flexor digitorum tendon and flexor hallucis longus tendon
Tenosynovitis of the tendons on the medial side in the left ankle
bullLIGAMENT INJURIESThe ligament partial tear ligament shows a hypoechoic
areas swollen with internal focal or diffuse In the complete
ruptures within the substance of the divided ligament rift is
observed corresponding to the hematoma hypoechoic and
the free ends of the divided ligament can be and retracted
appreciated corrugated in contrast with normal
appearance straight
Grade I Mild stretching of the ligament without breakage
or instability
Grade II Partial tearing of the ligament
Grade III Complete tearing
Degrees depending on the severity of the injury and the
place of employment
LATERAL COMPARTMENTThese injuries occur secondary to inversion sprains with internal rotation of
the foot combined with ankle plantar flexion
The anterior talar fibular ligament tears (ATFL) usually occur as isolated
involvement (70) or associated with calcaneal fibular ligament (CFL) (20-40)
but the posterior talar fibular ligament (PTFL) affects only major trauma
involving ankle dislocation
ATFL breaks is associated with breakage of the joint capsule and synovial fluid
extravasation into the anterolateral soft ankle whereas the complete tearing of
CFL can communicate the ankle joint and synovial sheath peroneal tendons
Rupture of CFL is rarely associated with superior peroneal retinaculum tear
The CFL is tensioned during dorsiflexion pulling on peroneal tendons laterally
so that absence of its displacement is sign of a complete tear
Within a damaged ligament can also observe calcifications that often
correspond to fragments of avulsion bone
During the ultrasound can be performed forced maneuvers to detect to joint
laxity and ligament injuries The anterior drawer test is performed with the feet
hanging over the edge of the examination table while the forefoot is pulled
anteriorly when the foot is in plantar flexion and inversion This maneuver
helps differentiate partial tears (grade II) of the ATFL to complete (grade III)
where the anterior displacement of the talus on the tibia open a crack in the
substance becoming more visible the ligament injury
The sindesmosys sprains are up to 10 of ankle
injuries happening in eversion and pronation
movements (like the deltoid ligament injury) and
primarily affect the anterior tibiofibular ligament (ATFL)
the failure is frequently associated with fracture of the
fibula
According to the place of employment are 4 degrees
useful for prognostic evaluation and therapeutic strategy
choice
Grade I stretch or partial tear of the ATFL
Grade II complete tearing but only the ATFL
Grade III complete tear of the ATFL and partial CFL
Grade IV complete tear of the ATFL and CFL
The grade I and II injuries usually scarred without any
significant instability whereas grade III and IV injuries
can cause chronic pain and require surgical treatment
Thickened but continued ATFL right in relation to the partial rupture
Grade 111 sprain of right ATFL
Thickened anterior talofibular ligament with calcifications and a partial rupture
Thickened tibiofibular ligament after trauma
Anterior Talofibular Ligament Partial Tear and Elastography
Tibio fibular ligament rupture with bony avulsion
Complete rupture of right ATFL
Bony avulsion with radiographic evidence as visible calcification in a grade III sprain ATFL
Moderately thickened and hypoechoic ATFL
Discontinuity of the ATFL with fluid surrounding the torn ends (arrow)
Thickening and hypoechogenicity of the fibular end of the ligament seen here passing over the subtalar joint which contains a small of fluid
Complete disruption to the tibiofibular ligament with bony irregularity of particularly the tibial margin and fluid in the gap
MEDIAL COMPARTMENTBecause of the low incidence of eversion ankle
sprains and the thickness of the deltoid ligament
is rarely injured in isolation and when the injury
does not usually full thickness Usually
accompanied by lesions of the medial malleolus
and lateral displacement of the talus with
consequent widening of the ankle mortise
Ultrasound is useful for differentiating ligament
injury of the posterior tibial tendon injury
(TP) adjacent they have similar symptoms
The inability to visualize the deltoid ligament may
indicate tear but this is not considered a reliable
sign as its full ultrasound is not always possible
Partial medial ligament rupture
Thickened heterogeneous abnormal deltoid demonstrating hyperemia
Ultrasonogram showing a disrupted deltoid ligament with the probe in the coronal plane The white arrow indicates the medial malleolus the blue arrow indicates the talus and the red arrows indicate the disrupted deltoid ligament (A) Radiograph showing the same injury (B)
bullJOINT AND BONE DISORDERSUltrasound reliably detect spills mild (gt 2 ml) inside
of the ankle joint by exploring the front and rear
recess as well as areas of synovial proliferation and
may even display using the colour Doppler
hyperemic areas in arthritis patients
The intraarticular joints are displayed surrounded
fluid in one of the recesses of the ankle or subtalar
joint Sonographically diagnosed when changing position to perform flexion and extension Fracture of the lateral process of the talus is overlooked up to 50 of cases with plain radiography Ultrasound may suspect the presence of focal cortical disruption helping further to exclude concomitant ligament injury
Rheumatoid arthritis with synovial thickening (1) and erosion of the tibia (2)
Infectious arthritis with a pus filled anterior recess of the ankle
Arthritis and tenosynovitis of the ankle in a patient with rheumatoid arthritis
bullTUMOURSUltrasound can differentiate between a mass complex
and solid and a cystic in addition to verifying the
existence of accessory muscles (peroneus fourth
accessory flexor digitorum longus and accessory
soleus) As in any other location can be found
neoformative soft tissue tumors inflammatory
infectious etc
Ganglions of this location are more often symptomatic
and larger with multiple partitions
branched and lobed edges Differential diagnosis must
be made with tenosynovitis abscesses seromas and
varicosities
Neurogenic tumours are described as pathognomonic
homogeneous hypoechoic oval mass in continuity with
a nerve of origin
Ganglion cysts are non-malignant cystic masses that occur in association with musculoskeletal structures They are sometimes also simply referred to as ganglia or a ganglion but should not be confused with the anatomical term ganglion UltrasoundThe vast majority are anechoic to hypoechoic on ultrasound and have well defined margins Many demonstrate internal septations as well as acoustic enhancement A synovial cyst is a small fluid-filled sac or pouch that can develop over a tendon or joint creating a mass under the skin Synovial cyst is rare in ankle joint A synovial cyst may or may not be painful depending on their size and location
Ganglion cyst in the foot with bony erosion between navicular and cuneiform bones
Tarsal synovial cyst
Anechoic ganglion situated in the sinus tarsi fat between the talus and calcaneous
Plantar fasciitis (PF) refers to inflammation of the
plantar fascia of the foot It is considered the most common cause of heel pain
Clinical presentation Pain on the undersurface of the heel on weight bearing is the principal complaint It can be worse when weight is borne after a period of rest (eg in the morning) and eases with walking Passive dorsiflexion of the toes may exacerbates discomfort
UltrasoundOften the initial imaging modality of choice Ultrasound typically shows increased thickness of the fascia and a hypoechoic fascia
Thickened hypoechoic origin of the plantar fascia which has a convex superior margin
Complete avulsion of the plantar fascia from the calcaneal tubercle
Plantar fasciitis
bull LOCATING FOREIGN BODIES AND FRACTURES
As in any other location the ankle
area is also subsidiary host foreign
whose classification location and
existence can be defined perfectly by
ultrasound Being a focused study to
the area of interest and with great
resolution for surface structures can
be considered more resolute
examination to screen these cases
Osseous diseases and fractures | Sonography discovered Medial Malleolus Fracture
Ultrasound examination of left ankle A Longitudinal sonogram left ankle demonstrates a wooden foreign body B Transverse view left ankle Note the hypervascularity in the inflamed area C Corresponding X-ray of left ankle Note the swelling on the lateral aspect No foreign body is visible
Thank You
Discreetly thickened right Achilles tendon at its insertion combining linear hyperechoic
and hypoechoic areas on small breaks intrasubstance and calcifications of the enthesis
Fat herniation into the defect by complete tear of the Achilles tendon
Complete tear of the Achilles tendon with retraction
of ends and integrity thin plantaris tendon
Tendinosis versus partial tear of Achilles tendon
bullPREACHILLES AND RETROACHILLES BURSITIS
Although bursitis can occur in isolation often are
related and systemic inflammatory diseases
In the ultrasound examination the distended
retrocalcaneal and preachilles appears are a
hypoechoic structure shaped coma interposed
between the Achilles tendon and the posterosuperior
aspect of the calcaneous Care must be taken not to
confuse it with the fatty space Kager containing oval
lobules of hyperechoic fat When bursitis is a
manifestation of synovitis is appreciated
hypervascular area with Doppler ultrasound
In the retroachilles bursitis exists thickening and
collection of fluid in the subcutaneous tissue
superficial to the tendon retrocalcaneal portion
Bursitis preachilles with typical morphology appreciating accumulation of fluid
in a coma between the anterior portion of the Achilles tendon and the calcaneous
Bursitis preachiacutelea that associated synovitis showing hyperemia with increased Doppler flow
Rheumatoid arthritis with retrocalcaneal bursitis (1) and calcaneal erosions (2)
ACCESSORY NAVICULAR BONEIn the distal insertion site may exist TP 2 types of bones
accessories
Accessory navicular bone type I (os tibiale externum) size
between the 2 and 6 mm can be contained within the TP and
being positioned immediately proximal posteromedial to the
navicular bone It generally produces symptoms and should
not be confused with a tendon calcification or avulsion
fracture
Type II accessory navicular bone is an accessory
ossification centre of the navicular bone with size between
9 and 12 mm triangular shaped and articulated through a
synchondrosis of the posterior and medial navicular bone
It insertion site of some fibers of TP and is associated with a
syndrome of pain and increased incidence of tendon rupture
caused by abnormal overloads Osteoarthritic changes may
underlie this synchondrosis which mimic tendon pathology
Accessory navicular bone within the posterior tibial tendon as anatomical variant
ANTERIOR COMPARTMENTThe tendons of the anterior ankle compared
with the rest of the ankle tendons are rarely
affected by disease The anterior tibial tendon
is the most prone to abnormalities like
tendinopathy tenosynovitis and its place
between the most frequent rupture is extensor
retinaculum and insertion into the first
cuneiform and the base of the first metatarsal
Sometimes the retracted tendon stump causes
a nodule on the anteromedial aspect of the
distal portion of the leg making clinically
confused with a tumour or cyst
Distal insertion tendinopathy of the anterior tibial tendon with increased vascularity
Tenosynovitis of the anterior tibial tendon with effusion
Anterior tibial tendon tenosynovitis with intratendinous ruptures
Anterior tibial tendon rupture with retraction of the tendon
Tenosynovitis of the extensor digitorum tendons with a synovial effusion
Tenosynovitis of the extensor digitorum tendon with hypervascularized thickened tendon and synovium and synovial fluid
Rheumatoid arthritis with tenosynovitis of the extensor digitorum and peroneal tendons
Thickening of the extensor hallucis longus tendon caused by osteosynthesis material
Multicystic non vascularized intramuscular mass in the extensor digitorum brevis muscle
LATERAL COMPARTMENTTENOSYNOVITIS OF THE PERONEAL TENDONSThe main sign of ultrasound is the presence of liquid inside the
common synovial sheath whereas usually tendinous
morphology is preserved We must differentiate tenosynovitis of
a spill within the common peroneal sheath secondary to a tear of
calcaneofibular ligament (PCL) The ultrasound diagnosis is the detection of the tendons in a lateral plane relative to the distal portion of the lateral malleolus instead of behind it The dynamic exploration foot dorsiflexion as both eversion may help identify cases of intermittent subluxation In long-standing disease can be observed fusiform thickening
of the peroneal tendons at the tip of the malleolus The complete tears of the peroneus brevis tendon (PC) and peroneus longus (PL) are rare occurring in the area of the lateral malleolus or midfoot Seen in patients with ankle sprains or history of chronic instability especially if they suffer widespread diseases (RA DM) or treated with corticosteroids The peroneal tendon ruptures causing the inability to eversion of the foot and cavus foot varus
Important thickening of both peroneal tendons (longus and brevis) associated
with moderate amount of fluid and thickening of the synovial sheath
Discreet amount of fluid in the common sheath of the peroneal tendons
associated with disorganization and a heterogeneous appearance
peroneus brevis tendon related to longitudinal rupture
Peroneal tenosynovitis and osteosynthesis
Tenosynovitis of the peroneal tendons and an intratendinous rupture of the short peroneal tendon
Intratendinous rupture and cyst in the peroneus brevis tendon
Peroneus quartus with an accessory muscle next to the peroneus longus and brevis tendons
Tumor next to the peroneal tendons that proved to be a benign fibrous mass
MEDIAL COMPARTMENT
ANOMALIES POSTERIOR TIBIAL TENDON (TP)
It is the most frequently injured in this compartment with ruptures
in asymptomatic middle-aged obese women as a result of
widespread disease (RA seronegative Spondyloarthropathy) or
associated with bone fractures It causes a gradual collapse of the
medial longitudinal arch with hindfoot valgus deformity and
excessive forefoot pronation
The presence of small vessels in inflammatory diseases
intratendinosis can simulate a fissuration tendon confusion can be ignored using colour Doppler Another possible diagnostic difficulty is when the undamaged tendon flexor digitorum longus (FLD) moves back and simulates the TP unbroken but it is smaller and in this case we only see in the groove retromalleolar 1 only tendon
Ultrasound has also proven to be an effective resource for identifying alterations associated tendon tenosynovitis serosa and hypertrophicSubluxation and dislocation anteriorly and medial TP relative to internal
malleolus is rare and valued sonographically placing the foot in dorsiflexion with forced supination
Thickening moderate amount of fluid surrounding calcifications and
hyperemia affecting the sheath and the posterior tibial tendon related
to chronic tenosynovitis in patient affects rheumatoid arthritis
Thickening moderate amount of surrounding fluid and calcifications (arrow) affecting the
posterior tibial tendon related to chronic tenosynovitis in patient affects rheumatoid arthritis
Tenosynovitis of the posterior tibial tendon caused by a bony ridge at the insertion of the retinaculum The retinaculum is thickened and the tendon subluxates
Psoriatic arthritis Ankle Grayscale examination Posterior tibial tendon on longitudinal (a) and transverse (b) scan Marked tendon sheath widening with homogeneous anechoic aspect (asterisks) of the content indicating an exudative tenosynovitis Note as the normal fibrillar echotexture is conserved Hand Flexor tendons of second finger The volar longitudinal (c) and transverse scan (d) shows a tendon sheath widening with signs of synovial proliferation presence of intense power Doppler signal surrounding the tendon and micro interruption of the margin (arrow) e Wrist Extensor carpi ulnaris tendon (sixth compartment of the extensor tendons ecu) on lateral longitudinal (e) and transverse (f) scan Chronic tenosynovitis with clear areas of low of echogenicity and loss of the continuity of tendon fibrils indicative of partial tendon tear (arrows) Moreover note the presence of power Doppler signal within the interruption indicating still activity of the inflammatory process g Dactylitis Volar longitudinal scan using the ldquoextended viewrdquo technique showing proliferative tenosynovitis of the finger flexor tendon (circle) exudative synovitis of both proximal and distal interphalangeal joint (white asterisks) and edema of the peritendinous tissue (black asterisks) TP posterior tibial tendon mm medial malleolus DP distal phalanx mp middle phalanx cu cubital bone ft flexor tendons
Tenosynovitis of the posterior tibial (1) and flexor digitorum longus tendon (2)
Tibialis Posterior Tendon rupture
Tenosynovitis of the posterior tibial tendon the flexor digitorum tendon and flexor hallucis longus tendon
Tenosynovitis of the tendons on the medial side in the left ankle
bullLIGAMENT INJURIESThe ligament partial tear ligament shows a hypoechoic
areas swollen with internal focal or diffuse In the complete
ruptures within the substance of the divided ligament rift is
observed corresponding to the hematoma hypoechoic and
the free ends of the divided ligament can be and retracted
appreciated corrugated in contrast with normal
appearance straight
Grade I Mild stretching of the ligament without breakage
or instability
Grade II Partial tearing of the ligament
Grade III Complete tearing
Degrees depending on the severity of the injury and the
place of employment
LATERAL COMPARTMENTThese injuries occur secondary to inversion sprains with internal rotation of
the foot combined with ankle plantar flexion
The anterior talar fibular ligament tears (ATFL) usually occur as isolated
involvement (70) or associated with calcaneal fibular ligament (CFL) (20-40)
but the posterior talar fibular ligament (PTFL) affects only major trauma
involving ankle dislocation
ATFL breaks is associated with breakage of the joint capsule and synovial fluid
extravasation into the anterolateral soft ankle whereas the complete tearing of
CFL can communicate the ankle joint and synovial sheath peroneal tendons
Rupture of CFL is rarely associated with superior peroneal retinaculum tear
The CFL is tensioned during dorsiflexion pulling on peroneal tendons laterally
so that absence of its displacement is sign of a complete tear
Within a damaged ligament can also observe calcifications that often
correspond to fragments of avulsion bone
During the ultrasound can be performed forced maneuvers to detect to joint
laxity and ligament injuries The anterior drawer test is performed with the feet
hanging over the edge of the examination table while the forefoot is pulled
anteriorly when the foot is in plantar flexion and inversion This maneuver
helps differentiate partial tears (grade II) of the ATFL to complete (grade III)
where the anterior displacement of the talus on the tibia open a crack in the
substance becoming more visible the ligament injury
The sindesmosys sprains are up to 10 of ankle
injuries happening in eversion and pronation
movements (like the deltoid ligament injury) and
primarily affect the anterior tibiofibular ligament (ATFL)
the failure is frequently associated with fracture of the
fibula
According to the place of employment are 4 degrees
useful for prognostic evaluation and therapeutic strategy
choice
Grade I stretch or partial tear of the ATFL
Grade II complete tearing but only the ATFL
Grade III complete tear of the ATFL and partial CFL
Grade IV complete tear of the ATFL and CFL
The grade I and II injuries usually scarred without any
significant instability whereas grade III and IV injuries
can cause chronic pain and require surgical treatment
Thickened but continued ATFL right in relation to the partial rupture
Grade 111 sprain of right ATFL
Thickened anterior talofibular ligament with calcifications and a partial rupture
Thickened tibiofibular ligament after trauma
Anterior Talofibular Ligament Partial Tear and Elastography
Tibio fibular ligament rupture with bony avulsion
Complete rupture of right ATFL
Bony avulsion with radiographic evidence as visible calcification in a grade III sprain ATFL
Moderately thickened and hypoechoic ATFL
Discontinuity of the ATFL with fluid surrounding the torn ends (arrow)
Thickening and hypoechogenicity of the fibular end of the ligament seen here passing over the subtalar joint which contains a small of fluid
Complete disruption to the tibiofibular ligament with bony irregularity of particularly the tibial margin and fluid in the gap
MEDIAL COMPARTMENTBecause of the low incidence of eversion ankle
sprains and the thickness of the deltoid ligament
is rarely injured in isolation and when the injury
does not usually full thickness Usually
accompanied by lesions of the medial malleolus
and lateral displacement of the talus with
consequent widening of the ankle mortise
Ultrasound is useful for differentiating ligament
injury of the posterior tibial tendon injury
(TP) adjacent they have similar symptoms
The inability to visualize the deltoid ligament may
indicate tear but this is not considered a reliable
sign as its full ultrasound is not always possible
Partial medial ligament rupture
Thickened heterogeneous abnormal deltoid demonstrating hyperemia
Ultrasonogram showing a disrupted deltoid ligament with the probe in the coronal plane The white arrow indicates the medial malleolus the blue arrow indicates the talus and the red arrows indicate the disrupted deltoid ligament (A) Radiograph showing the same injury (B)
bullJOINT AND BONE DISORDERSUltrasound reliably detect spills mild (gt 2 ml) inside
of the ankle joint by exploring the front and rear
recess as well as areas of synovial proliferation and
may even display using the colour Doppler
hyperemic areas in arthritis patients
The intraarticular joints are displayed surrounded
fluid in one of the recesses of the ankle or subtalar
joint Sonographically diagnosed when changing position to perform flexion and extension Fracture of the lateral process of the talus is overlooked up to 50 of cases with plain radiography Ultrasound may suspect the presence of focal cortical disruption helping further to exclude concomitant ligament injury
Rheumatoid arthritis with synovial thickening (1) and erosion of the tibia (2)
Infectious arthritis with a pus filled anterior recess of the ankle
Arthritis and tenosynovitis of the ankle in a patient with rheumatoid arthritis
bullTUMOURSUltrasound can differentiate between a mass complex
and solid and a cystic in addition to verifying the
existence of accessory muscles (peroneus fourth
accessory flexor digitorum longus and accessory
soleus) As in any other location can be found
neoformative soft tissue tumors inflammatory
infectious etc
Ganglions of this location are more often symptomatic
and larger with multiple partitions
branched and lobed edges Differential diagnosis must
be made with tenosynovitis abscesses seromas and
varicosities
Neurogenic tumours are described as pathognomonic
homogeneous hypoechoic oval mass in continuity with
a nerve of origin
Ganglion cysts are non-malignant cystic masses that occur in association with musculoskeletal structures They are sometimes also simply referred to as ganglia or a ganglion but should not be confused with the anatomical term ganglion UltrasoundThe vast majority are anechoic to hypoechoic on ultrasound and have well defined margins Many demonstrate internal septations as well as acoustic enhancement A synovial cyst is a small fluid-filled sac or pouch that can develop over a tendon or joint creating a mass under the skin Synovial cyst is rare in ankle joint A synovial cyst may or may not be painful depending on their size and location
Ganglion cyst in the foot with bony erosion between navicular and cuneiform bones
Tarsal synovial cyst
Anechoic ganglion situated in the sinus tarsi fat between the talus and calcaneous
Plantar fasciitis (PF) refers to inflammation of the
plantar fascia of the foot It is considered the most common cause of heel pain
Clinical presentation Pain on the undersurface of the heel on weight bearing is the principal complaint It can be worse when weight is borne after a period of rest (eg in the morning) and eases with walking Passive dorsiflexion of the toes may exacerbates discomfort
UltrasoundOften the initial imaging modality of choice Ultrasound typically shows increased thickness of the fascia and a hypoechoic fascia
Thickened hypoechoic origin of the plantar fascia which has a convex superior margin
Complete avulsion of the plantar fascia from the calcaneal tubercle
Plantar fasciitis
bull LOCATING FOREIGN BODIES AND FRACTURES
As in any other location the ankle
area is also subsidiary host foreign
whose classification location and
existence can be defined perfectly by
ultrasound Being a focused study to
the area of interest and with great
resolution for surface structures can
be considered more resolute
examination to screen these cases
Osseous diseases and fractures | Sonography discovered Medial Malleolus Fracture
Ultrasound examination of left ankle A Longitudinal sonogram left ankle demonstrates a wooden foreign body B Transverse view left ankle Note the hypervascularity in the inflamed area C Corresponding X-ray of left ankle Note the swelling on the lateral aspect No foreign body is visible
Thank You
Fat herniation into the defect by complete tear of the Achilles tendon
Complete tear of the Achilles tendon with retraction
of ends and integrity thin plantaris tendon
Tendinosis versus partial tear of Achilles tendon
bullPREACHILLES AND RETROACHILLES BURSITIS
Although bursitis can occur in isolation often are
related and systemic inflammatory diseases
In the ultrasound examination the distended
retrocalcaneal and preachilles appears are a
hypoechoic structure shaped coma interposed
between the Achilles tendon and the posterosuperior
aspect of the calcaneous Care must be taken not to
confuse it with the fatty space Kager containing oval
lobules of hyperechoic fat When bursitis is a
manifestation of synovitis is appreciated
hypervascular area with Doppler ultrasound
In the retroachilles bursitis exists thickening and
collection of fluid in the subcutaneous tissue
superficial to the tendon retrocalcaneal portion
Bursitis preachilles with typical morphology appreciating accumulation of fluid
in a coma between the anterior portion of the Achilles tendon and the calcaneous
Bursitis preachiacutelea that associated synovitis showing hyperemia with increased Doppler flow
Rheumatoid arthritis with retrocalcaneal bursitis (1) and calcaneal erosions (2)
ACCESSORY NAVICULAR BONEIn the distal insertion site may exist TP 2 types of bones
accessories
Accessory navicular bone type I (os tibiale externum) size
between the 2 and 6 mm can be contained within the TP and
being positioned immediately proximal posteromedial to the
navicular bone It generally produces symptoms and should
not be confused with a tendon calcification or avulsion
fracture
Type II accessory navicular bone is an accessory
ossification centre of the navicular bone with size between
9 and 12 mm triangular shaped and articulated through a
synchondrosis of the posterior and medial navicular bone
It insertion site of some fibers of TP and is associated with a
syndrome of pain and increased incidence of tendon rupture
caused by abnormal overloads Osteoarthritic changes may
underlie this synchondrosis which mimic tendon pathology
Accessory navicular bone within the posterior tibial tendon as anatomical variant
ANTERIOR COMPARTMENTThe tendons of the anterior ankle compared
with the rest of the ankle tendons are rarely
affected by disease The anterior tibial tendon
is the most prone to abnormalities like
tendinopathy tenosynovitis and its place
between the most frequent rupture is extensor
retinaculum and insertion into the first
cuneiform and the base of the first metatarsal
Sometimes the retracted tendon stump causes
a nodule on the anteromedial aspect of the
distal portion of the leg making clinically
confused with a tumour or cyst
Distal insertion tendinopathy of the anterior tibial tendon with increased vascularity
Tenosynovitis of the anterior tibial tendon with effusion
Anterior tibial tendon tenosynovitis with intratendinous ruptures
Anterior tibial tendon rupture with retraction of the tendon
Tenosynovitis of the extensor digitorum tendons with a synovial effusion
Tenosynovitis of the extensor digitorum tendon with hypervascularized thickened tendon and synovium and synovial fluid
Rheumatoid arthritis with tenosynovitis of the extensor digitorum and peroneal tendons
Thickening of the extensor hallucis longus tendon caused by osteosynthesis material
Multicystic non vascularized intramuscular mass in the extensor digitorum brevis muscle
LATERAL COMPARTMENTTENOSYNOVITIS OF THE PERONEAL TENDONSThe main sign of ultrasound is the presence of liquid inside the
common synovial sheath whereas usually tendinous
morphology is preserved We must differentiate tenosynovitis of
a spill within the common peroneal sheath secondary to a tear of
calcaneofibular ligament (PCL) The ultrasound diagnosis is the detection of the tendons in a lateral plane relative to the distal portion of the lateral malleolus instead of behind it The dynamic exploration foot dorsiflexion as both eversion may help identify cases of intermittent subluxation In long-standing disease can be observed fusiform thickening
of the peroneal tendons at the tip of the malleolus The complete tears of the peroneus brevis tendon (PC) and peroneus longus (PL) are rare occurring in the area of the lateral malleolus or midfoot Seen in patients with ankle sprains or history of chronic instability especially if they suffer widespread diseases (RA DM) or treated with corticosteroids The peroneal tendon ruptures causing the inability to eversion of the foot and cavus foot varus
Important thickening of both peroneal tendons (longus and brevis) associated
with moderate amount of fluid and thickening of the synovial sheath
Discreet amount of fluid in the common sheath of the peroneal tendons
associated with disorganization and a heterogeneous appearance
peroneus brevis tendon related to longitudinal rupture
Peroneal tenosynovitis and osteosynthesis
Tenosynovitis of the peroneal tendons and an intratendinous rupture of the short peroneal tendon
Intratendinous rupture and cyst in the peroneus brevis tendon
Peroneus quartus with an accessory muscle next to the peroneus longus and brevis tendons
Tumor next to the peroneal tendons that proved to be a benign fibrous mass
MEDIAL COMPARTMENT
ANOMALIES POSTERIOR TIBIAL TENDON (TP)
It is the most frequently injured in this compartment with ruptures
in asymptomatic middle-aged obese women as a result of
widespread disease (RA seronegative Spondyloarthropathy) or
associated with bone fractures It causes a gradual collapse of the
medial longitudinal arch with hindfoot valgus deformity and
excessive forefoot pronation
The presence of small vessels in inflammatory diseases
intratendinosis can simulate a fissuration tendon confusion can be ignored using colour Doppler Another possible diagnostic difficulty is when the undamaged tendon flexor digitorum longus (FLD) moves back and simulates the TP unbroken but it is smaller and in this case we only see in the groove retromalleolar 1 only tendon
Ultrasound has also proven to be an effective resource for identifying alterations associated tendon tenosynovitis serosa and hypertrophicSubluxation and dislocation anteriorly and medial TP relative to internal
malleolus is rare and valued sonographically placing the foot in dorsiflexion with forced supination
Thickening moderate amount of fluid surrounding calcifications and
hyperemia affecting the sheath and the posterior tibial tendon related
to chronic tenosynovitis in patient affects rheumatoid arthritis
Thickening moderate amount of surrounding fluid and calcifications (arrow) affecting the
posterior tibial tendon related to chronic tenosynovitis in patient affects rheumatoid arthritis
Tenosynovitis of the posterior tibial tendon caused by a bony ridge at the insertion of the retinaculum The retinaculum is thickened and the tendon subluxates
Psoriatic arthritis Ankle Grayscale examination Posterior tibial tendon on longitudinal (a) and transverse (b) scan Marked tendon sheath widening with homogeneous anechoic aspect (asterisks) of the content indicating an exudative tenosynovitis Note as the normal fibrillar echotexture is conserved Hand Flexor tendons of second finger The volar longitudinal (c) and transverse scan (d) shows a tendon sheath widening with signs of synovial proliferation presence of intense power Doppler signal surrounding the tendon and micro interruption of the margin (arrow) e Wrist Extensor carpi ulnaris tendon (sixth compartment of the extensor tendons ecu) on lateral longitudinal (e) and transverse (f) scan Chronic tenosynovitis with clear areas of low of echogenicity and loss of the continuity of tendon fibrils indicative of partial tendon tear (arrows) Moreover note the presence of power Doppler signal within the interruption indicating still activity of the inflammatory process g Dactylitis Volar longitudinal scan using the ldquoextended viewrdquo technique showing proliferative tenosynovitis of the finger flexor tendon (circle) exudative synovitis of both proximal and distal interphalangeal joint (white asterisks) and edema of the peritendinous tissue (black asterisks) TP posterior tibial tendon mm medial malleolus DP distal phalanx mp middle phalanx cu cubital bone ft flexor tendons
Tenosynovitis of the posterior tibial (1) and flexor digitorum longus tendon (2)
Tibialis Posterior Tendon rupture
Tenosynovitis of the posterior tibial tendon the flexor digitorum tendon and flexor hallucis longus tendon
Tenosynovitis of the tendons on the medial side in the left ankle
bullLIGAMENT INJURIESThe ligament partial tear ligament shows a hypoechoic
areas swollen with internal focal or diffuse In the complete
ruptures within the substance of the divided ligament rift is
observed corresponding to the hematoma hypoechoic and
the free ends of the divided ligament can be and retracted
appreciated corrugated in contrast with normal
appearance straight
Grade I Mild stretching of the ligament without breakage
or instability
Grade II Partial tearing of the ligament
Grade III Complete tearing
Degrees depending on the severity of the injury and the
place of employment
LATERAL COMPARTMENTThese injuries occur secondary to inversion sprains with internal rotation of
the foot combined with ankle plantar flexion
The anterior talar fibular ligament tears (ATFL) usually occur as isolated
involvement (70) or associated with calcaneal fibular ligament (CFL) (20-40)
but the posterior talar fibular ligament (PTFL) affects only major trauma
involving ankle dislocation
ATFL breaks is associated with breakage of the joint capsule and synovial fluid
extravasation into the anterolateral soft ankle whereas the complete tearing of
CFL can communicate the ankle joint and synovial sheath peroneal tendons
Rupture of CFL is rarely associated with superior peroneal retinaculum tear
The CFL is tensioned during dorsiflexion pulling on peroneal tendons laterally
so that absence of its displacement is sign of a complete tear
Within a damaged ligament can also observe calcifications that often
correspond to fragments of avulsion bone
During the ultrasound can be performed forced maneuvers to detect to joint
laxity and ligament injuries The anterior drawer test is performed with the feet
hanging over the edge of the examination table while the forefoot is pulled
anteriorly when the foot is in plantar flexion and inversion This maneuver
helps differentiate partial tears (grade II) of the ATFL to complete (grade III)
where the anterior displacement of the talus on the tibia open a crack in the
substance becoming more visible the ligament injury
The sindesmosys sprains are up to 10 of ankle
injuries happening in eversion and pronation
movements (like the deltoid ligament injury) and
primarily affect the anterior tibiofibular ligament (ATFL)
the failure is frequently associated with fracture of the
fibula
According to the place of employment are 4 degrees
useful for prognostic evaluation and therapeutic strategy
choice
Grade I stretch or partial tear of the ATFL
Grade II complete tearing but only the ATFL
Grade III complete tear of the ATFL and partial CFL
Grade IV complete tear of the ATFL and CFL
The grade I and II injuries usually scarred without any
significant instability whereas grade III and IV injuries
can cause chronic pain and require surgical treatment
Thickened but continued ATFL right in relation to the partial rupture
Grade 111 sprain of right ATFL
Thickened anterior talofibular ligament with calcifications and a partial rupture
Thickened tibiofibular ligament after trauma
Anterior Talofibular Ligament Partial Tear and Elastography
Tibio fibular ligament rupture with bony avulsion
Complete rupture of right ATFL
Bony avulsion with radiographic evidence as visible calcification in a grade III sprain ATFL
Moderately thickened and hypoechoic ATFL
Discontinuity of the ATFL with fluid surrounding the torn ends (arrow)
Thickening and hypoechogenicity of the fibular end of the ligament seen here passing over the subtalar joint which contains a small of fluid
Complete disruption to the tibiofibular ligament with bony irregularity of particularly the tibial margin and fluid in the gap
MEDIAL COMPARTMENTBecause of the low incidence of eversion ankle
sprains and the thickness of the deltoid ligament
is rarely injured in isolation and when the injury
does not usually full thickness Usually
accompanied by lesions of the medial malleolus
and lateral displacement of the talus with
consequent widening of the ankle mortise
Ultrasound is useful for differentiating ligament
injury of the posterior tibial tendon injury
(TP) adjacent they have similar symptoms
The inability to visualize the deltoid ligament may
indicate tear but this is not considered a reliable
sign as its full ultrasound is not always possible
Partial medial ligament rupture
Thickened heterogeneous abnormal deltoid demonstrating hyperemia
Ultrasonogram showing a disrupted deltoid ligament with the probe in the coronal plane The white arrow indicates the medial malleolus the blue arrow indicates the talus and the red arrows indicate the disrupted deltoid ligament (A) Radiograph showing the same injury (B)
bullJOINT AND BONE DISORDERSUltrasound reliably detect spills mild (gt 2 ml) inside
of the ankle joint by exploring the front and rear
recess as well as areas of synovial proliferation and
may even display using the colour Doppler
hyperemic areas in arthritis patients
The intraarticular joints are displayed surrounded
fluid in one of the recesses of the ankle or subtalar
joint Sonographically diagnosed when changing position to perform flexion and extension Fracture of the lateral process of the talus is overlooked up to 50 of cases with plain radiography Ultrasound may suspect the presence of focal cortical disruption helping further to exclude concomitant ligament injury
Rheumatoid arthritis with synovial thickening (1) and erosion of the tibia (2)
Infectious arthritis with a pus filled anterior recess of the ankle
Arthritis and tenosynovitis of the ankle in a patient with rheumatoid arthritis
bullTUMOURSUltrasound can differentiate between a mass complex
and solid and a cystic in addition to verifying the
existence of accessory muscles (peroneus fourth
accessory flexor digitorum longus and accessory
soleus) As in any other location can be found
neoformative soft tissue tumors inflammatory
infectious etc
Ganglions of this location are more often symptomatic
and larger with multiple partitions
branched and lobed edges Differential diagnosis must
be made with tenosynovitis abscesses seromas and
varicosities
Neurogenic tumours are described as pathognomonic
homogeneous hypoechoic oval mass in continuity with
a nerve of origin
Ganglion cysts are non-malignant cystic masses that occur in association with musculoskeletal structures They are sometimes also simply referred to as ganglia or a ganglion but should not be confused with the anatomical term ganglion UltrasoundThe vast majority are anechoic to hypoechoic on ultrasound and have well defined margins Many demonstrate internal septations as well as acoustic enhancement A synovial cyst is a small fluid-filled sac or pouch that can develop over a tendon or joint creating a mass under the skin Synovial cyst is rare in ankle joint A synovial cyst may or may not be painful depending on their size and location
Ganglion cyst in the foot with bony erosion between navicular and cuneiform bones
Tarsal synovial cyst
Anechoic ganglion situated in the sinus tarsi fat between the talus and calcaneous
Plantar fasciitis (PF) refers to inflammation of the
plantar fascia of the foot It is considered the most common cause of heel pain
Clinical presentation Pain on the undersurface of the heel on weight bearing is the principal complaint It can be worse when weight is borne after a period of rest (eg in the morning) and eases with walking Passive dorsiflexion of the toes may exacerbates discomfort
UltrasoundOften the initial imaging modality of choice Ultrasound typically shows increased thickness of the fascia and a hypoechoic fascia
Thickened hypoechoic origin of the plantar fascia which has a convex superior margin
Complete avulsion of the plantar fascia from the calcaneal tubercle
Plantar fasciitis
bull LOCATING FOREIGN BODIES AND FRACTURES
As in any other location the ankle
area is also subsidiary host foreign
whose classification location and
existence can be defined perfectly by
ultrasound Being a focused study to
the area of interest and with great
resolution for surface structures can
be considered more resolute
examination to screen these cases
Osseous diseases and fractures | Sonography discovered Medial Malleolus Fracture
Ultrasound examination of left ankle A Longitudinal sonogram left ankle demonstrates a wooden foreign body B Transverse view left ankle Note the hypervascularity in the inflamed area C Corresponding X-ray of left ankle Note the swelling on the lateral aspect No foreign body is visible
Thank You
Complete tear of the Achilles tendon with retraction
of ends and integrity thin plantaris tendon
Tendinosis versus partial tear of Achilles tendon
bullPREACHILLES AND RETROACHILLES BURSITIS
Although bursitis can occur in isolation often are
related and systemic inflammatory diseases
In the ultrasound examination the distended
retrocalcaneal and preachilles appears are a
hypoechoic structure shaped coma interposed
between the Achilles tendon and the posterosuperior
aspect of the calcaneous Care must be taken not to
confuse it with the fatty space Kager containing oval
lobules of hyperechoic fat When bursitis is a
manifestation of synovitis is appreciated
hypervascular area with Doppler ultrasound
In the retroachilles bursitis exists thickening and
collection of fluid in the subcutaneous tissue
superficial to the tendon retrocalcaneal portion
Bursitis preachilles with typical morphology appreciating accumulation of fluid
in a coma between the anterior portion of the Achilles tendon and the calcaneous
Bursitis preachiacutelea that associated synovitis showing hyperemia with increased Doppler flow
Rheumatoid arthritis with retrocalcaneal bursitis (1) and calcaneal erosions (2)
ACCESSORY NAVICULAR BONEIn the distal insertion site may exist TP 2 types of bones
accessories
Accessory navicular bone type I (os tibiale externum) size
between the 2 and 6 mm can be contained within the TP and
being positioned immediately proximal posteromedial to the
navicular bone It generally produces symptoms and should
not be confused with a tendon calcification or avulsion
fracture
Type II accessory navicular bone is an accessory
ossification centre of the navicular bone with size between
9 and 12 mm triangular shaped and articulated through a
synchondrosis of the posterior and medial navicular bone
It insertion site of some fibers of TP and is associated with a
syndrome of pain and increased incidence of tendon rupture
caused by abnormal overloads Osteoarthritic changes may
underlie this synchondrosis which mimic tendon pathology
Accessory navicular bone within the posterior tibial tendon as anatomical variant
ANTERIOR COMPARTMENTThe tendons of the anterior ankle compared
with the rest of the ankle tendons are rarely
affected by disease The anterior tibial tendon
is the most prone to abnormalities like
tendinopathy tenosynovitis and its place
between the most frequent rupture is extensor
retinaculum and insertion into the first
cuneiform and the base of the first metatarsal
Sometimes the retracted tendon stump causes
a nodule on the anteromedial aspect of the
distal portion of the leg making clinically
confused with a tumour or cyst
Distal insertion tendinopathy of the anterior tibial tendon with increased vascularity
Tenosynovitis of the anterior tibial tendon with effusion
Anterior tibial tendon tenosynovitis with intratendinous ruptures
Anterior tibial tendon rupture with retraction of the tendon
Tenosynovitis of the extensor digitorum tendons with a synovial effusion
Tenosynovitis of the extensor digitorum tendon with hypervascularized thickened tendon and synovium and synovial fluid
Rheumatoid arthritis with tenosynovitis of the extensor digitorum and peroneal tendons
Thickening of the extensor hallucis longus tendon caused by osteosynthesis material
Multicystic non vascularized intramuscular mass in the extensor digitorum brevis muscle
LATERAL COMPARTMENTTENOSYNOVITIS OF THE PERONEAL TENDONSThe main sign of ultrasound is the presence of liquid inside the
common synovial sheath whereas usually tendinous
morphology is preserved We must differentiate tenosynovitis of
a spill within the common peroneal sheath secondary to a tear of
calcaneofibular ligament (PCL) The ultrasound diagnosis is the detection of the tendons in a lateral plane relative to the distal portion of the lateral malleolus instead of behind it The dynamic exploration foot dorsiflexion as both eversion may help identify cases of intermittent subluxation In long-standing disease can be observed fusiform thickening
of the peroneal tendons at the tip of the malleolus The complete tears of the peroneus brevis tendon (PC) and peroneus longus (PL) are rare occurring in the area of the lateral malleolus or midfoot Seen in patients with ankle sprains or history of chronic instability especially if they suffer widespread diseases (RA DM) or treated with corticosteroids The peroneal tendon ruptures causing the inability to eversion of the foot and cavus foot varus
Important thickening of both peroneal tendons (longus and brevis) associated
with moderate amount of fluid and thickening of the synovial sheath
Discreet amount of fluid in the common sheath of the peroneal tendons
associated with disorganization and a heterogeneous appearance
peroneus brevis tendon related to longitudinal rupture
Peroneal tenosynovitis and osteosynthesis
Tenosynovitis of the peroneal tendons and an intratendinous rupture of the short peroneal tendon
Intratendinous rupture and cyst in the peroneus brevis tendon
Peroneus quartus with an accessory muscle next to the peroneus longus and brevis tendons
Tumor next to the peroneal tendons that proved to be a benign fibrous mass
MEDIAL COMPARTMENT
ANOMALIES POSTERIOR TIBIAL TENDON (TP)
It is the most frequently injured in this compartment with ruptures
in asymptomatic middle-aged obese women as a result of
widespread disease (RA seronegative Spondyloarthropathy) or
associated with bone fractures It causes a gradual collapse of the
medial longitudinal arch with hindfoot valgus deformity and
excessive forefoot pronation
The presence of small vessels in inflammatory diseases
intratendinosis can simulate a fissuration tendon confusion can be ignored using colour Doppler Another possible diagnostic difficulty is when the undamaged tendon flexor digitorum longus (FLD) moves back and simulates the TP unbroken but it is smaller and in this case we only see in the groove retromalleolar 1 only tendon
Ultrasound has also proven to be an effective resource for identifying alterations associated tendon tenosynovitis serosa and hypertrophicSubluxation and dislocation anteriorly and medial TP relative to internal
malleolus is rare and valued sonographically placing the foot in dorsiflexion with forced supination
Thickening moderate amount of fluid surrounding calcifications and
hyperemia affecting the sheath and the posterior tibial tendon related
to chronic tenosynovitis in patient affects rheumatoid arthritis
Thickening moderate amount of surrounding fluid and calcifications (arrow) affecting the
posterior tibial tendon related to chronic tenosynovitis in patient affects rheumatoid arthritis
Tenosynovitis of the posterior tibial tendon caused by a bony ridge at the insertion of the retinaculum The retinaculum is thickened and the tendon subluxates
Psoriatic arthritis Ankle Grayscale examination Posterior tibial tendon on longitudinal (a) and transverse (b) scan Marked tendon sheath widening with homogeneous anechoic aspect (asterisks) of the content indicating an exudative tenosynovitis Note as the normal fibrillar echotexture is conserved Hand Flexor tendons of second finger The volar longitudinal (c) and transverse scan (d) shows a tendon sheath widening with signs of synovial proliferation presence of intense power Doppler signal surrounding the tendon and micro interruption of the margin (arrow) e Wrist Extensor carpi ulnaris tendon (sixth compartment of the extensor tendons ecu) on lateral longitudinal (e) and transverse (f) scan Chronic tenosynovitis with clear areas of low of echogenicity and loss of the continuity of tendon fibrils indicative of partial tendon tear (arrows) Moreover note the presence of power Doppler signal within the interruption indicating still activity of the inflammatory process g Dactylitis Volar longitudinal scan using the ldquoextended viewrdquo technique showing proliferative tenosynovitis of the finger flexor tendon (circle) exudative synovitis of both proximal and distal interphalangeal joint (white asterisks) and edema of the peritendinous tissue (black asterisks) TP posterior tibial tendon mm medial malleolus DP distal phalanx mp middle phalanx cu cubital bone ft flexor tendons
Tenosynovitis of the posterior tibial (1) and flexor digitorum longus tendon (2)
Tibialis Posterior Tendon rupture
Tenosynovitis of the posterior tibial tendon the flexor digitorum tendon and flexor hallucis longus tendon
Tenosynovitis of the tendons on the medial side in the left ankle
bullLIGAMENT INJURIESThe ligament partial tear ligament shows a hypoechoic
areas swollen with internal focal or diffuse In the complete
ruptures within the substance of the divided ligament rift is
observed corresponding to the hematoma hypoechoic and
the free ends of the divided ligament can be and retracted
appreciated corrugated in contrast with normal
appearance straight
Grade I Mild stretching of the ligament without breakage
or instability
Grade II Partial tearing of the ligament
Grade III Complete tearing
Degrees depending on the severity of the injury and the
place of employment
LATERAL COMPARTMENTThese injuries occur secondary to inversion sprains with internal rotation of
the foot combined with ankle plantar flexion
The anterior talar fibular ligament tears (ATFL) usually occur as isolated
involvement (70) or associated with calcaneal fibular ligament (CFL) (20-40)
but the posterior talar fibular ligament (PTFL) affects only major trauma
involving ankle dislocation
ATFL breaks is associated with breakage of the joint capsule and synovial fluid
extravasation into the anterolateral soft ankle whereas the complete tearing of
CFL can communicate the ankle joint and synovial sheath peroneal tendons
Rupture of CFL is rarely associated with superior peroneal retinaculum tear
The CFL is tensioned during dorsiflexion pulling on peroneal tendons laterally
so that absence of its displacement is sign of a complete tear
Within a damaged ligament can also observe calcifications that often
correspond to fragments of avulsion bone
During the ultrasound can be performed forced maneuvers to detect to joint
laxity and ligament injuries The anterior drawer test is performed with the feet
hanging over the edge of the examination table while the forefoot is pulled
anteriorly when the foot is in plantar flexion and inversion This maneuver
helps differentiate partial tears (grade II) of the ATFL to complete (grade III)
where the anterior displacement of the talus on the tibia open a crack in the
substance becoming more visible the ligament injury
The sindesmosys sprains are up to 10 of ankle
injuries happening in eversion and pronation
movements (like the deltoid ligament injury) and
primarily affect the anterior tibiofibular ligament (ATFL)
the failure is frequently associated with fracture of the
fibula
According to the place of employment are 4 degrees
useful for prognostic evaluation and therapeutic strategy
choice
Grade I stretch or partial tear of the ATFL
Grade II complete tearing but only the ATFL
Grade III complete tear of the ATFL and partial CFL
Grade IV complete tear of the ATFL and CFL
The grade I and II injuries usually scarred without any
significant instability whereas grade III and IV injuries
can cause chronic pain and require surgical treatment
Thickened but continued ATFL right in relation to the partial rupture
Grade 111 sprain of right ATFL
Thickened anterior talofibular ligament with calcifications and a partial rupture
Thickened tibiofibular ligament after trauma
Anterior Talofibular Ligament Partial Tear and Elastography
Tibio fibular ligament rupture with bony avulsion
Complete rupture of right ATFL
Bony avulsion with radiographic evidence as visible calcification in a grade III sprain ATFL
Moderately thickened and hypoechoic ATFL
Discontinuity of the ATFL with fluid surrounding the torn ends (arrow)
Thickening and hypoechogenicity of the fibular end of the ligament seen here passing over the subtalar joint which contains a small of fluid
Complete disruption to the tibiofibular ligament with bony irregularity of particularly the tibial margin and fluid in the gap
MEDIAL COMPARTMENTBecause of the low incidence of eversion ankle
sprains and the thickness of the deltoid ligament
is rarely injured in isolation and when the injury
does not usually full thickness Usually
accompanied by lesions of the medial malleolus
and lateral displacement of the talus with
consequent widening of the ankle mortise
Ultrasound is useful for differentiating ligament
injury of the posterior tibial tendon injury
(TP) adjacent they have similar symptoms
The inability to visualize the deltoid ligament may
indicate tear but this is not considered a reliable
sign as its full ultrasound is not always possible
Partial medial ligament rupture
Thickened heterogeneous abnormal deltoid demonstrating hyperemia
Ultrasonogram showing a disrupted deltoid ligament with the probe in the coronal plane The white arrow indicates the medial malleolus the blue arrow indicates the talus and the red arrows indicate the disrupted deltoid ligament (A) Radiograph showing the same injury (B)
bullJOINT AND BONE DISORDERSUltrasound reliably detect spills mild (gt 2 ml) inside
of the ankle joint by exploring the front and rear
recess as well as areas of synovial proliferation and
may even display using the colour Doppler
hyperemic areas in arthritis patients
The intraarticular joints are displayed surrounded
fluid in one of the recesses of the ankle or subtalar
joint Sonographically diagnosed when changing position to perform flexion and extension Fracture of the lateral process of the talus is overlooked up to 50 of cases with plain radiography Ultrasound may suspect the presence of focal cortical disruption helping further to exclude concomitant ligament injury
Rheumatoid arthritis with synovial thickening (1) and erosion of the tibia (2)
Infectious arthritis with a pus filled anterior recess of the ankle
Arthritis and tenosynovitis of the ankle in a patient with rheumatoid arthritis
bullTUMOURSUltrasound can differentiate between a mass complex
and solid and a cystic in addition to verifying the
existence of accessory muscles (peroneus fourth
accessory flexor digitorum longus and accessory
soleus) As in any other location can be found
neoformative soft tissue tumors inflammatory
infectious etc
Ganglions of this location are more often symptomatic
and larger with multiple partitions
branched and lobed edges Differential diagnosis must
be made with tenosynovitis abscesses seromas and
varicosities
Neurogenic tumours are described as pathognomonic
homogeneous hypoechoic oval mass in continuity with
a nerve of origin
Ganglion cysts are non-malignant cystic masses that occur in association with musculoskeletal structures They are sometimes also simply referred to as ganglia or a ganglion but should not be confused with the anatomical term ganglion UltrasoundThe vast majority are anechoic to hypoechoic on ultrasound and have well defined margins Many demonstrate internal septations as well as acoustic enhancement A synovial cyst is a small fluid-filled sac or pouch that can develop over a tendon or joint creating a mass under the skin Synovial cyst is rare in ankle joint A synovial cyst may or may not be painful depending on their size and location
Ganglion cyst in the foot with bony erosion between navicular and cuneiform bones
Tarsal synovial cyst
Anechoic ganglion situated in the sinus tarsi fat between the talus and calcaneous
Plantar fasciitis (PF) refers to inflammation of the
plantar fascia of the foot It is considered the most common cause of heel pain
Clinical presentation Pain on the undersurface of the heel on weight bearing is the principal complaint It can be worse when weight is borne after a period of rest (eg in the morning) and eases with walking Passive dorsiflexion of the toes may exacerbates discomfort
UltrasoundOften the initial imaging modality of choice Ultrasound typically shows increased thickness of the fascia and a hypoechoic fascia
Thickened hypoechoic origin of the plantar fascia which has a convex superior margin
Complete avulsion of the plantar fascia from the calcaneal tubercle
Plantar fasciitis
bull LOCATING FOREIGN BODIES AND FRACTURES
As in any other location the ankle
area is also subsidiary host foreign
whose classification location and
existence can be defined perfectly by
ultrasound Being a focused study to
the area of interest and with great
resolution for surface structures can
be considered more resolute
examination to screen these cases
Osseous diseases and fractures | Sonography discovered Medial Malleolus Fracture
Ultrasound examination of left ankle A Longitudinal sonogram left ankle demonstrates a wooden foreign body B Transverse view left ankle Note the hypervascularity in the inflamed area C Corresponding X-ray of left ankle Note the swelling on the lateral aspect No foreign body is visible
Thank You
Tendinosis versus partial tear of Achilles tendon
bullPREACHILLES AND RETROACHILLES BURSITIS
Although bursitis can occur in isolation often are
related and systemic inflammatory diseases
In the ultrasound examination the distended
retrocalcaneal and preachilles appears are a
hypoechoic structure shaped coma interposed
between the Achilles tendon and the posterosuperior
aspect of the calcaneous Care must be taken not to
confuse it with the fatty space Kager containing oval
lobules of hyperechoic fat When bursitis is a
manifestation of synovitis is appreciated
hypervascular area with Doppler ultrasound
In the retroachilles bursitis exists thickening and
collection of fluid in the subcutaneous tissue
superficial to the tendon retrocalcaneal portion
Bursitis preachilles with typical morphology appreciating accumulation of fluid
in a coma between the anterior portion of the Achilles tendon and the calcaneous
Bursitis preachiacutelea that associated synovitis showing hyperemia with increased Doppler flow
Rheumatoid arthritis with retrocalcaneal bursitis (1) and calcaneal erosions (2)
ACCESSORY NAVICULAR BONEIn the distal insertion site may exist TP 2 types of bones
accessories
Accessory navicular bone type I (os tibiale externum) size
between the 2 and 6 mm can be contained within the TP and
being positioned immediately proximal posteromedial to the
navicular bone It generally produces symptoms and should
not be confused with a tendon calcification or avulsion
fracture
Type II accessory navicular bone is an accessory
ossification centre of the navicular bone with size between
9 and 12 mm triangular shaped and articulated through a
synchondrosis of the posterior and medial navicular bone
It insertion site of some fibers of TP and is associated with a
syndrome of pain and increased incidence of tendon rupture
caused by abnormal overloads Osteoarthritic changes may
underlie this synchondrosis which mimic tendon pathology
Accessory navicular bone within the posterior tibial tendon as anatomical variant
ANTERIOR COMPARTMENTThe tendons of the anterior ankle compared
with the rest of the ankle tendons are rarely
affected by disease The anterior tibial tendon
is the most prone to abnormalities like
tendinopathy tenosynovitis and its place
between the most frequent rupture is extensor
retinaculum and insertion into the first
cuneiform and the base of the first metatarsal
Sometimes the retracted tendon stump causes
a nodule on the anteromedial aspect of the
distal portion of the leg making clinically
confused with a tumour or cyst
Distal insertion tendinopathy of the anterior tibial tendon with increased vascularity
Tenosynovitis of the anterior tibial tendon with effusion
Anterior tibial tendon tenosynovitis with intratendinous ruptures
Anterior tibial tendon rupture with retraction of the tendon
Tenosynovitis of the extensor digitorum tendons with a synovial effusion
Tenosynovitis of the extensor digitorum tendon with hypervascularized thickened tendon and synovium and synovial fluid
Rheumatoid arthritis with tenosynovitis of the extensor digitorum and peroneal tendons
Thickening of the extensor hallucis longus tendon caused by osteosynthesis material
Multicystic non vascularized intramuscular mass in the extensor digitorum brevis muscle
LATERAL COMPARTMENTTENOSYNOVITIS OF THE PERONEAL TENDONSThe main sign of ultrasound is the presence of liquid inside the
common synovial sheath whereas usually tendinous
morphology is preserved We must differentiate tenosynovitis of
a spill within the common peroneal sheath secondary to a tear of
calcaneofibular ligament (PCL) The ultrasound diagnosis is the detection of the tendons in a lateral plane relative to the distal portion of the lateral malleolus instead of behind it The dynamic exploration foot dorsiflexion as both eversion may help identify cases of intermittent subluxation In long-standing disease can be observed fusiform thickening
of the peroneal tendons at the tip of the malleolus The complete tears of the peroneus brevis tendon (PC) and peroneus longus (PL) are rare occurring in the area of the lateral malleolus or midfoot Seen in patients with ankle sprains or history of chronic instability especially if they suffer widespread diseases (RA DM) or treated with corticosteroids The peroneal tendon ruptures causing the inability to eversion of the foot and cavus foot varus
Important thickening of both peroneal tendons (longus and brevis) associated
with moderate amount of fluid and thickening of the synovial sheath
Discreet amount of fluid in the common sheath of the peroneal tendons
associated with disorganization and a heterogeneous appearance
peroneus brevis tendon related to longitudinal rupture
Peroneal tenosynovitis and osteosynthesis
Tenosynovitis of the peroneal tendons and an intratendinous rupture of the short peroneal tendon
Intratendinous rupture and cyst in the peroneus brevis tendon
Peroneus quartus with an accessory muscle next to the peroneus longus and brevis tendons
Tumor next to the peroneal tendons that proved to be a benign fibrous mass
MEDIAL COMPARTMENT
ANOMALIES POSTERIOR TIBIAL TENDON (TP)
It is the most frequently injured in this compartment with ruptures
in asymptomatic middle-aged obese women as a result of
widespread disease (RA seronegative Spondyloarthropathy) or
associated with bone fractures It causes a gradual collapse of the
medial longitudinal arch with hindfoot valgus deformity and
excessive forefoot pronation
The presence of small vessels in inflammatory diseases
intratendinosis can simulate a fissuration tendon confusion can be ignored using colour Doppler Another possible diagnostic difficulty is when the undamaged tendon flexor digitorum longus (FLD) moves back and simulates the TP unbroken but it is smaller and in this case we only see in the groove retromalleolar 1 only tendon
Ultrasound has also proven to be an effective resource for identifying alterations associated tendon tenosynovitis serosa and hypertrophicSubluxation and dislocation anteriorly and medial TP relative to internal
malleolus is rare and valued sonographically placing the foot in dorsiflexion with forced supination
Thickening moderate amount of fluid surrounding calcifications and
hyperemia affecting the sheath and the posterior tibial tendon related
to chronic tenosynovitis in patient affects rheumatoid arthritis
Thickening moderate amount of surrounding fluid and calcifications (arrow) affecting the
posterior tibial tendon related to chronic tenosynovitis in patient affects rheumatoid arthritis
Tenosynovitis of the posterior tibial tendon caused by a bony ridge at the insertion of the retinaculum The retinaculum is thickened and the tendon subluxates
Psoriatic arthritis Ankle Grayscale examination Posterior tibial tendon on longitudinal (a) and transverse (b) scan Marked tendon sheath widening with homogeneous anechoic aspect (asterisks) of the content indicating an exudative tenosynovitis Note as the normal fibrillar echotexture is conserved Hand Flexor tendons of second finger The volar longitudinal (c) and transverse scan (d) shows a tendon sheath widening with signs of synovial proliferation presence of intense power Doppler signal surrounding the tendon and micro interruption of the margin (arrow) e Wrist Extensor carpi ulnaris tendon (sixth compartment of the extensor tendons ecu) on lateral longitudinal (e) and transverse (f) scan Chronic tenosynovitis with clear areas of low of echogenicity and loss of the continuity of tendon fibrils indicative of partial tendon tear (arrows) Moreover note the presence of power Doppler signal within the interruption indicating still activity of the inflammatory process g Dactylitis Volar longitudinal scan using the ldquoextended viewrdquo technique showing proliferative tenosynovitis of the finger flexor tendon (circle) exudative synovitis of both proximal and distal interphalangeal joint (white asterisks) and edema of the peritendinous tissue (black asterisks) TP posterior tibial tendon mm medial malleolus DP distal phalanx mp middle phalanx cu cubital bone ft flexor tendons
Tenosynovitis of the posterior tibial (1) and flexor digitorum longus tendon (2)
Tibialis Posterior Tendon rupture
Tenosynovitis of the posterior tibial tendon the flexor digitorum tendon and flexor hallucis longus tendon
Tenosynovitis of the tendons on the medial side in the left ankle
bullLIGAMENT INJURIESThe ligament partial tear ligament shows a hypoechoic
areas swollen with internal focal or diffuse In the complete
ruptures within the substance of the divided ligament rift is
observed corresponding to the hematoma hypoechoic and
the free ends of the divided ligament can be and retracted
appreciated corrugated in contrast with normal
appearance straight
Grade I Mild stretching of the ligament without breakage
or instability
Grade II Partial tearing of the ligament
Grade III Complete tearing
Degrees depending on the severity of the injury and the
place of employment
LATERAL COMPARTMENTThese injuries occur secondary to inversion sprains with internal rotation of
the foot combined with ankle plantar flexion
The anterior talar fibular ligament tears (ATFL) usually occur as isolated
involvement (70) or associated with calcaneal fibular ligament (CFL) (20-40)
but the posterior talar fibular ligament (PTFL) affects only major trauma
involving ankle dislocation
ATFL breaks is associated with breakage of the joint capsule and synovial fluid
extravasation into the anterolateral soft ankle whereas the complete tearing of
CFL can communicate the ankle joint and synovial sheath peroneal tendons
Rupture of CFL is rarely associated with superior peroneal retinaculum tear
The CFL is tensioned during dorsiflexion pulling on peroneal tendons laterally
so that absence of its displacement is sign of a complete tear
Within a damaged ligament can also observe calcifications that often
correspond to fragments of avulsion bone
During the ultrasound can be performed forced maneuvers to detect to joint
laxity and ligament injuries The anterior drawer test is performed with the feet
hanging over the edge of the examination table while the forefoot is pulled
anteriorly when the foot is in plantar flexion and inversion This maneuver
helps differentiate partial tears (grade II) of the ATFL to complete (grade III)
where the anterior displacement of the talus on the tibia open a crack in the
substance becoming more visible the ligament injury
The sindesmosys sprains are up to 10 of ankle
injuries happening in eversion and pronation
movements (like the deltoid ligament injury) and
primarily affect the anterior tibiofibular ligament (ATFL)
the failure is frequently associated with fracture of the
fibula
According to the place of employment are 4 degrees
useful for prognostic evaluation and therapeutic strategy
choice
Grade I stretch or partial tear of the ATFL
Grade II complete tearing but only the ATFL
Grade III complete tear of the ATFL and partial CFL
Grade IV complete tear of the ATFL and CFL
The grade I and II injuries usually scarred without any
significant instability whereas grade III and IV injuries
can cause chronic pain and require surgical treatment
Thickened but continued ATFL right in relation to the partial rupture
Grade 111 sprain of right ATFL
Thickened anterior talofibular ligament with calcifications and a partial rupture
Thickened tibiofibular ligament after trauma
Anterior Talofibular Ligament Partial Tear and Elastography
Tibio fibular ligament rupture with bony avulsion
Complete rupture of right ATFL
Bony avulsion with radiographic evidence as visible calcification in a grade III sprain ATFL
Moderately thickened and hypoechoic ATFL
Discontinuity of the ATFL with fluid surrounding the torn ends (arrow)
Thickening and hypoechogenicity of the fibular end of the ligament seen here passing over the subtalar joint which contains a small of fluid
Complete disruption to the tibiofibular ligament with bony irregularity of particularly the tibial margin and fluid in the gap
MEDIAL COMPARTMENTBecause of the low incidence of eversion ankle
sprains and the thickness of the deltoid ligament
is rarely injured in isolation and when the injury
does not usually full thickness Usually
accompanied by lesions of the medial malleolus
and lateral displacement of the talus with
consequent widening of the ankle mortise
Ultrasound is useful for differentiating ligament
injury of the posterior tibial tendon injury
(TP) adjacent they have similar symptoms
The inability to visualize the deltoid ligament may
indicate tear but this is not considered a reliable
sign as its full ultrasound is not always possible
Partial medial ligament rupture
Thickened heterogeneous abnormal deltoid demonstrating hyperemia
Ultrasonogram showing a disrupted deltoid ligament with the probe in the coronal plane The white arrow indicates the medial malleolus the blue arrow indicates the talus and the red arrows indicate the disrupted deltoid ligament (A) Radiograph showing the same injury (B)
bullJOINT AND BONE DISORDERSUltrasound reliably detect spills mild (gt 2 ml) inside
of the ankle joint by exploring the front and rear
recess as well as areas of synovial proliferation and
may even display using the colour Doppler
hyperemic areas in arthritis patients
The intraarticular joints are displayed surrounded
fluid in one of the recesses of the ankle or subtalar
joint Sonographically diagnosed when changing position to perform flexion and extension Fracture of the lateral process of the talus is overlooked up to 50 of cases with plain radiography Ultrasound may suspect the presence of focal cortical disruption helping further to exclude concomitant ligament injury
Rheumatoid arthritis with synovial thickening (1) and erosion of the tibia (2)
Infectious arthritis with a pus filled anterior recess of the ankle
Arthritis and tenosynovitis of the ankle in a patient with rheumatoid arthritis
bullTUMOURSUltrasound can differentiate between a mass complex
and solid and a cystic in addition to verifying the
existence of accessory muscles (peroneus fourth
accessory flexor digitorum longus and accessory
soleus) As in any other location can be found
neoformative soft tissue tumors inflammatory
infectious etc
Ganglions of this location are more often symptomatic
and larger with multiple partitions
branched and lobed edges Differential diagnosis must
be made with tenosynovitis abscesses seromas and
varicosities
Neurogenic tumours are described as pathognomonic
homogeneous hypoechoic oval mass in continuity with
a nerve of origin
Ganglion cysts are non-malignant cystic masses that occur in association with musculoskeletal structures They are sometimes also simply referred to as ganglia or a ganglion but should not be confused with the anatomical term ganglion UltrasoundThe vast majority are anechoic to hypoechoic on ultrasound and have well defined margins Many demonstrate internal septations as well as acoustic enhancement A synovial cyst is a small fluid-filled sac or pouch that can develop over a tendon or joint creating a mass under the skin Synovial cyst is rare in ankle joint A synovial cyst may or may not be painful depending on their size and location
Ganglion cyst in the foot with bony erosion between navicular and cuneiform bones
Tarsal synovial cyst
Anechoic ganglion situated in the sinus tarsi fat between the talus and calcaneous
Plantar fasciitis (PF) refers to inflammation of the
plantar fascia of the foot It is considered the most common cause of heel pain
Clinical presentation Pain on the undersurface of the heel on weight bearing is the principal complaint It can be worse when weight is borne after a period of rest (eg in the morning) and eases with walking Passive dorsiflexion of the toes may exacerbates discomfort
UltrasoundOften the initial imaging modality of choice Ultrasound typically shows increased thickness of the fascia and a hypoechoic fascia
Thickened hypoechoic origin of the plantar fascia which has a convex superior margin
Complete avulsion of the plantar fascia from the calcaneal tubercle
Plantar fasciitis
bull LOCATING FOREIGN BODIES AND FRACTURES
As in any other location the ankle
area is also subsidiary host foreign
whose classification location and
existence can be defined perfectly by
ultrasound Being a focused study to
the area of interest and with great
resolution for surface structures can
be considered more resolute
examination to screen these cases
Osseous diseases and fractures | Sonography discovered Medial Malleolus Fracture
Ultrasound examination of left ankle A Longitudinal sonogram left ankle demonstrates a wooden foreign body B Transverse view left ankle Note the hypervascularity in the inflamed area C Corresponding X-ray of left ankle Note the swelling on the lateral aspect No foreign body is visible
Thank You
bullPREACHILLES AND RETROACHILLES BURSITIS
Although bursitis can occur in isolation often are
related and systemic inflammatory diseases
In the ultrasound examination the distended
retrocalcaneal and preachilles appears are a
hypoechoic structure shaped coma interposed
between the Achilles tendon and the posterosuperior
aspect of the calcaneous Care must be taken not to
confuse it with the fatty space Kager containing oval
lobules of hyperechoic fat When bursitis is a
manifestation of synovitis is appreciated
hypervascular area with Doppler ultrasound
In the retroachilles bursitis exists thickening and
collection of fluid in the subcutaneous tissue
superficial to the tendon retrocalcaneal portion
Bursitis preachilles with typical morphology appreciating accumulation of fluid
in a coma between the anterior portion of the Achilles tendon and the calcaneous
Bursitis preachiacutelea that associated synovitis showing hyperemia with increased Doppler flow
Rheumatoid arthritis with retrocalcaneal bursitis (1) and calcaneal erosions (2)
ACCESSORY NAVICULAR BONEIn the distal insertion site may exist TP 2 types of bones
accessories
Accessory navicular bone type I (os tibiale externum) size
between the 2 and 6 mm can be contained within the TP and
being positioned immediately proximal posteromedial to the
navicular bone It generally produces symptoms and should
not be confused with a tendon calcification or avulsion
fracture
Type II accessory navicular bone is an accessory
ossification centre of the navicular bone with size between
9 and 12 mm triangular shaped and articulated through a
synchondrosis of the posterior and medial navicular bone
It insertion site of some fibers of TP and is associated with a
syndrome of pain and increased incidence of tendon rupture
caused by abnormal overloads Osteoarthritic changes may
underlie this synchondrosis which mimic tendon pathology
Accessory navicular bone within the posterior tibial tendon as anatomical variant
ANTERIOR COMPARTMENTThe tendons of the anterior ankle compared
with the rest of the ankle tendons are rarely
affected by disease The anterior tibial tendon
is the most prone to abnormalities like
tendinopathy tenosynovitis and its place
between the most frequent rupture is extensor
retinaculum and insertion into the first
cuneiform and the base of the first metatarsal
Sometimes the retracted tendon stump causes
a nodule on the anteromedial aspect of the
distal portion of the leg making clinically
confused with a tumour or cyst
Distal insertion tendinopathy of the anterior tibial tendon with increased vascularity
Tenosynovitis of the anterior tibial tendon with effusion
Anterior tibial tendon tenosynovitis with intratendinous ruptures
Anterior tibial tendon rupture with retraction of the tendon
Tenosynovitis of the extensor digitorum tendons with a synovial effusion
Tenosynovitis of the extensor digitorum tendon with hypervascularized thickened tendon and synovium and synovial fluid
Rheumatoid arthritis with tenosynovitis of the extensor digitorum and peroneal tendons
Thickening of the extensor hallucis longus tendon caused by osteosynthesis material
Multicystic non vascularized intramuscular mass in the extensor digitorum brevis muscle
LATERAL COMPARTMENTTENOSYNOVITIS OF THE PERONEAL TENDONSThe main sign of ultrasound is the presence of liquid inside the
common synovial sheath whereas usually tendinous
morphology is preserved We must differentiate tenosynovitis of
a spill within the common peroneal sheath secondary to a tear of
calcaneofibular ligament (PCL) The ultrasound diagnosis is the detection of the tendons in a lateral plane relative to the distal portion of the lateral malleolus instead of behind it The dynamic exploration foot dorsiflexion as both eversion may help identify cases of intermittent subluxation In long-standing disease can be observed fusiform thickening
of the peroneal tendons at the tip of the malleolus The complete tears of the peroneus brevis tendon (PC) and peroneus longus (PL) are rare occurring in the area of the lateral malleolus or midfoot Seen in patients with ankle sprains or history of chronic instability especially if they suffer widespread diseases (RA DM) or treated with corticosteroids The peroneal tendon ruptures causing the inability to eversion of the foot and cavus foot varus
Important thickening of both peroneal tendons (longus and brevis) associated
with moderate amount of fluid and thickening of the synovial sheath
Discreet amount of fluid in the common sheath of the peroneal tendons
associated with disorganization and a heterogeneous appearance
peroneus brevis tendon related to longitudinal rupture
Peroneal tenosynovitis and osteosynthesis
Tenosynovitis of the peroneal tendons and an intratendinous rupture of the short peroneal tendon
Intratendinous rupture and cyst in the peroneus brevis tendon
Peroneus quartus with an accessory muscle next to the peroneus longus and brevis tendons
Tumor next to the peroneal tendons that proved to be a benign fibrous mass
MEDIAL COMPARTMENT
ANOMALIES POSTERIOR TIBIAL TENDON (TP)
It is the most frequently injured in this compartment with ruptures
in asymptomatic middle-aged obese women as a result of
widespread disease (RA seronegative Spondyloarthropathy) or
associated with bone fractures It causes a gradual collapse of the
medial longitudinal arch with hindfoot valgus deformity and
excessive forefoot pronation
The presence of small vessels in inflammatory diseases
intratendinosis can simulate a fissuration tendon confusion can be ignored using colour Doppler Another possible diagnostic difficulty is when the undamaged tendon flexor digitorum longus (FLD) moves back and simulates the TP unbroken but it is smaller and in this case we only see in the groove retromalleolar 1 only tendon
Ultrasound has also proven to be an effective resource for identifying alterations associated tendon tenosynovitis serosa and hypertrophicSubluxation and dislocation anteriorly and medial TP relative to internal
malleolus is rare and valued sonographically placing the foot in dorsiflexion with forced supination
Thickening moderate amount of fluid surrounding calcifications and
hyperemia affecting the sheath and the posterior tibial tendon related
to chronic tenosynovitis in patient affects rheumatoid arthritis
Thickening moderate amount of surrounding fluid and calcifications (arrow) affecting the
posterior tibial tendon related to chronic tenosynovitis in patient affects rheumatoid arthritis
Tenosynovitis of the posterior tibial tendon caused by a bony ridge at the insertion of the retinaculum The retinaculum is thickened and the tendon subluxates
Psoriatic arthritis Ankle Grayscale examination Posterior tibial tendon on longitudinal (a) and transverse (b) scan Marked tendon sheath widening with homogeneous anechoic aspect (asterisks) of the content indicating an exudative tenosynovitis Note as the normal fibrillar echotexture is conserved Hand Flexor tendons of second finger The volar longitudinal (c) and transverse scan (d) shows a tendon sheath widening with signs of synovial proliferation presence of intense power Doppler signal surrounding the tendon and micro interruption of the margin (arrow) e Wrist Extensor carpi ulnaris tendon (sixth compartment of the extensor tendons ecu) on lateral longitudinal (e) and transverse (f) scan Chronic tenosynovitis with clear areas of low of echogenicity and loss of the continuity of tendon fibrils indicative of partial tendon tear (arrows) Moreover note the presence of power Doppler signal within the interruption indicating still activity of the inflammatory process g Dactylitis Volar longitudinal scan using the ldquoextended viewrdquo technique showing proliferative tenosynovitis of the finger flexor tendon (circle) exudative synovitis of both proximal and distal interphalangeal joint (white asterisks) and edema of the peritendinous tissue (black asterisks) TP posterior tibial tendon mm medial malleolus DP distal phalanx mp middle phalanx cu cubital bone ft flexor tendons
Tenosynovitis of the posterior tibial (1) and flexor digitorum longus tendon (2)
Tibialis Posterior Tendon rupture
Tenosynovitis of the posterior tibial tendon the flexor digitorum tendon and flexor hallucis longus tendon
Tenosynovitis of the tendons on the medial side in the left ankle
bullLIGAMENT INJURIESThe ligament partial tear ligament shows a hypoechoic
areas swollen with internal focal or diffuse In the complete
ruptures within the substance of the divided ligament rift is
observed corresponding to the hematoma hypoechoic and
the free ends of the divided ligament can be and retracted
appreciated corrugated in contrast with normal
appearance straight
Grade I Mild stretching of the ligament without breakage
or instability
Grade II Partial tearing of the ligament
Grade III Complete tearing
Degrees depending on the severity of the injury and the
place of employment
LATERAL COMPARTMENTThese injuries occur secondary to inversion sprains with internal rotation of
the foot combined with ankle plantar flexion
The anterior talar fibular ligament tears (ATFL) usually occur as isolated
involvement (70) or associated with calcaneal fibular ligament (CFL) (20-40)
but the posterior talar fibular ligament (PTFL) affects only major trauma
involving ankle dislocation
ATFL breaks is associated with breakage of the joint capsule and synovial fluid
extravasation into the anterolateral soft ankle whereas the complete tearing of
CFL can communicate the ankle joint and synovial sheath peroneal tendons
Rupture of CFL is rarely associated with superior peroneal retinaculum tear
The CFL is tensioned during dorsiflexion pulling on peroneal tendons laterally
so that absence of its displacement is sign of a complete tear
Within a damaged ligament can also observe calcifications that often
correspond to fragments of avulsion bone
During the ultrasound can be performed forced maneuvers to detect to joint
laxity and ligament injuries The anterior drawer test is performed with the feet
hanging over the edge of the examination table while the forefoot is pulled
anteriorly when the foot is in plantar flexion and inversion This maneuver
helps differentiate partial tears (grade II) of the ATFL to complete (grade III)
where the anterior displacement of the talus on the tibia open a crack in the
substance becoming more visible the ligament injury
The sindesmosys sprains are up to 10 of ankle
injuries happening in eversion and pronation
movements (like the deltoid ligament injury) and
primarily affect the anterior tibiofibular ligament (ATFL)
the failure is frequently associated with fracture of the
fibula
According to the place of employment are 4 degrees
useful for prognostic evaluation and therapeutic strategy
choice
Grade I stretch or partial tear of the ATFL
Grade II complete tearing but only the ATFL
Grade III complete tear of the ATFL and partial CFL
Grade IV complete tear of the ATFL and CFL
The grade I and II injuries usually scarred without any
significant instability whereas grade III and IV injuries
can cause chronic pain and require surgical treatment
Thickened but continued ATFL right in relation to the partial rupture
Grade 111 sprain of right ATFL
Thickened anterior talofibular ligament with calcifications and a partial rupture
Thickened tibiofibular ligament after trauma
Anterior Talofibular Ligament Partial Tear and Elastography
Tibio fibular ligament rupture with bony avulsion
Complete rupture of right ATFL
Bony avulsion with radiographic evidence as visible calcification in a grade III sprain ATFL
Moderately thickened and hypoechoic ATFL
Discontinuity of the ATFL with fluid surrounding the torn ends (arrow)
Thickening and hypoechogenicity of the fibular end of the ligament seen here passing over the subtalar joint which contains a small of fluid
Complete disruption to the tibiofibular ligament with bony irregularity of particularly the tibial margin and fluid in the gap
MEDIAL COMPARTMENTBecause of the low incidence of eversion ankle
sprains and the thickness of the deltoid ligament
is rarely injured in isolation and when the injury
does not usually full thickness Usually
accompanied by lesions of the medial malleolus
and lateral displacement of the talus with
consequent widening of the ankle mortise
Ultrasound is useful for differentiating ligament
injury of the posterior tibial tendon injury
(TP) adjacent they have similar symptoms
The inability to visualize the deltoid ligament may
indicate tear but this is not considered a reliable
sign as its full ultrasound is not always possible
Partial medial ligament rupture
Thickened heterogeneous abnormal deltoid demonstrating hyperemia
Ultrasonogram showing a disrupted deltoid ligament with the probe in the coronal plane The white arrow indicates the medial malleolus the blue arrow indicates the talus and the red arrows indicate the disrupted deltoid ligament (A) Radiograph showing the same injury (B)
bullJOINT AND BONE DISORDERSUltrasound reliably detect spills mild (gt 2 ml) inside
of the ankle joint by exploring the front and rear
recess as well as areas of synovial proliferation and
may even display using the colour Doppler
hyperemic areas in arthritis patients
The intraarticular joints are displayed surrounded
fluid in one of the recesses of the ankle or subtalar
joint Sonographically diagnosed when changing position to perform flexion and extension Fracture of the lateral process of the talus is overlooked up to 50 of cases with plain radiography Ultrasound may suspect the presence of focal cortical disruption helping further to exclude concomitant ligament injury
Rheumatoid arthritis with synovial thickening (1) and erosion of the tibia (2)
Infectious arthritis with a pus filled anterior recess of the ankle
Arthritis and tenosynovitis of the ankle in a patient with rheumatoid arthritis
bullTUMOURSUltrasound can differentiate between a mass complex
and solid and a cystic in addition to verifying the
existence of accessory muscles (peroneus fourth
accessory flexor digitorum longus and accessory
soleus) As in any other location can be found
neoformative soft tissue tumors inflammatory
infectious etc
Ganglions of this location are more often symptomatic
and larger with multiple partitions
branched and lobed edges Differential diagnosis must
be made with tenosynovitis abscesses seromas and
varicosities
Neurogenic tumours are described as pathognomonic
homogeneous hypoechoic oval mass in continuity with
a nerve of origin
Ganglion cysts are non-malignant cystic masses that occur in association with musculoskeletal structures They are sometimes also simply referred to as ganglia or a ganglion but should not be confused with the anatomical term ganglion UltrasoundThe vast majority are anechoic to hypoechoic on ultrasound and have well defined margins Many demonstrate internal septations as well as acoustic enhancement A synovial cyst is a small fluid-filled sac or pouch that can develop over a tendon or joint creating a mass under the skin Synovial cyst is rare in ankle joint A synovial cyst may or may not be painful depending on their size and location
Ganglion cyst in the foot with bony erosion between navicular and cuneiform bones
Tarsal synovial cyst
Anechoic ganglion situated in the sinus tarsi fat between the talus and calcaneous
Plantar fasciitis (PF) refers to inflammation of the
plantar fascia of the foot It is considered the most common cause of heel pain
Clinical presentation Pain on the undersurface of the heel on weight bearing is the principal complaint It can be worse when weight is borne after a period of rest (eg in the morning) and eases with walking Passive dorsiflexion of the toes may exacerbates discomfort
UltrasoundOften the initial imaging modality of choice Ultrasound typically shows increased thickness of the fascia and a hypoechoic fascia
Thickened hypoechoic origin of the plantar fascia which has a convex superior margin
Complete avulsion of the plantar fascia from the calcaneal tubercle
Plantar fasciitis
bull LOCATING FOREIGN BODIES AND FRACTURES
As in any other location the ankle
area is also subsidiary host foreign
whose classification location and
existence can be defined perfectly by
ultrasound Being a focused study to
the area of interest and with great
resolution for surface structures can
be considered more resolute
examination to screen these cases
Osseous diseases and fractures | Sonography discovered Medial Malleolus Fracture
Ultrasound examination of left ankle A Longitudinal sonogram left ankle demonstrates a wooden foreign body B Transverse view left ankle Note the hypervascularity in the inflamed area C Corresponding X-ray of left ankle Note the swelling on the lateral aspect No foreign body is visible
Thank You
Bursitis preachilles with typical morphology appreciating accumulation of fluid
in a coma between the anterior portion of the Achilles tendon and the calcaneous
Bursitis preachiacutelea that associated synovitis showing hyperemia with increased Doppler flow
Rheumatoid arthritis with retrocalcaneal bursitis (1) and calcaneal erosions (2)
ACCESSORY NAVICULAR BONEIn the distal insertion site may exist TP 2 types of bones
accessories
Accessory navicular bone type I (os tibiale externum) size
between the 2 and 6 mm can be contained within the TP and
being positioned immediately proximal posteromedial to the
navicular bone It generally produces symptoms and should
not be confused with a tendon calcification or avulsion
fracture
Type II accessory navicular bone is an accessory
ossification centre of the navicular bone with size between
9 and 12 mm triangular shaped and articulated through a
synchondrosis of the posterior and medial navicular bone
It insertion site of some fibers of TP and is associated with a
syndrome of pain and increased incidence of tendon rupture
caused by abnormal overloads Osteoarthritic changes may
underlie this synchondrosis which mimic tendon pathology
Accessory navicular bone within the posterior tibial tendon as anatomical variant
ANTERIOR COMPARTMENTThe tendons of the anterior ankle compared
with the rest of the ankle tendons are rarely
affected by disease The anterior tibial tendon
is the most prone to abnormalities like
tendinopathy tenosynovitis and its place
between the most frequent rupture is extensor
retinaculum and insertion into the first
cuneiform and the base of the first metatarsal
Sometimes the retracted tendon stump causes
a nodule on the anteromedial aspect of the
distal portion of the leg making clinically
confused with a tumour or cyst
Distal insertion tendinopathy of the anterior tibial tendon with increased vascularity
Tenosynovitis of the anterior tibial tendon with effusion
Anterior tibial tendon tenosynovitis with intratendinous ruptures
Anterior tibial tendon rupture with retraction of the tendon
Tenosynovitis of the extensor digitorum tendons with a synovial effusion
Tenosynovitis of the extensor digitorum tendon with hypervascularized thickened tendon and synovium and synovial fluid
Rheumatoid arthritis with tenosynovitis of the extensor digitorum and peroneal tendons
Thickening of the extensor hallucis longus tendon caused by osteosynthesis material
Multicystic non vascularized intramuscular mass in the extensor digitorum brevis muscle
LATERAL COMPARTMENTTENOSYNOVITIS OF THE PERONEAL TENDONSThe main sign of ultrasound is the presence of liquid inside the
common synovial sheath whereas usually tendinous
morphology is preserved We must differentiate tenosynovitis of
a spill within the common peroneal sheath secondary to a tear of
calcaneofibular ligament (PCL) The ultrasound diagnosis is the detection of the tendons in a lateral plane relative to the distal portion of the lateral malleolus instead of behind it The dynamic exploration foot dorsiflexion as both eversion may help identify cases of intermittent subluxation In long-standing disease can be observed fusiform thickening
of the peroneal tendons at the tip of the malleolus The complete tears of the peroneus brevis tendon (PC) and peroneus longus (PL) are rare occurring in the area of the lateral malleolus or midfoot Seen in patients with ankle sprains or history of chronic instability especially if they suffer widespread diseases (RA DM) or treated with corticosteroids The peroneal tendon ruptures causing the inability to eversion of the foot and cavus foot varus
Important thickening of both peroneal tendons (longus and brevis) associated
with moderate amount of fluid and thickening of the synovial sheath
Discreet amount of fluid in the common sheath of the peroneal tendons
associated with disorganization and a heterogeneous appearance
peroneus brevis tendon related to longitudinal rupture
Peroneal tenosynovitis and osteosynthesis
Tenosynovitis of the peroneal tendons and an intratendinous rupture of the short peroneal tendon
Intratendinous rupture and cyst in the peroneus brevis tendon
Peroneus quartus with an accessory muscle next to the peroneus longus and brevis tendons
Tumor next to the peroneal tendons that proved to be a benign fibrous mass
MEDIAL COMPARTMENT
ANOMALIES POSTERIOR TIBIAL TENDON (TP)
It is the most frequently injured in this compartment with ruptures
in asymptomatic middle-aged obese women as a result of
widespread disease (RA seronegative Spondyloarthropathy) or
associated with bone fractures It causes a gradual collapse of the
medial longitudinal arch with hindfoot valgus deformity and
excessive forefoot pronation
The presence of small vessels in inflammatory diseases
intratendinosis can simulate a fissuration tendon confusion can be ignored using colour Doppler Another possible diagnostic difficulty is when the undamaged tendon flexor digitorum longus (FLD) moves back and simulates the TP unbroken but it is smaller and in this case we only see in the groove retromalleolar 1 only tendon
Ultrasound has also proven to be an effective resource for identifying alterations associated tendon tenosynovitis serosa and hypertrophicSubluxation and dislocation anteriorly and medial TP relative to internal
malleolus is rare and valued sonographically placing the foot in dorsiflexion with forced supination
Thickening moderate amount of fluid surrounding calcifications and
hyperemia affecting the sheath and the posterior tibial tendon related
to chronic tenosynovitis in patient affects rheumatoid arthritis
Thickening moderate amount of surrounding fluid and calcifications (arrow) affecting the
posterior tibial tendon related to chronic tenosynovitis in patient affects rheumatoid arthritis
Tenosynovitis of the posterior tibial tendon caused by a bony ridge at the insertion of the retinaculum The retinaculum is thickened and the tendon subluxates
Psoriatic arthritis Ankle Grayscale examination Posterior tibial tendon on longitudinal (a) and transverse (b) scan Marked tendon sheath widening with homogeneous anechoic aspect (asterisks) of the content indicating an exudative tenosynovitis Note as the normal fibrillar echotexture is conserved Hand Flexor tendons of second finger The volar longitudinal (c) and transverse scan (d) shows a tendon sheath widening with signs of synovial proliferation presence of intense power Doppler signal surrounding the tendon and micro interruption of the margin (arrow) e Wrist Extensor carpi ulnaris tendon (sixth compartment of the extensor tendons ecu) on lateral longitudinal (e) and transverse (f) scan Chronic tenosynovitis with clear areas of low of echogenicity and loss of the continuity of tendon fibrils indicative of partial tendon tear (arrows) Moreover note the presence of power Doppler signal within the interruption indicating still activity of the inflammatory process g Dactylitis Volar longitudinal scan using the ldquoextended viewrdquo technique showing proliferative tenosynovitis of the finger flexor tendon (circle) exudative synovitis of both proximal and distal interphalangeal joint (white asterisks) and edema of the peritendinous tissue (black asterisks) TP posterior tibial tendon mm medial malleolus DP distal phalanx mp middle phalanx cu cubital bone ft flexor tendons
Tenosynovitis of the posterior tibial (1) and flexor digitorum longus tendon (2)
Tibialis Posterior Tendon rupture
Tenosynovitis of the posterior tibial tendon the flexor digitorum tendon and flexor hallucis longus tendon
Tenosynovitis of the tendons on the medial side in the left ankle
bullLIGAMENT INJURIESThe ligament partial tear ligament shows a hypoechoic
areas swollen with internal focal or diffuse In the complete
ruptures within the substance of the divided ligament rift is
observed corresponding to the hematoma hypoechoic and
the free ends of the divided ligament can be and retracted
appreciated corrugated in contrast with normal
appearance straight
Grade I Mild stretching of the ligament without breakage
or instability
Grade II Partial tearing of the ligament
Grade III Complete tearing
Degrees depending on the severity of the injury and the
place of employment
LATERAL COMPARTMENTThese injuries occur secondary to inversion sprains with internal rotation of
the foot combined with ankle plantar flexion
The anterior talar fibular ligament tears (ATFL) usually occur as isolated
involvement (70) or associated with calcaneal fibular ligament (CFL) (20-40)
but the posterior talar fibular ligament (PTFL) affects only major trauma
involving ankle dislocation
ATFL breaks is associated with breakage of the joint capsule and synovial fluid
extravasation into the anterolateral soft ankle whereas the complete tearing of
CFL can communicate the ankle joint and synovial sheath peroneal tendons
Rupture of CFL is rarely associated with superior peroneal retinaculum tear
The CFL is tensioned during dorsiflexion pulling on peroneal tendons laterally
so that absence of its displacement is sign of a complete tear
Within a damaged ligament can also observe calcifications that often
correspond to fragments of avulsion bone
During the ultrasound can be performed forced maneuvers to detect to joint
laxity and ligament injuries The anterior drawer test is performed with the feet
hanging over the edge of the examination table while the forefoot is pulled
anteriorly when the foot is in plantar flexion and inversion This maneuver
helps differentiate partial tears (grade II) of the ATFL to complete (grade III)
where the anterior displacement of the talus on the tibia open a crack in the
substance becoming more visible the ligament injury
The sindesmosys sprains are up to 10 of ankle
injuries happening in eversion and pronation
movements (like the deltoid ligament injury) and
primarily affect the anterior tibiofibular ligament (ATFL)
the failure is frequently associated with fracture of the
fibula
According to the place of employment are 4 degrees
useful for prognostic evaluation and therapeutic strategy
choice
Grade I stretch or partial tear of the ATFL
Grade II complete tearing but only the ATFL
Grade III complete tear of the ATFL and partial CFL
Grade IV complete tear of the ATFL and CFL
The grade I and II injuries usually scarred without any
significant instability whereas grade III and IV injuries
can cause chronic pain and require surgical treatment
Thickened but continued ATFL right in relation to the partial rupture
Grade 111 sprain of right ATFL
Thickened anterior talofibular ligament with calcifications and a partial rupture
Thickened tibiofibular ligament after trauma
Anterior Talofibular Ligament Partial Tear and Elastography
Tibio fibular ligament rupture with bony avulsion
Complete rupture of right ATFL
Bony avulsion with radiographic evidence as visible calcification in a grade III sprain ATFL
Moderately thickened and hypoechoic ATFL
Discontinuity of the ATFL with fluid surrounding the torn ends (arrow)
Thickening and hypoechogenicity of the fibular end of the ligament seen here passing over the subtalar joint which contains a small of fluid
Complete disruption to the tibiofibular ligament with bony irregularity of particularly the tibial margin and fluid in the gap
MEDIAL COMPARTMENTBecause of the low incidence of eversion ankle
sprains and the thickness of the deltoid ligament
is rarely injured in isolation and when the injury
does not usually full thickness Usually
accompanied by lesions of the medial malleolus
and lateral displacement of the talus with
consequent widening of the ankle mortise
Ultrasound is useful for differentiating ligament
injury of the posterior tibial tendon injury
(TP) adjacent they have similar symptoms
The inability to visualize the deltoid ligament may
indicate tear but this is not considered a reliable
sign as its full ultrasound is not always possible
Partial medial ligament rupture
Thickened heterogeneous abnormal deltoid demonstrating hyperemia
Ultrasonogram showing a disrupted deltoid ligament with the probe in the coronal plane The white arrow indicates the medial malleolus the blue arrow indicates the talus and the red arrows indicate the disrupted deltoid ligament (A) Radiograph showing the same injury (B)
bullJOINT AND BONE DISORDERSUltrasound reliably detect spills mild (gt 2 ml) inside
of the ankle joint by exploring the front and rear
recess as well as areas of synovial proliferation and
may even display using the colour Doppler
hyperemic areas in arthritis patients
The intraarticular joints are displayed surrounded
fluid in one of the recesses of the ankle or subtalar
joint Sonographically diagnosed when changing position to perform flexion and extension Fracture of the lateral process of the talus is overlooked up to 50 of cases with plain radiography Ultrasound may suspect the presence of focal cortical disruption helping further to exclude concomitant ligament injury
Rheumatoid arthritis with synovial thickening (1) and erosion of the tibia (2)
Infectious arthritis with a pus filled anterior recess of the ankle
Arthritis and tenosynovitis of the ankle in a patient with rheumatoid arthritis
bullTUMOURSUltrasound can differentiate between a mass complex
and solid and a cystic in addition to verifying the
existence of accessory muscles (peroneus fourth
accessory flexor digitorum longus and accessory
soleus) As in any other location can be found
neoformative soft tissue tumors inflammatory
infectious etc
Ganglions of this location are more often symptomatic
and larger with multiple partitions
branched and lobed edges Differential diagnosis must
be made with tenosynovitis abscesses seromas and
varicosities
Neurogenic tumours are described as pathognomonic
homogeneous hypoechoic oval mass in continuity with
a nerve of origin
Ganglion cysts are non-malignant cystic masses that occur in association with musculoskeletal structures They are sometimes also simply referred to as ganglia or a ganglion but should not be confused with the anatomical term ganglion UltrasoundThe vast majority are anechoic to hypoechoic on ultrasound and have well defined margins Many demonstrate internal septations as well as acoustic enhancement A synovial cyst is a small fluid-filled sac or pouch that can develop over a tendon or joint creating a mass under the skin Synovial cyst is rare in ankle joint A synovial cyst may or may not be painful depending on their size and location
Ganglion cyst in the foot with bony erosion between navicular and cuneiform bones
Tarsal synovial cyst
Anechoic ganglion situated in the sinus tarsi fat between the talus and calcaneous
Plantar fasciitis (PF) refers to inflammation of the
plantar fascia of the foot It is considered the most common cause of heel pain
Clinical presentation Pain on the undersurface of the heel on weight bearing is the principal complaint It can be worse when weight is borne after a period of rest (eg in the morning) and eases with walking Passive dorsiflexion of the toes may exacerbates discomfort
UltrasoundOften the initial imaging modality of choice Ultrasound typically shows increased thickness of the fascia and a hypoechoic fascia
Thickened hypoechoic origin of the plantar fascia which has a convex superior margin
Complete avulsion of the plantar fascia from the calcaneal tubercle
Plantar fasciitis
bull LOCATING FOREIGN BODIES AND FRACTURES
As in any other location the ankle
area is also subsidiary host foreign
whose classification location and
existence can be defined perfectly by
ultrasound Being a focused study to
the area of interest and with great
resolution for surface structures can
be considered more resolute
examination to screen these cases
Osseous diseases and fractures | Sonography discovered Medial Malleolus Fracture
Ultrasound examination of left ankle A Longitudinal sonogram left ankle demonstrates a wooden foreign body B Transverse view left ankle Note the hypervascularity in the inflamed area C Corresponding X-ray of left ankle Note the swelling on the lateral aspect No foreign body is visible
Thank You
Bursitis preachiacutelea that associated synovitis showing hyperemia with increased Doppler flow
Rheumatoid arthritis with retrocalcaneal bursitis (1) and calcaneal erosions (2)
ACCESSORY NAVICULAR BONEIn the distal insertion site may exist TP 2 types of bones
accessories
Accessory navicular bone type I (os tibiale externum) size
between the 2 and 6 mm can be contained within the TP and
being positioned immediately proximal posteromedial to the
navicular bone It generally produces symptoms and should
not be confused with a tendon calcification or avulsion
fracture
Type II accessory navicular bone is an accessory
ossification centre of the navicular bone with size between
9 and 12 mm triangular shaped and articulated through a
synchondrosis of the posterior and medial navicular bone
It insertion site of some fibers of TP and is associated with a
syndrome of pain and increased incidence of tendon rupture
caused by abnormal overloads Osteoarthritic changes may
underlie this synchondrosis which mimic tendon pathology
Accessory navicular bone within the posterior tibial tendon as anatomical variant
ANTERIOR COMPARTMENTThe tendons of the anterior ankle compared
with the rest of the ankle tendons are rarely
affected by disease The anterior tibial tendon
is the most prone to abnormalities like
tendinopathy tenosynovitis and its place
between the most frequent rupture is extensor
retinaculum and insertion into the first
cuneiform and the base of the first metatarsal
Sometimes the retracted tendon stump causes
a nodule on the anteromedial aspect of the
distal portion of the leg making clinically
confused with a tumour or cyst
Distal insertion tendinopathy of the anterior tibial tendon with increased vascularity
Tenosynovitis of the anterior tibial tendon with effusion
Anterior tibial tendon tenosynovitis with intratendinous ruptures
Anterior tibial tendon rupture with retraction of the tendon
Tenosynovitis of the extensor digitorum tendons with a synovial effusion
Tenosynovitis of the extensor digitorum tendon with hypervascularized thickened tendon and synovium and synovial fluid
Rheumatoid arthritis with tenosynovitis of the extensor digitorum and peroneal tendons
Thickening of the extensor hallucis longus tendon caused by osteosynthesis material
Multicystic non vascularized intramuscular mass in the extensor digitorum brevis muscle
LATERAL COMPARTMENTTENOSYNOVITIS OF THE PERONEAL TENDONSThe main sign of ultrasound is the presence of liquid inside the
common synovial sheath whereas usually tendinous
morphology is preserved We must differentiate tenosynovitis of
a spill within the common peroneal sheath secondary to a tear of
calcaneofibular ligament (PCL) The ultrasound diagnosis is the detection of the tendons in a lateral plane relative to the distal portion of the lateral malleolus instead of behind it The dynamic exploration foot dorsiflexion as both eversion may help identify cases of intermittent subluxation In long-standing disease can be observed fusiform thickening
of the peroneal tendons at the tip of the malleolus The complete tears of the peroneus brevis tendon (PC) and peroneus longus (PL) are rare occurring in the area of the lateral malleolus or midfoot Seen in patients with ankle sprains or history of chronic instability especially if they suffer widespread diseases (RA DM) or treated with corticosteroids The peroneal tendon ruptures causing the inability to eversion of the foot and cavus foot varus
Important thickening of both peroneal tendons (longus and brevis) associated
with moderate amount of fluid and thickening of the synovial sheath
Discreet amount of fluid in the common sheath of the peroneal tendons
associated with disorganization and a heterogeneous appearance
peroneus brevis tendon related to longitudinal rupture
Peroneal tenosynovitis and osteosynthesis
Tenosynovitis of the peroneal tendons and an intratendinous rupture of the short peroneal tendon
Intratendinous rupture and cyst in the peroneus brevis tendon
Peroneus quartus with an accessory muscle next to the peroneus longus and brevis tendons
Tumor next to the peroneal tendons that proved to be a benign fibrous mass
MEDIAL COMPARTMENT
ANOMALIES POSTERIOR TIBIAL TENDON (TP)
It is the most frequently injured in this compartment with ruptures
in asymptomatic middle-aged obese women as a result of
widespread disease (RA seronegative Spondyloarthropathy) or
associated with bone fractures It causes a gradual collapse of the
medial longitudinal arch with hindfoot valgus deformity and
excessive forefoot pronation
The presence of small vessels in inflammatory diseases
intratendinosis can simulate a fissuration tendon confusion can be ignored using colour Doppler Another possible diagnostic difficulty is when the undamaged tendon flexor digitorum longus (FLD) moves back and simulates the TP unbroken but it is smaller and in this case we only see in the groove retromalleolar 1 only tendon
Ultrasound has also proven to be an effective resource for identifying alterations associated tendon tenosynovitis serosa and hypertrophicSubluxation and dislocation anteriorly and medial TP relative to internal
malleolus is rare and valued sonographically placing the foot in dorsiflexion with forced supination
Thickening moderate amount of fluid surrounding calcifications and
hyperemia affecting the sheath and the posterior tibial tendon related
to chronic tenosynovitis in patient affects rheumatoid arthritis
Thickening moderate amount of surrounding fluid and calcifications (arrow) affecting the
posterior tibial tendon related to chronic tenosynovitis in patient affects rheumatoid arthritis
Tenosynovitis of the posterior tibial tendon caused by a bony ridge at the insertion of the retinaculum The retinaculum is thickened and the tendon subluxates
Psoriatic arthritis Ankle Grayscale examination Posterior tibial tendon on longitudinal (a) and transverse (b) scan Marked tendon sheath widening with homogeneous anechoic aspect (asterisks) of the content indicating an exudative tenosynovitis Note as the normal fibrillar echotexture is conserved Hand Flexor tendons of second finger The volar longitudinal (c) and transverse scan (d) shows a tendon sheath widening with signs of synovial proliferation presence of intense power Doppler signal surrounding the tendon and micro interruption of the margin (arrow) e Wrist Extensor carpi ulnaris tendon (sixth compartment of the extensor tendons ecu) on lateral longitudinal (e) and transverse (f) scan Chronic tenosynovitis with clear areas of low of echogenicity and loss of the continuity of tendon fibrils indicative of partial tendon tear (arrows) Moreover note the presence of power Doppler signal within the interruption indicating still activity of the inflammatory process g Dactylitis Volar longitudinal scan using the ldquoextended viewrdquo technique showing proliferative tenosynovitis of the finger flexor tendon (circle) exudative synovitis of both proximal and distal interphalangeal joint (white asterisks) and edema of the peritendinous tissue (black asterisks) TP posterior tibial tendon mm medial malleolus DP distal phalanx mp middle phalanx cu cubital bone ft flexor tendons
Tenosynovitis of the posterior tibial (1) and flexor digitorum longus tendon (2)
Tibialis Posterior Tendon rupture
Tenosynovitis of the posterior tibial tendon the flexor digitorum tendon and flexor hallucis longus tendon
Tenosynovitis of the tendons on the medial side in the left ankle
bullLIGAMENT INJURIESThe ligament partial tear ligament shows a hypoechoic
areas swollen with internal focal or diffuse In the complete
ruptures within the substance of the divided ligament rift is
observed corresponding to the hematoma hypoechoic and
the free ends of the divided ligament can be and retracted
appreciated corrugated in contrast with normal
appearance straight
Grade I Mild stretching of the ligament without breakage
or instability
Grade II Partial tearing of the ligament
Grade III Complete tearing
Degrees depending on the severity of the injury and the
place of employment
LATERAL COMPARTMENTThese injuries occur secondary to inversion sprains with internal rotation of
the foot combined with ankle plantar flexion
The anterior talar fibular ligament tears (ATFL) usually occur as isolated
involvement (70) or associated with calcaneal fibular ligament (CFL) (20-40)
but the posterior talar fibular ligament (PTFL) affects only major trauma
involving ankle dislocation
ATFL breaks is associated with breakage of the joint capsule and synovial fluid
extravasation into the anterolateral soft ankle whereas the complete tearing of
CFL can communicate the ankle joint and synovial sheath peroneal tendons
Rupture of CFL is rarely associated with superior peroneal retinaculum tear
The CFL is tensioned during dorsiflexion pulling on peroneal tendons laterally
so that absence of its displacement is sign of a complete tear
Within a damaged ligament can also observe calcifications that often
correspond to fragments of avulsion bone
During the ultrasound can be performed forced maneuvers to detect to joint
laxity and ligament injuries The anterior drawer test is performed with the feet
hanging over the edge of the examination table while the forefoot is pulled
anteriorly when the foot is in plantar flexion and inversion This maneuver
helps differentiate partial tears (grade II) of the ATFL to complete (grade III)
where the anterior displacement of the talus on the tibia open a crack in the
substance becoming more visible the ligament injury
The sindesmosys sprains are up to 10 of ankle
injuries happening in eversion and pronation
movements (like the deltoid ligament injury) and
primarily affect the anterior tibiofibular ligament (ATFL)
the failure is frequently associated with fracture of the
fibula
According to the place of employment are 4 degrees
useful for prognostic evaluation and therapeutic strategy
choice
Grade I stretch or partial tear of the ATFL
Grade II complete tearing but only the ATFL
Grade III complete tear of the ATFL and partial CFL
Grade IV complete tear of the ATFL and CFL
The grade I and II injuries usually scarred without any
significant instability whereas grade III and IV injuries
can cause chronic pain and require surgical treatment
Thickened but continued ATFL right in relation to the partial rupture
Grade 111 sprain of right ATFL
Thickened anterior talofibular ligament with calcifications and a partial rupture
Thickened tibiofibular ligament after trauma
Anterior Talofibular Ligament Partial Tear and Elastography
Tibio fibular ligament rupture with bony avulsion
Complete rupture of right ATFL
Bony avulsion with radiographic evidence as visible calcification in a grade III sprain ATFL
Moderately thickened and hypoechoic ATFL
Discontinuity of the ATFL with fluid surrounding the torn ends (arrow)
Thickening and hypoechogenicity of the fibular end of the ligament seen here passing over the subtalar joint which contains a small of fluid
Complete disruption to the tibiofibular ligament with bony irregularity of particularly the tibial margin and fluid in the gap
MEDIAL COMPARTMENTBecause of the low incidence of eversion ankle
sprains and the thickness of the deltoid ligament
is rarely injured in isolation and when the injury
does not usually full thickness Usually
accompanied by lesions of the medial malleolus
and lateral displacement of the talus with
consequent widening of the ankle mortise
Ultrasound is useful for differentiating ligament
injury of the posterior tibial tendon injury
(TP) adjacent they have similar symptoms
The inability to visualize the deltoid ligament may
indicate tear but this is not considered a reliable
sign as its full ultrasound is not always possible
Partial medial ligament rupture
Thickened heterogeneous abnormal deltoid demonstrating hyperemia
Ultrasonogram showing a disrupted deltoid ligament with the probe in the coronal plane The white arrow indicates the medial malleolus the blue arrow indicates the talus and the red arrows indicate the disrupted deltoid ligament (A) Radiograph showing the same injury (B)
bullJOINT AND BONE DISORDERSUltrasound reliably detect spills mild (gt 2 ml) inside
of the ankle joint by exploring the front and rear
recess as well as areas of synovial proliferation and
may even display using the colour Doppler
hyperemic areas in arthritis patients
The intraarticular joints are displayed surrounded
fluid in one of the recesses of the ankle or subtalar
joint Sonographically diagnosed when changing position to perform flexion and extension Fracture of the lateral process of the talus is overlooked up to 50 of cases with plain radiography Ultrasound may suspect the presence of focal cortical disruption helping further to exclude concomitant ligament injury
Rheumatoid arthritis with synovial thickening (1) and erosion of the tibia (2)
Infectious arthritis with a pus filled anterior recess of the ankle
Arthritis and tenosynovitis of the ankle in a patient with rheumatoid arthritis
bullTUMOURSUltrasound can differentiate between a mass complex
and solid and a cystic in addition to verifying the
existence of accessory muscles (peroneus fourth
accessory flexor digitorum longus and accessory
soleus) As in any other location can be found
neoformative soft tissue tumors inflammatory
infectious etc
Ganglions of this location are more often symptomatic
and larger with multiple partitions
branched and lobed edges Differential diagnosis must
be made with tenosynovitis abscesses seromas and
varicosities
Neurogenic tumours are described as pathognomonic
homogeneous hypoechoic oval mass in continuity with
a nerve of origin
Ganglion cysts are non-malignant cystic masses that occur in association with musculoskeletal structures They are sometimes also simply referred to as ganglia or a ganglion but should not be confused with the anatomical term ganglion UltrasoundThe vast majority are anechoic to hypoechoic on ultrasound and have well defined margins Many demonstrate internal septations as well as acoustic enhancement A synovial cyst is a small fluid-filled sac or pouch that can develop over a tendon or joint creating a mass under the skin Synovial cyst is rare in ankle joint A synovial cyst may or may not be painful depending on their size and location
Ganglion cyst in the foot with bony erosion between navicular and cuneiform bones
Tarsal synovial cyst
Anechoic ganglion situated in the sinus tarsi fat between the talus and calcaneous
Plantar fasciitis (PF) refers to inflammation of the
plantar fascia of the foot It is considered the most common cause of heel pain
Clinical presentation Pain on the undersurface of the heel on weight bearing is the principal complaint It can be worse when weight is borne after a period of rest (eg in the morning) and eases with walking Passive dorsiflexion of the toes may exacerbates discomfort
UltrasoundOften the initial imaging modality of choice Ultrasound typically shows increased thickness of the fascia and a hypoechoic fascia
Thickened hypoechoic origin of the plantar fascia which has a convex superior margin
Complete avulsion of the plantar fascia from the calcaneal tubercle
Plantar fasciitis
bull LOCATING FOREIGN BODIES AND FRACTURES
As in any other location the ankle
area is also subsidiary host foreign
whose classification location and
existence can be defined perfectly by
ultrasound Being a focused study to
the area of interest and with great
resolution for surface structures can
be considered more resolute
examination to screen these cases
Osseous diseases and fractures | Sonography discovered Medial Malleolus Fracture
Ultrasound examination of left ankle A Longitudinal sonogram left ankle demonstrates a wooden foreign body B Transverse view left ankle Note the hypervascularity in the inflamed area C Corresponding X-ray of left ankle Note the swelling on the lateral aspect No foreign body is visible
Thank You
Rheumatoid arthritis with retrocalcaneal bursitis (1) and calcaneal erosions (2)
ACCESSORY NAVICULAR BONEIn the distal insertion site may exist TP 2 types of bones
accessories
Accessory navicular bone type I (os tibiale externum) size
between the 2 and 6 mm can be contained within the TP and
being positioned immediately proximal posteromedial to the
navicular bone It generally produces symptoms and should
not be confused with a tendon calcification or avulsion
fracture
Type II accessory navicular bone is an accessory
ossification centre of the navicular bone with size between
9 and 12 mm triangular shaped and articulated through a
synchondrosis of the posterior and medial navicular bone
It insertion site of some fibers of TP and is associated with a
syndrome of pain and increased incidence of tendon rupture
caused by abnormal overloads Osteoarthritic changes may
underlie this synchondrosis which mimic tendon pathology
Accessory navicular bone within the posterior tibial tendon as anatomical variant
ANTERIOR COMPARTMENTThe tendons of the anterior ankle compared
with the rest of the ankle tendons are rarely
affected by disease The anterior tibial tendon
is the most prone to abnormalities like
tendinopathy tenosynovitis and its place
between the most frequent rupture is extensor
retinaculum and insertion into the first
cuneiform and the base of the first metatarsal
Sometimes the retracted tendon stump causes
a nodule on the anteromedial aspect of the
distal portion of the leg making clinically
confused with a tumour or cyst
Distal insertion tendinopathy of the anterior tibial tendon with increased vascularity
Tenosynovitis of the anterior tibial tendon with effusion
Anterior tibial tendon tenosynovitis with intratendinous ruptures
Anterior tibial tendon rupture with retraction of the tendon
Tenosynovitis of the extensor digitorum tendons with a synovial effusion
Tenosynovitis of the extensor digitorum tendon with hypervascularized thickened tendon and synovium and synovial fluid
Rheumatoid arthritis with tenosynovitis of the extensor digitorum and peroneal tendons
Thickening of the extensor hallucis longus tendon caused by osteosynthesis material
Multicystic non vascularized intramuscular mass in the extensor digitorum brevis muscle
LATERAL COMPARTMENTTENOSYNOVITIS OF THE PERONEAL TENDONSThe main sign of ultrasound is the presence of liquid inside the
common synovial sheath whereas usually tendinous
morphology is preserved We must differentiate tenosynovitis of
a spill within the common peroneal sheath secondary to a tear of
calcaneofibular ligament (PCL) The ultrasound diagnosis is the detection of the tendons in a lateral plane relative to the distal portion of the lateral malleolus instead of behind it The dynamic exploration foot dorsiflexion as both eversion may help identify cases of intermittent subluxation In long-standing disease can be observed fusiform thickening
of the peroneal tendons at the tip of the malleolus The complete tears of the peroneus brevis tendon (PC) and peroneus longus (PL) are rare occurring in the area of the lateral malleolus or midfoot Seen in patients with ankle sprains or history of chronic instability especially if they suffer widespread diseases (RA DM) or treated with corticosteroids The peroneal tendon ruptures causing the inability to eversion of the foot and cavus foot varus
Important thickening of both peroneal tendons (longus and brevis) associated
with moderate amount of fluid and thickening of the synovial sheath
Discreet amount of fluid in the common sheath of the peroneal tendons
associated with disorganization and a heterogeneous appearance
peroneus brevis tendon related to longitudinal rupture
Peroneal tenosynovitis and osteosynthesis
Tenosynovitis of the peroneal tendons and an intratendinous rupture of the short peroneal tendon
Intratendinous rupture and cyst in the peroneus brevis tendon
Peroneus quartus with an accessory muscle next to the peroneus longus and brevis tendons
Tumor next to the peroneal tendons that proved to be a benign fibrous mass
MEDIAL COMPARTMENT
ANOMALIES POSTERIOR TIBIAL TENDON (TP)
It is the most frequently injured in this compartment with ruptures
in asymptomatic middle-aged obese women as a result of
widespread disease (RA seronegative Spondyloarthropathy) or
associated with bone fractures It causes a gradual collapse of the
medial longitudinal arch with hindfoot valgus deformity and
excessive forefoot pronation
The presence of small vessels in inflammatory diseases
intratendinosis can simulate a fissuration tendon confusion can be ignored using colour Doppler Another possible diagnostic difficulty is when the undamaged tendon flexor digitorum longus (FLD) moves back and simulates the TP unbroken but it is smaller and in this case we only see in the groove retromalleolar 1 only tendon
Ultrasound has also proven to be an effective resource for identifying alterations associated tendon tenosynovitis serosa and hypertrophicSubluxation and dislocation anteriorly and medial TP relative to internal
malleolus is rare and valued sonographically placing the foot in dorsiflexion with forced supination
Thickening moderate amount of fluid surrounding calcifications and
hyperemia affecting the sheath and the posterior tibial tendon related
to chronic tenosynovitis in patient affects rheumatoid arthritis
Thickening moderate amount of surrounding fluid and calcifications (arrow) affecting the
posterior tibial tendon related to chronic tenosynovitis in patient affects rheumatoid arthritis
Tenosynovitis of the posterior tibial tendon caused by a bony ridge at the insertion of the retinaculum The retinaculum is thickened and the tendon subluxates
Psoriatic arthritis Ankle Grayscale examination Posterior tibial tendon on longitudinal (a) and transverse (b) scan Marked tendon sheath widening with homogeneous anechoic aspect (asterisks) of the content indicating an exudative tenosynovitis Note as the normal fibrillar echotexture is conserved Hand Flexor tendons of second finger The volar longitudinal (c) and transverse scan (d) shows a tendon sheath widening with signs of synovial proliferation presence of intense power Doppler signal surrounding the tendon and micro interruption of the margin (arrow) e Wrist Extensor carpi ulnaris tendon (sixth compartment of the extensor tendons ecu) on lateral longitudinal (e) and transverse (f) scan Chronic tenosynovitis with clear areas of low of echogenicity and loss of the continuity of tendon fibrils indicative of partial tendon tear (arrows) Moreover note the presence of power Doppler signal within the interruption indicating still activity of the inflammatory process g Dactylitis Volar longitudinal scan using the ldquoextended viewrdquo technique showing proliferative tenosynovitis of the finger flexor tendon (circle) exudative synovitis of both proximal and distal interphalangeal joint (white asterisks) and edema of the peritendinous tissue (black asterisks) TP posterior tibial tendon mm medial malleolus DP distal phalanx mp middle phalanx cu cubital bone ft flexor tendons
Tenosynovitis of the posterior tibial (1) and flexor digitorum longus tendon (2)
Tibialis Posterior Tendon rupture
Tenosynovitis of the posterior tibial tendon the flexor digitorum tendon and flexor hallucis longus tendon
Tenosynovitis of the tendons on the medial side in the left ankle
bullLIGAMENT INJURIESThe ligament partial tear ligament shows a hypoechoic
areas swollen with internal focal or diffuse In the complete
ruptures within the substance of the divided ligament rift is
observed corresponding to the hematoma hypoechoic and
the free ends of the divided ligament can be and retracted
appreciated corrugated in contrast with normal
appearance straight
Grade I Mild stretching of the ligament without breakage
or instability
Grade II Partial tearing of the ligament
Grade III Complete tearing
Degrees depending on the severity of the injury and the
place of employment
LATERAL COMPARTMENTThese injuries occur secondary to inversion sprains with internal rotation of
the foot combined with ankle plantar flexion
The anterior talar fibular ligament tears (ATFL) usually occur as isolated
involvement (70) or associated with calcaneal fibular ligament (CFL) (20-40)
but the posterior talar fibular ligament (PTFL) affects only major trauma
involving ankle dislocation
ATFL breaks is associated with breakage of the joint capsule and synovial fluid
extravasation into the anterolateral soft ankle whereas the complete tearing of
CFL can communicate the ankle joint and synovial sheath peroneal tendons
Rupture of CFL is rarely associated with superior peroneal retinaculum tear
The CFL is tensioned during dorsiflexion pulling on peroneal tendons laterally
so that absence of its displacement is sign of a complete tear
Within a damaged ligament can also observe calcifications that often
correspond to fragments of avulsion bone
During the ultrasound can be performed forced maneuvers to detect to joint
laxity and ligament injuries The anterior drawer test is performed with the feet
hanging over the edge of the examination table while the forefoot is pulled
anteriorly when the foot is in plantar flexion and inversion This maneuver
helps differentiate partial tears (grade II) of the ATFL to complete (grade III)
where the anterior displacement of the talus on the tibia open a crack in the
substance becoming more visible the ligament injury
The sindesmosys sprains are up to 10 of ankle
injuries happening in eversion and pronation
movements (like the deltoid ligament injury) and
primarily affect the anterior tibiofibular ligament (ATFL)
the failure is frequently associated with fracture of the
fibula
According to the place of employment are 4 degrees
useful for prognostic evaluation and therapeutic strategy
choice
Grade I stretch or partial tear of the ATFL
Grade II complete tearing but only the ATFL
Grade III complete tear of the ATFL and partial CFL
Grade IV complete tear of the ATFL and CFL
The grade I and II injuries usually scarred without any
significant instability whereas grade III and IV injuries
can cause chronic pain and require surgical treatment
Thickened but continued ATFL right in relation to the partial rupture
Grade 111 sprain of right ATFL
Thickened anterior talofibular ligament with calcifications and a partial rupture
Thickened tibiofibular ligament after trauma
Anterior Talofibular Ligament Partial Tear and Elastography
Tibio fibular ligament rupture with bony avulsion
Complete rupture of right ATFL
Bony avulsion with radiographic evidence as visible calcification in a grade III sprain ATFL
Moderately thickened and hypoechoic ATFL
Discontinuity of the ATFL with fluid surrounding the torn ends (arrow)
Thickening and hypoechogenicity of the fibular end of the ligament seen here passing over the subtalar joint which contains a small of fluid
Complete disruption to the tibiofibular ligament with bony irregularity of particularly the tibial margin and fluid in the gap
MEDIAL COMPARTMENTBecause of the low incidence of eversion ankle
sprains and the thickness of the deltoid ligament
is rarely injured in isolation and when the injury
does not usually full thickness Usually
accompanied by lesions of the medial malleolus
and lateral displacement of the talus with
consequent widening of the ankle mortise
Ultrasound is useful for differentiating ligament
injury of the posterior tibial tendon injury
(TP) adjacent they have similar symptoms
The inability to visualize the deltoid ligament may
indicate tear but this is not considered a reliable
sign as its full ultrasound is not always possible
Partial medial ligament rupture
Thickened heterogeneous abnormal deltoid demonstrating hyperemia
Ultrasonogram showing a disrupted deltoid ligament with the probe in the coronal plane The white arrow indicates the medial malleolus the blue arrow indicates the talus and the red arrows indicate the disrupted deltoid ligament (A) Radiograph showing the same injury (B)
bullJOINT AND BONE DISORDERSUltrasound reliably detect spills mild (gt 2 ml) inside
of the ankle joint by exploring the front and rear
recess as well as areas of synovial proliferation and
may even display using the colour Doppler
hyperemic areas in arthritis patients
The intraarticular joints are displayed surrounded
fluid in one of the recesses of the ankle or subtalar
joint Sonographically diagnosed when changing position to perform flexion and extension Fracture of the lateral process of the talus is overlooked up to 50 of cases with plain radiography Ultrasound may suspect the presence of focal cortical disruption helping further to exclude concomitant ligament injury
Rheumatoid arthritis with synovial thickening (1) and erosion of the tibia (2)
Infectious arthritis with a pus filled anterior recess of the ankle
Arthritis and tenosynovitis of the ankle in a patient with rheumatoid arthritis
bullTUMOURSUltrasound can differentiate between a mass complex
and solid and a cystic in addition to verifying the
existence of accessory muscles (peroneus fourth
accessory flexor digitorum longus and accessory
soleus) As in any other location can be found
neoformative soft tissue tumors inflammatory
infectious etc
Ganglions of this location are more often symptomatic
and larger with multiple partitions
branched and lobed edges Differential diagnosis must
be made with tenosynovitis abscesses seromas and
varicosities
Neurogenic tumours are described as pathognomonic
homogeneous hypoechoic oval mass in continuity with
a nerve of origin
Ganglion cysts are non-malignant cystic masses that occur in association with musculoskeletal structures They are sometimes also simply referred to as ganglia or a ganglion but should not be confused with the anatomical term ganglion UltrasoundThe vast majority are anechoic to hypoechoic on ultrasound and have well defined margins Many demonstrate internal septations as well as acoustic enhancement A synovial cyst is a small fluid-filled sac or pouch that can develop over a tendon or joint creating a mass under the skin Synovial cyst is rare in ankle joint A synovial cyst may or may not be painful depending on their size and location
Ganglion cyst in the foot with bony erosion between navicular and cuneiform bones
Tarsal synovial cyst
Anechoic ganglion situated in the sinus tarsi fat between the talus and calcaneous
Plantar fasciitis (PF) refers to inflammation of the
plantar fascia of the foot It is considered the most common cause of heel pain
Clinical presentation Pain on the undersurface of the heel on weight bearing is the principal complaint It can be worse when weight is borne after a period of rest (eg in the morning) and eases with walking Passive dorsiflexion of the toes may exacerbates discomfort
UltrasoundOften the initial imaging modality of choice Ultrasound typically shows increased thickness of the fascia and a hypoechoic fascia
Thickened hypoechoic origin of the plantar fascia which has a convex superior margin
Complete avulsion of the plantar fascia from the calcaneal tubercle
Plantar fasciitis
bull LOCATING FOREIGN BODIES AND FRACTURES
As in any other location the ankle
area is also subsidiary host foreign
whose classification location and
existence can be defined perfectly by
ultrasound Being a focused study to
the area of interest and with great
resolution for surface structures can
be considered more resolute
examination to screen these cases
Osseous diseases and fractures | Sonography discovered Medial Malleolus Fracture
Ultrasound examination of left ankle A Longitudinal sonogram left ankle demonstrates a wooden foreign body B Transverse view left ankle Note the hypervascularity in the inflamed area C Corresponding X-ray of left ankle Note the swelling on the lateral aspect No foreign body is visible
Thank You
ACCESSORY NAVICULAR BONEIn the distal insertion site may exist TP 2 types of bones
accessories
Accessory navicular bone type I (os tibiale externum) size
between the 2 and 6 mm can be contained within the TP and
being positioned immediately proximal posteromedial to the
navicular bone It generally produces symptoms and should
not be confused with a tendon calcification or avulsion
fracture
Type II accessory navicular bone is an accessory
ossification centre of the navicular bone with size between
9 and 12 mm triangular shaped and articulated through a
synchondrosis of the posterior and medial navicular bone
It insertion site of some fibers of TP and is associated with a
syndrome of pain and increased incidence of tendon rupture
caused by abnormal overloads Osteoarthritic changes may
underlie this synchondrosis which mimic tendon pathology
Accessory navicular bone within the posterior tibial tendon as anatomical variant
ANTERIOR COMPARTMENTThe tendons of the anterior ankle compared
with the rest of the ankle tendons are rarely
affected by disease The anterior tibial tendon
is the most prone to abnormalities like
tendinopathy tenosynovitis and its place
between the most frequent rupture is extensor
retinaculum and insertion into the first
cuneiform and the base of the first metatarsal
Sometimes the retracted tendon stump causes
a nodule on the anteromedial aspect of the
distal portion of the leg making clinically
confused with a tumour or cyst
Distal insertion tendinopathy of the anterior tibial tendon with increased vascularity
Tenosynovitis of the anterior tibial tendon with effusion
Anterior tibial tendon tenosynovitis with intratendinous ruptures
Anterior tibial tendon rupture with retraction of the tendon
Tenosynovitis of the extensor digitorum tendons with a synovial effusion
Tenosynovitis of the extensor digitorum tendon with hypervascularized thickened tendon and synovium and synovial fluid
Rheumatoid arthritis with tenosynovitis of the extensor digitorum and peroneal tendons
Thickening of the extensor hallucis longus tendon caused by osteosynthesis material
Multicystic non vascularized intramuscular mass in the extensor digitorum brevis muscle
LATERAL COMPARTMENTTENOSYNOVITIS OF THE PERONEAL TENDONSThe main sign of ultrasound is the presence of liquid inside the
common synovial sheath whereas usually tendinous
morphology is preserved We must differentiate tenosynovitis of
a spill within the common peroneal sheath secondary to a tear of
calcaneofibular ligament (PCL) The ultrasound diagnosis is the detection of the tendons in a lateral plane relative to the distal portion of the lateral malleolus instead of behind it The dynamic exploration foot dorsiflexion as both eversion may help identify cases of intermittent subluxation In long-standing disease can be observed fusiform thickening
of the peroneal tendons at the tip of the malleolus The complete tears of the peroneus brevis tendon (PC) and peroneus longus (PL) are rare occurring in the area of the lateral malleolus or midfoot Seen in patients with ankle sprains or history of chronic instability especially if they suffer widespread diseases (RA DM) or treated with corticosteroids The peroneal tendon ruptures causing the inability to eversion of the foot and cavus foot varus
Important thickening of both peroneal tendons (longus and brevis) associated
with moderate amount of fluid and thickening of the synovial sheath
Discreet amount of fluid in the common sheath of the peroneal tendons
associated with disorganization and a heterogeneous appearance
peroneus brevis tendon related to longitudinal rupture
Peroneal tenosynovitis and osteosynthesis
Tenosynovitis of the peroneal tendons and an intratendinous rupture of the short peroneal tendon
Intratendinous rupture and cyst in the peroneus brevis tendon
Peroneus quartus with an accessory muscle next to the peroneus longus and brevis tendons
Tumor next to the peroneal tendons that proved to be a benign fibrous mass
MEDIAL COMPARTMENT
ANOMALIES POSTERIOR TIBIAL TENDON (TP)
It is the most frequently injured in this compartment with ruptures
in asymptomatic middle-aged obese women as a result of
widespread disease (RA seronegative Spondyloarthropathy) or
associated with bone fractures It causes a gradual collapse of the
medial longitudinal arch with hindfoot valgus deformity and
excessive forefoot pronation
The presence of small vessels in inflammatory diseases
intratendinosis can simulate a fissuration tendon confusion can be ignored using colour Doppler Another possible diagnostic difficulty is when the undamaged tendon flexor digitorum longus (FLD) moves back and simulates the TP unbroken but it is smaller and in this case we only see in the groove retromalleolar 1 only tendon
Ultrasound has also proven to be an effective resource for identifying alterations associated tendon tenosynovitis serosa and hypertrophicSubluxation and dislocation anteriorly and medial TP relative to internal
malleolus is rare and valued sonographically placing the foot in dorsiflexion with forced supination
Thickening moderate amount of fluid surrounding calcifications and
hyperemia affecting the sheath and the posterior tibial tendon related
to chronic tenosynovitis in patient affects rheumatoid arthritis
Thickening moderate amount of surrounding fluid and calcifications (arrow) affecting the
posterior tibial tendon related to chronic tenosynovitis in patient affects rheumatoid arthritis
Tenosynovitis of the posterior tibial tendon caused by a bony ridge at the insertion of the retinaculum The retinaculum is thickened and the tendon subluxates
Psoriatic arthritis Ankle Grayscale examination Posterior tibial tendon on longitudinal (a) and transverse (b) scan Marked tendon sheath widening with homogeneous anechoic aspect (asterisks) of the content indicating an exudative tenosynovitis Note as the normal fibrillar echotexture is conserved Hand Flexor tendons of second finger The volar longitudinal (c) and transverse scan (d) shows a tendon sheath widening with signs of synovial proliferation presence of intense power Doppler signal surrounding the tendon and micro interruption of the margin (arrow) e Wrist Extensor carpi ulnaris tendon (sixth compartment of the extensor tendons ecu) on lateral longitudinal (e) and transverse (f) scan Chronic tenosynovitis with clear areas of low of echogenicity and loss of the continuity of tendon fibrils indicative of partial tendon tear (arrows) Moreover note the presence of power Doppler signal within the interruption indicating still activity of the inflammatory process g Dactylitis Volar longitudinal scan using the ldquoextended viewrdquo technique showing proliferative tenosynovitis of the finger flexor tendon (circle) exudative synovitis of both proximal and distal interphalangeal joint (white asterisks) and edema of the peritendinous tissue (black asterisks) TP posterior tibial tendon mm medial malleolus DP distal phalanx mp middle phalanx cu cubital bone ft flexor tendons
Tenosynovitis of the posterior tibial (1) and flexor digitorum longus tendon (2)
Tibialis Posterior Tendon rupture
Tenosynovitis of the posterior tibial tendon the flexor digitorum tendon and flexor hallucis longus tendon
Tenosynovitis of the tendons on the medial side in the left ankle
bullLIGAMENT INJURIESThe ligament partial tear ligament shows a hypoechoic
areas swollen with internal focal or diffuse In the complete
ruptures within the substance of the divided ligament rift is
observed corresponding to the hematoma hypoechoic and
the free ends of the divided ligament can be and retracted
appreciated corrugated in contrast with normal
appearance straight
Grade I Mild stretching of the ligament without breakage
or instability
Grade II Partial tearing of the ligament
Grade III Complete tearing
Degrees depending on the severity of the injury and the
place of employment
LATERAL COMPARTMENTThese injuries occur secondary to inversion sprains with internal rotation of
the foot combined with ankle plantar flexion
The anterior talar fibular ligament tears (ATFL) usually occur as isolated
involvement (70) or associated with calcaneal fibular ligament (CFL) (20-40)
but the posterior talar fibular ligament (PTFL) affects only major trauma
involving ankle dislocation
ATFL breaks is associated with breakage of the joint capsule and synovial fluid
extravasation into the anterolateral soft ankle whereas the complete tearing of
CFL can communicate the ankle joint and synovial sheath peroneal tendons
Rupture of CFL is rarely associated with superior peroneal retinaculum tear
The CFL is tensioned during dorsiflexion pulling on peroneal tendons laterally
so that absence of its displacement is sign of a complete tear
Within a damaged ligament can also observe calcifications that often
correspond to fragments of avulsion bone
During the ultrasound can be performed forced maneuvers to detect to joint
laxity and ligament injuries The anterior drawer test is performed with the feet
hanging over the edge of the examination table while the forefoot is pulled
anteriorly when the foot is in plantar flexion and inversion This maneuver
helps differentiate partial tears (grade II) of the ATFL to complete (grade III)
where the anterior displacement of the talus on the tibia open a crack in the
substance becoming more visible the ligament injury
The sindesmosys sprains are up to 10 of ankle
injuries happening in eversion and pronation
movements (like the deltoid ligament injury) and
primarily affect the anterior tibiofibular ligament (ATFL)
the failure is frequently associated with fracture of the
fibula
According to the place of employment are 4 degrees
useful for prognostic evaluation and therapeutic strategy
choice
Grade I stretch or partial tear of the ATFL
Grade II complete tearing but only the ATFL
Grade III complete tear of the ATFL and partial CFL
Grade IV complete tear of the ATFL and CFL
The grade I and II injuries usually scarred without any
significant instability whereas grade III and IV injuries
can cause chronic pain and require surgical treatment
Thickened but continued ATFL right in relation to the partial rupture
Grade 111 sprain of right ATFL
Thickened anterior talofibular ligament with calcifications and a partial rupture
Thickened tibiofibular ligament after trauma
Anterior Talofibular Ligament Partial Tear and Elastography
Tibio fibular ligament rupture with bony avulsion
Complete rupture of right ATFL
Bony avulsion with radiographic evidence as visible calcification in a grade III sprain ATFL
Moderately thickened and hypoechoic ATFL
Discontinuity of the ATFL with fluid surrounding the torn ends (arrow)
Thickening and hypoechogenicity of the fibular end of the ligament seen here passing over the subtalar joint which contains a small of fluid
Complete disruption to the tibiofibular ligament with bony irregularity of particularly the tibial margin and fluid in the gap
MEDIAL COMPARTMENTBecause of the low incidence of eversion ankle
sprains and the thickness of the deltoid ligament
is rarely injured in isolation and when the injury
does not usually full thickness Usually
accompanied by lesions of the medial malleolus
and lateral displacement of the talus with
consequent widening of the ankle mortise
Ultrasound is useful for differentiating ligament
injury of the posterior tibial tendon injury
(TP) adjacent they have similar symptoms
The inability to visualize the deltoid ligament may
indicate tear but this is not considered a reliable
sign as its full ultrasound is not always possible
Partial medial ligament rupture
Thickened heterogeneous abnormal deltoid demonstrating hyperemia
Ultrasonogram showing a disrupted deltoid ligament with the probe in the coronal plane The white arrow indicates the medial malleolus the blue arrow indicates the talus and the red arrows indicate the disrupted deltoid ligament (A) Radiograph showing the same injury (B)
bullJOINT AND BONE DISORDERSUltrasound reliably detect spills mild (gt 2 ml) inside
of the ankle joint by exploring the front and rear
recess as well as areas of synovial proliferation and
may even display using the colour Doppler
hyperemic areas in arthritis patients
The intraarticular joints are displayed surrounded
fluid in one of the recesses of the ankle or subtalar
joint Sonographically diagnosed when changing position to perform flexion and extension Fracture of the lateral process of the talus is overlooked up to 50 of cases with plain radiography Ultrasound may suspect the presence of focal cortical disruption helping further to exclude concomitant ligament injury
Rheumatoid arthritis with synovial thickening (1) and erosion of the tibia (2)
Infectious arthritis with a pus filled anterior recess of the ankle
Arthritis and tenosynovitis of the ankle in a patient with rheumatoid arthritis
bullTUMOURSUltrasound can differentiate between a mass complex
and solid and a cystic in addition to verifying the
existence of accessory muscles (peroneus fourth
accessory flexor digitorum longus and accessory
soleus) As in any other location can be found
neoformative soft tissue tumors inflammatory
infectious etc
Ganglions of this location are more often symptomatic
and larger with multiple partitions
branched and lobed edges Differential diagnosis must
be made with tenosynovitis abscesses seromas and
varicosities
Neurogenic tumours are described as pathognomonic
homogeneous hypoechoic oval mass in continuity with
a nerve of origin
Ganglion cysts are non-malignant cystic masses that occur in association with musculoskeletal structures They are sometimes also simply referred to as ganglia or a ganglion but should not be confused with the anatomical term ganglion UltrasoundThe vast majority are anechoic to hypoechoic on ultrasound and have well defined margins Many demonstrate internal septations as well as acoustic enhancement A synovial cyst is a small fluid-filled sac or pouch that can develop over a tendon or joint creating a mass under the skin Synovial cyst is rare in ankle joint A synovial cyst may or may not be painful depending on their size and location
Ganglion cyst in the foot with bony erosion between navicular and cuneiform bones
Tarsal synovial cyst
Anechoic ganglion situated in the sinus tarsi fat between the talus and calcaneous
Plantar fasciitis (PF) refers to inflammation of the
plantar fascia of the foot It is considered the most common cause of heel pain
Clinical presentation Pain on the undersurface of the heel on weight bearing is the principal complaint It can be worse when weight is borne after a period of rest (eg in the morning) and eases with walking Passive dorsiflexion of the toes may exacerbates discomfort
UltrasoundOften the initial imaging modality of choice Ultrasound typically shows increased thickness of the fascia and a hypoechoic fascia
Thickened hypoechoic origin of the plantar fascia which has a convex superior margin
Complete avulsion of the plantar fascia from the calcaneal tubercle
Plantar fasciitis
bull LOCATING FOREIGN BODIES AND FRACTURES
As in any other location the ankle
area is also subsidiary host foreign
whose classification location and
existence can be defined perfectly by
ultrasound Being a focused study to
the area of interest and with great
resolution for surface structures can
be considered more resolute
examination to screen these cases
Osseous diseases and fractures | Sonography discovered Medial Malleolus Fracture
Ultrasound examination of left ankle A Longitudinal sonogram left ankle demonstrates a wooden foreign body B Transverse view left ankle Note the hypervascularity in the inflamed area C Corresponding X-ray of left ankle Note the swelling on the lateral aspect No foreign body is visible
Thank You
Accessory navicular bone within the posterior tibial tendon as anatomical variant
ANTERIOR COMPARTMENTThe tendons of the anterior ankle compared
with the rest of the ankle tendons are rarely
affected by disease The anterior tibial tendon
is the most prone to abnormalities like
tendinopathy tenosynovitis and its place
between the most frequent rupture is extensor
retinaculum and insertion into the first
cuneiform and the base of the first metatarsal
Sometimes the retracted tendon stump causes
a nodule on the anteromedial aspect of the
distal portion of the leg making clinically
confused with a tumour or cyst
Distal insertion tendinopathy of the anterior tibial tendon with increased vascularity
Tenosynovitis of the anterior tibial tendon with effusion
Anterior tibial tendon tenosynovitis with intratendinous ruptures
Anterior tibial tendon rupture with retraction of the tendon
Tenosynovitis of the extensor digitorum tendons with a synovial effusion
Tenosynovitis of the extensor digitorum tendon with hypervascularized thickened tendon and synovium and synovial fluid
Rheumatoid arthritis with tenosynovitis of the extensor digitorum and peroneal tendons
Thickening of the extensor hallucis longus tendon caused by osteosynthesis material
Multicystic non vascularized intramuscular mass in the extensor digitorum brevis muscle
LATERAL COMPARTMENTTENOSYNOVITIS OF THE PERONEAL TENDONSThe main sign of ultrasound is the presence of liquid inside the
common synovial sheath whereas usually tendinous
morphology is preserved We must differentiate tenosynovitis of
a spill within the common peroneal sheath secondary to a tear of
calcaneofibular ligament (PCL) The ultrasound diagnosis is the detection of the tendons in a lateral plane relative to the distal portion of the lateral malleolus instead of behind it The dynamic exploration foot dorsiflexion as both eversion may help identify cases of intermittent subluxation In long-standing disease can be observed fusiform thickening
of the peroneal tendons at the tip of the malleolus The complete tears of the peroneus brevis tendon (PC) and peroneus longus (PL) are rare occurring in the area of the lateral malleolus or midfoot Seen in patients with ankle sprains or history of chronic instability especially if they suffer widespread diseases (RA DM) or treated with corticosteroids The peroneal tendon ruptures causing the inability to eversion of the foot and cavus foot varus
Important thickening of both peroneal tendons (longus and brevis) associated
with moderate amount of fluid and thickening of the synovial sheath
Discreet amount of fluid in the common sheath of the peroneal tendons
associated with disorganization and a heterogeneous appearance
peroneus brevis tendon related to longitudinal rupture
Peroneal tenosynovitis and osteosynthesis
Tenosynovitis of the peroneal tendons and an intratendinous rupture of the short peroneal tendon
Intratendinous rupture and cyst in the peroneus brevis tendon
Peroneus quartus with an accessory muscle next to the peroneus longus and brevis tendons
Tumor next to the peroneal tendons that proved to be a benign fibrous mass
MEDIAL COMPARTMENT
ANOMALIES POSTERIOR TIBIAL TENDON (TP)
It is the most frequently injured in this compartment with ruptures
in asymptomatic middle-aged obese women as a result of
widespread disease (RA seronegative Spondyloarthropathy) or
associated with bone fractures It causes a gradual collapse of the
medial longitudinal arch with hindfoot valgus deformity and
excessive forefoot pronation
The presence of small vessels in inflammatory diseases
intratendinosis can simulate a fissuration tendon confusion can be ignored using colour Doppler Another possible diagnostic difficulty is when the undamaged tendon flexor digitorum longus (FLD) moves back and simulates the TP unbroken but it is smaller and in this case we only see in the groove retromalleolar 1 only tendon
Ultrasound has also proven to be an effective resource for identifying alterations associated tendon tenosynovitis serosa and hypertrophicSubluxation and dislocation anteriorly and medial TP relative to internal
malleolus is rare and valued sonographically placing the foot in dorsiflexion with forced supination
Thickening moderate amount of fluid surrounding calcifications and
hyperemia affecting the sheath and the posterior tibial tendon related
to chronic tenosynovitis in patient affects rheumatoid arthritis
Thickening moderate amount of surrounding fluid and calcifications (arrow) affecting the
posterior tibial tendon related to chronic tenosynovitis in patient affects rheumatoid arthritis
Tenosynovitis of the posterior tibial tendon caused by a bony ridge at the insertion of the retinaculum The retinaculum is thickened and the tendon subluxates
Psoriatic arthritis Ankle Grayscale examination Posterior tibial tendon on longitudinal (a) and transverse (b) scan Marked tendon sheath widening with homogeneous anechoic aspect (asterisks) of the content indicating an exudative tenosynovitis Note as the normal fibrillar echotexture is conserved Hand Flexor tendons of second finger The volar longitudinal (c) and transverse scan (d) shows a tendon sheath widening with signs of synovial proliferation presence of intense power Doppler signal surrounding the tendon and micro interruption of the margin (arrow) e Wrist Extensor carpi ulnaris tendon (sixth compartment of the extensor tendons ecu) on lateral longitudinal (e) and transverse (f) scan Chronic tenosynovitis with clear areas of low of echogenicity and loss of the continuity of tendon fibrils indicative of partial tendon tear (arrows) Moreover note the presence of power Doppler signal within the interruption indicating still activity of the inflammatory process g Dactylitis Volar longitudinal scan using the ldquoextended viewrdquo technique showing proliferative tenosynovitis of the finger flexor tendon (circle) exudative synovitis of both proximal and distal interphalangeal joint (white asterisks) and edema of the peritendinous tissue (black asterisks) TP posterior tibial tendon mm medial malleolus DP distal phalanx mp middle phalanx cu cubital bone ft flexor tendons
Tenosynovitis of the posterior tibial (1) and flexor digitorum longus tendon (2)
Tibialis Posterior Tendon rupture
Tenosynovitis of the posterior tibial tendon the flexor digitorum tendon and flexor hallucis longus tendon
Tenosynovitis of the tendons on the medial side in the left ankle
bullLIGAMENT INJURIESThe ligament partial tear ligament shows a hypoechoic
areas swollen with internal focal or diffuse In the complete
ruptures within the substance of the divided ligament rift is
observed corresponding to the hematoma hypoechoic and
the free ends of the divided ligament can be and retracted
appreciated corrugated in contrast with normal
appearance straight
Grade I Mild stretching of the ligament without breakage
or instability
Grade II Partial tearing of the ligament
Grade III Complete tearing
Degrees depending on the severity of the injury and the
place of employment
LATERAL COMPARTMENTThese injuries occur secondary to inversion sprains with internal rotation of
the foot combined with ankle plantar flexion
The anterior talar fibular ligament tears (ATFL) usually occur as isolated
involvement (70) or associated with calcaneal fibular ligament (CFL) (20-40)
but the posterior talar fibular ligament (PTFL) affects only major trauma
involving ankle dislocation
ATFL breaks is associated with breakage of the joint capsule and synovial fluid
extravasation into the anterolateral soft ankle whereas the complete tearing of
CFL can communicate the ankle joint and synovial sheath peroneal tendons
Rupture of CFL is rarely associated with superior peroneal retinaculum tear
The CFL is tensioned during dorsiflexion pulling on peroneal tendons laterally
so that absence of its displacement is sign of a complete tear
Within a damaged ligament can also observe calcifications that often
correspond to fragments of avulsion bone
During the ultrasound can be performed forced maneuvers to detect to joint
laxity and ligament injuries The anterior drawer test is performed with the feet
hanging over the edge of the examination table while the forefoot is pulled
anteriorly when the foot is in plantar flexion and inversion This maneuver
helps differentiate partial tears (grade II) of the ATFL to complete (grade III)
where the anterior displacement of the talus on the tibia open a crack in the
substance becoming more visible the ligament injury
The sindesmosys sprains are up to 10 of ankle
injuries happening in eversion and pronation
movements (like the deltoid ligament injury) and
primarily affect the anterior tibiofibular ligament (ATFL)
the failure is frequently associated with fracture of the
fibula
According to the place of employment are 4 degrees
useful for prognostic evaluation and therapeutic strategy
choice
Grade I stretch or partial tear of the ATFL
Grade II complete tearing but only the ATFL
Grade III complete tear of the ATFL and partial CFL
Grade IV complete tear of the ATFL and CFL
The grade I and II injuries usually scarred without any
significant instability whereas grade III and IV injuries
can cause chronic pain and require surgical treatment
Thickened but continued ATFL right in relation to the partial rupture
Grade 111 sprain of right ATFL
Thickened anterior talofibular ligament with calcifications and a partial rupture
Thickened tibiofibular ligament after trauma
Anterior Talofibular Ligament Partial Tear and Elastography
Tibio fibular ligament rupture with bony avulsion
Complete rupture of right ATFL
Bony avulsion with radiographic evidence as visible calcification in a grade III sprain ATFL
Moderately thickened and hypoechoic ATFL
Discontinuity of the ATFL with fluid surrounding the torn ends (arrow)
Thickening and hypoechogenicity of the fibular end of the ligament seen here passing over the subtalar joint which contains a small of fluid
Complete disruption to the tibiofibular ligament with bony irregularity of particularly the tibial margin and fluid in the gap
MEDIAL COMPARTMENTBecause of the low incidence of eversion ankle
sprains and the thickness of the deltoid ligament
is rarely injured in isolation and when the injury
does not usually full thickness Usually
accompanied by lesions of the medial malleolus
and lateral displacement of the talus with
consequent widening of the ankle mortise
Ultrasound is useful for differentiating ligament
injury of the posterior tibial tendon injury
(TP) adjacent they have similar symptoms
The inability to visualize the deltoid ligament may
indicate tear but this is not considered a reliable
sign as its full ultrasound is not always possible
Partial medial ligament rupture
Thickened heterogeneous abnormal deltoid demonstrating hyperemia
Ultrasonogram showing a disrupted deltoid ligament with the probe in the coronal plane The white arrow indicates the medial malleolus the blue arrow indicates the talus and the red arrows indicate the disrupted deltoid ligament (A) Radiograph showing the same injury (B)
bullJOINT AND BONE DISORDERSUltrasound reliably detect spills mild (gt 2 ml) inside
of the ankle joint by exploring the front and rear
recess as well as areas of synovial proliferation and
may even display using the colour Doppler
hyperemic areas in arthritis patients
The intraarticular joints are displayed surrounded
fluid in one of the recesses of the ankle or subtalar
joint Sonographically diagnosed when changing position to perform flexion and extension Fracture of the lateral process of the talus is overlooked up to 50 of cases with plain radiography Ultrasound may suspect the presence of focal cortical disruption helping further to exclude concomitant ligament injury
Rheumatoid arthritis with synovial thickening (1) and erosion of the tibia (2)
Infectious arthritis with a pus filled anterior recess of the ankle
Arthritis and tenosynovitis of the ankle in a patient with rheumatoid arthritis
bullTUMOURSUltrasound can differentiate between a mass complex
and solid and a cystic in addition to verifying the
existence of accessory muscles (peroneus fourth
accessory flexor digitorum longus and accessory
soleus) As in any other location can be found
neoformative soft tissue tumors inflammatory
infectious etc
Ganglions of this location are more often symptomatic
and larger with multiple partitions
branched and lobed edges Differential diagnosis must
be made with tenosynovitis abscesses seromas and
varicosities
Neurogenic tumours are described as pathognomonic
homogeneous hypoechoic oval mass in continuity with
a nerve of origin
Ganglion cysts are non-malignant cystic masses that occur in association with musculoskeletal structures They are sometimes also simply referred to as ganglia or a ganglion but should not be confused with the anatomical term ganglion UltrasoundThe vast majority are anechoic to hypoechoic on ultrasound and have well defined margins Many demonstrate internal septations as well as acoustic enhancement A synovial cyst is a small fluid-filled sac or pouch that can develop over a tendon or joint creating a mass under the skin Synovial cyst is rare in ankle joint A synovial cyst may or may not be painful depending on their size and location
Ganglion cyst in the foot with bony erosion between navicular and cuneiform bones
Tarsal synovial cyst
Anechoic ganglion situated in the sinus tarsi fat between the talus and calcaneous
Plantar fasciitis (PF) refers to inflammation of the
plantar fascia of the foot It is considered the most common cause of heel pain
Clinical presentation Pain on the undersurface of the heel on weight bearing is the principal complaint It can be worse when weight is borne after a period of rest (eg in the morning) and eases with walking Passive dorsiflexion of the toes may exacerbates discomfort
UltrasoundOften the initial imaging modality of choice Ultrasound typically shows increased thickness of the fascia and a hypoechoic fascia
Thickened hypoechoic origin of the plantar fascia which has a convex superior margin
Complete avulsion of the plantar fascia from the calcaneal tubercle
Plantar fasciitis
bull LOCATING FOREIGN BODIES AND FRACTURES
As in any other location the ankle
area is also subsidiary host foreign
whose classification location and
existence can be defined perfectly by
ultrasound Being a focused study to
the area of interest and with great
resolution for surface structures can
be considered more resolute
examination to screen these cases
Osseous diseases and fractures | Sonography discovered Medial Malleolus Fracture
Ultrasound examination of left ankle A Longitudinal sonogram left ankle demonstrates a wooden foreign body B Transverse view left ankle Note the hypervascularity in the inflamed area C Corresponding X-ray of left ankle Note the swelling on the lateral aspect No foreign body is visible
Thank You
ANTERIOR COMPARTMENTThe tendons of the anterior ankle compared
with the rest of the ankle tendons are rarely
affected by disease The anterior tibial tendon
is the most prone to abnormalities like
tendinopathy tenosynovitis and its place
between the most frequent rupture is extensor
retinaculum and insertion into the first
cuneiform and the base of the first metatarsal
Sometimes the retracted tendon stump causes
a nodule on the anteromedial aspect of the
distal portion of the leg making clinically
confused with a tumour or cyst
Distal insertion tendinopathy of the anterior tibial tendon with increased vascularity
Tenosynovitis of the anterior tibial tendon with effusion
Anterior tibial tendon tenosynovitis with intratendinous ruptures
Anterior tibial tendon rupture with retraction of the tendon
Tenosynovitis of the extensor digitorum tendons with a synovial effusion
Tenosynovitis of the extensor digitorum tendon with hypervascularized thickened tendon and synovium and synovial fluid
Rheumatoid arthritis with tenosynovitis of the extensor digitorum and peroneal tendons
Thickening of the extensor hallucis longus tendon caused by osteosynthesis material
Multicystic non vascularized intramuscular mass in the extensor digitorum brevis muscle
LATERAL COMPARTMENTTENOSYNOVITIS OF THE PERONEAL TENDONSThe main sign of ultrasound is the presence of liquid inside the
common synovial sheath whereas usually tendinous
morphology is preserved We must differentiate tenosynovitis of
a spill within the common peroneal sheath secondary to a tear of
calcaneofibular ligament (PCL) The ultrasound diagnosis is the detection of the tendons in a lateral plane relative to the distal portion of the lateral malleolus instead of behind it The dynamic exploration foot dorsiflexion as both eversion may help identify cases of intermittent subluxation In long-standing disease can be observed fusiform thickening
of the peroneal tendons at the tip of the malleolus The complete tears of the peroneus brevis tendon (PC) and peroneus longus (PL) are rare occurring in the area of the lateral malleolus or midfoot Seen in patients with ankle sprains or history of chronic instability especially if they suffer widespread diseases (RA DM) or treated with corticosteroids The peroneal tendon ruptures causing the inability to eversion of the foot and cavus foot varus
Important thickening of both peroneal tendons (longus and brevis) associated
with moderate amount of fluid and thickening of the synovial sheath
Discreet amount of fluid in the common sheath of the peroneal tendons
associated with disorganization and a heterogeneous appearance
peroneus brevis tendon related to longitudinal rupture
Peroneal tenosynovitis and osteosynthesis
Tenosynovitis of the peroneal tendons and an intratendinous rupture of the short peroneal tendon
Intratendinous rupture and cyst in the peroneus brevis tendon
Peroneus quartus with an accessory muscle next to the peroneus longus and brevis tendons
Tumor next to the peroneal tendons that proved to be a benign fibrous mass
MEDIAL COMPARTMENT
ANOMALIES POSTERIOR TIBIAL TENDON (TP)
It is the most frequently injured in this compartment with ruptures
in asymptomatic middle-aged obese women as a result of
widespread disease (RA seronegative Spondyloarthropathy) or
associated with bone fractures It causes a gradual collapse of the
medial longitudinal arch with hindfoot valgus deformity and
excessive forefoot pronation
The presence of small vessels in inflammatory diseases
intratendinosis can simulate a fissuration tendon confusion can be ignored using colour Doppler Another possible diagnostic difficulty is when the undamaged tendon flexor digitorum longus (FLD) moves back and simulates the TP unbroken but it is smaller and in this case we only see in the groove retromalleolar 1 only tendon
Ultrasound has also proven to be an effective resource for identifying alterations associated tendon tenosynovitis serosa and hypertrophicSubluxation and dislocation anteriorly and medial TP relative to internal
malleolus is rare and valued sonographically placing the foot in dorsiflexion with forced supination
Thickening moderate amount of fluid surrounding calcifications and
hyperemia affecting the sheath and the posterior tibial tendon related
to chronic tenosynovitis in patient affects rheumatoid arthritis
Thickening moderate amount of surrounding fluid and calcifications (arrow) affecting the
posterior tibial tendon related to chronic tenosynovitis in patient affects rheumatoid arthritis
Tenosynovitis of the posterior tibial tendon caused by a bony ridge at the insertion of the retinaculum The retinaculum is thickened and the tendon subluxates
Psoriatic arthritis Ankle Grayscale examination Posterior tibial tendon on longitudinal (a) and transverse (b) scan Marked tendon sheath widening with homogeneous anechoic aspect (asterisks) of the content indicating an exudative tenosynovitis Note as the normal fibrillar echotexture is conserved Hand Flexor tendons of second finger The volar longitudinal (c) and transverse scan (d) shows a tendon sheath widening with signs of synovial proliferation presence of intense power Doppler signal surrounding the tendon and micro interruption of the margin (arrow) e Wrist Extensor carpi ulnaris tendon (sixth compartment of the extensor tendons ecu) on lateral longitudinal (e) and transverse (f) scan Chronic tenosynovitis with clear areas of low of echogenicity and loss of the continuity of tendon fibrils indicative of partial tendon tear (arrows) Moreover note the presence of power Doppler signal within the interruption indicating still activity of the inflammatory process g Dactylitis Volar longitudinal scan using the ldquoextended viewrdquo technique showing proliferative tenosynovitis of the finger flexor tendon (circle) exudative synovitis of both proximal and distal interphalangeal joint (white asterisks) and edema of the peritendinous tissue (black asterisks) TP posterior tibial tendon mm medial malleolus DP distal phalanx mp middle phalanx cu cubital bone ft flexor tendons
Tenosynovitis of the posterior tibial (1) and flexor digitorum longus tendon (2)
Tibialis Posterior Tendon rupture
Tenosynovitis of the posterior tibial tendon the flexor digitorum tendon and flexor hallucis longus tendon
Tenosynovitis of the tendons on the medial side in the left ankle
bullLIGAMENT INJURIESThe ligament partial tear ligament shows a hypoechoic
areas swollen with internal focal or diffuse In the complete
ruptures within the substance of the divided ligament rift is
observed corresponding to the hematoma hypoechoic and
the free ends of the divided ligament can be and retracted
appreciated corrugated in contrast with normal
appearance straight
Grade I Mild stretching of the ligament without breakage
or instability
Grade II Partial tearing of the ligament
Grade III Complete tearing
Degrees depending on the severity of the injury and the
place of employment
LATERAL COMPARTMENTThese injuries occur secondary to inversion sprains with internal rotation of
the foot combined with ankle plantar flexion
The anterior talar fibular ligament tears (ATFL) usually occur as isolated
involvement (70) or associated with calcaneal fibular ligament (CFL) (20-40)
but the posterior talar fibular ligament (PTFL) affects only major trauma
involving ankle dislocation
ATFL breaks is associated with breakage of the joint capsule and synovial fluid
extravasation into the anterolateral soft ankle whereas the complete tearing of
CFL can communicate the ankle joint and synovial sheath peroneal tendons
Rupture of CFL is rarely associated with superior peroneal retinaculum tear
The CFL is tensioned during dorsiflexion pulling on peroneal tendons laterally
so that absence of its displacement is sign of a complete tear
Within a damaged ligament can also observe calcifications that often
correspond to fragments of avulsion bone
During the ultrasound can be performed forced maneuvers to detect to joint
laxity and ligament injuries The anterior drawer test is performed with the feet
hanging over the edge of the examination table while the forefoot is pulled
anteriorly when the foot is in plantar flexion and inversion This maneuver
helps differentiate partial tears (grade II) of the ATFL to complete (grade III)
where the anterior displacement of the talus on the tibia open a crack in the
substance becoming more visible the ligament injury
The sindesmosys sprains are up to 10 of ankle
injuries happening in eversion and pronation
movements (like the deltoid ligament injury) and
primarily affect the anterior tibiofibular ligament (ATFL)
the failure is frequently associated with fracture of the
fibula
According to the place of employment are 4 degrees
useful for prognostic evaluation and therapeutic strategy
choice
Grade I stretch or partial tear of the ATFL
Grade II complete tearing but only the ATFL
Grade III complete tear of the ATFL and partial CFL
Grade IV complete tear of the ATFL and CFL
The grade I and II injuries usually scarred without any
significant instability whereas grade III and IV injuries
can cause chronic pain and require surgical treatment
Thickened but continued ATFL right in relation to the partial rupture
Grade 111 sprain of right ATFL
Thickened anterior talofibular ligament with calcifications and a partial rupture
Thickened tibiofibular ligament after trauma
Anterior Talofibular Ligament Partial Tear and Elastography
Tibio fibular ligament rupture with bony avulsion
Complete rupture of right ATFL
Bony avulsion with radiographic evidence as visible calcification in a grade III sprain ATFL
Moderately thickened and hypoechoic ATFL
Discontinuity of the ATFL with fluid surrounding the torn ends (arrow)
Thickening and hypoechogenicity of the fibular end of the ligament seen here passing over the subtalar joint which contains a small of fluid
Complete disruption to the tibiofibular ligament with bony irregularity of particularly the tibial margin and fluid in the gap
MEDIAL COMPARTMENTBecause of the low incidence of eversion ankle
sprains and the thickness of the deltoid ligament
is rarely injured in isolation and when the injury
does not usually full thickness Usually
accompanied by lesions of the medial malleolus
and lateral displacement of the talus with
consequent widening of the ankle mortise
Ultrasound is useful for differentiating ligament
injury of the posterior tibial tendon injury
(TP) adjacent they have similar symptoms
The inability to visualize the deltoid ligament may
indicate tear but this is not considered a reliable
sign as its full ultrasound is not always possible
Partial medial ligament rupture
Thickened heterogeneous abnormal deltoid demonstrating hyperemia
Ultrasonogram showing a disrupted deltoid ligament with the probe in the coronal plane The white arrow indicates the medial malleolus the blue arrow indicates the talus and the red arrows indicate the disrupted deltoid ligament (A) Radiograph showing the same injury (B)
bullJOINT AND BONE DISORDERSUltrasound reliably detect spills mild (gt 2 ml) inside
of the ankle joint by exploring the front and rear
recess as well as areas of synovial proliferation and
may even display using the colour Doppler
hyperemic areas in arthritis patients
The intraarticular joints are displayed surrounded
fluid in one of the recesses of the ankle or subtalar
joint Sonographically diagnosed when changing position to perform flexion and extension Fracture of the lateral process of the talus is overlooked up to 50 of cases with plain radiography Ultrasound may suspect the presence of focal cortical disruption helping further to exclude concomitant ligament injury
Rheumatoid arthritis with synovial thickening (1) and erosion of the tibia (2)
Infectious arthritis with a pus filled anterior recess of the ankle
Arthritis and tenosynovitis of the ankle in a patient with rheumatoid arthritis
bullTUMOURSUltrasound can differentiate between a mass complex
and solid and a cystic in addition to verifying the
existence of accessory muscles (peroneus fourth
accessory flexor digitorum longus and accessory
soleus) As in any other location can be found
neoformative soft tissue tumors inflammatory
infectious etc
Ganglions of this location are more often symptomatic
and larger with multiple partitions
branched and lobed edges Differential diagnosis must
be made with tenosynovitis abscesses seromas and
varicosities
Neurogenic tumours are described as pathognomonic
homogeneous hypoechoic oval mass in continuity with
a nerve of origin
Ganglion cysts are non-malignant cystic masses that occur in association with musculoskeletal structures They are sometimes also simply referred to as ganglia or a ganglion but should not be confused with the anatomical term ganglion UltrasoundThe vast majority are anechoic to hypoechoic on ultrasound and have well defined margins Many demonstrate internal septations as well as acoustic enhancement A synovial cyst is a small fluid-filled sac or pouch that can develop over a tendon or joint creating a mass under the skin Synovial cyst is rare in ankle joint A synovial cyst may or may not be painful depending on their size and location
Ganglion cyst in the foot with bony erosion between navicular and cuneiform bones
Tarsal synovial cyst
Anechoic ganglion situated in the sinus tarsi fat between the talus and calcaneous
Plantar fasciitis (PF) refers to inflammation of the
plantar fascia of the foot It is considered the most common cause of heel pain
Clinical presentation Pain on the undersurface of the heel on weight bearing is the principal complaint It can be worse when weight is borne after a period of rest (eg in the morning) and eases with walking Passive dorsiflexion of the toes may exacerbates discomfort
UltrasoundOften the initial imaging modality of choice Ultrasound typically shows increased thickness of the fascia and a hypoechoic fascia
Thickened hypoechoic origin of the plantar fascia which has a convex superior margin
Complete avulsion of the plantar fascia from the calcaneal tubercle
Plantar fasciitis
bull LOCATING FOREIGN BODIES AND FRACTURES
As in any other location the ankle
area is also subsidiary host foreign
whose classification location and
existence can be defined perfectly by
ultrasound Being a focused study to
the area of interest and with great
resolution for surface structures can
be considered more resolute
examination to screen these cases
Osseous diseases and fractures | Sonography discovered Medial Malleolus Fracture
Ultrasound examination of left ankle A Longitudinal sonogram left ankle demonstrates a wooden foreign body B Transverse view left ankle Note the hypervascularity in the inflamed area C Corresponding X-ray of left ankle Note the swelling on the lateral aspect No foreign body is visible
Thank You
Distal insertion tendinopathy of the anterior tibial tendon with increased vascularity
Tenosynovitis of the anterior tibial tendon with effusion
Anterior tibial tendon tenosynovitis with intratendinous ruptures
Anterior tibial tendon rupture with retraction of the tendon
Tenosynovitis of the extensor digitorum tendons with a synovial effusion
Tenosynovitis of the extensor digitorum tendon with hypervascularized thickened tendon and synovium and synovial fluid
Rheumatoid arthritis with tenosynovitis of the extensor digitorum and peroneal tendons
Thickening of the extensor hallucis longus tendon caused by osteosynthesis material
Multicystic non vascularized intramuscular mass in the extensor digitorum brevis muscle
LATERAL COMPARTMENTTENOSYNOVITIS OF THE PERONEAL TENDONSThe main sign of ultrasound is the presence of liquid inside the
common synovial sheath whereas usually tendinous
morphology is preserved We must differentiate tenosynovitis of
a spill within the common peroneal sheath secondary to a tear of
calcaneofibular ligament (PCL) The ultrasound diagnosis is the detection of the tendons in a lateral plane relative to the distal portion of the lateral malleolus instead of behind it The dynamic exploration foot dorsiflexion as both eversion may help identify cases of intermittent subluxation In long-standing disease can be observed fusiform thickening
of the peroneal tendons at the tip of the malleolus The complete tears of the peroneus brevis tendon (PC) and peroneus longus (PL) are rare occurring in the area of the lateral malleolus or midfoot Seen in patients with ankle sprains or history of chronic instability especially if they suffer widespread diseases (RA DM) or treated with corticosteroids The peroneal tendon ruptures causing the inability to eversion of the foot and cavus foot varus
Important thickening of both peroneal tendons (longus and brevis) associated
with moderate amount of fluid and thickening of the synovial sheath
Discreet amount of fluid in the common sheath of the peroneal tendons
associated with disorganization and a heterogeneous appearance
peroneus brevis tendon related to longitudinal rupture
Peroneal tenosynovitis and osteosynthesis
Tenosynovitis of the peroneal tendons and an intratendinous rupture of the short peroneal tendon
Intratendinous rupture and cyst in the peroneus brevis tendon
Peroneus quartus with an accessory muscle next to the peroneus longus and brevis tendons
Tumor next to the peroneal tendons that proved to be a benign fibrous mass
MEDIAL COMPARTMENT
ANOMALIES POSTERIOR TIBIAL TENDON (TP)
It is the most frequently injured in this compartment with ruptures
in asymptomatic middle-aged obese women as a result of
widespread disease (RA seronegative Spondyloarthropathy) or
associated with bone fractures It causes a gradual collapse of the
medial longitudinal arch with hindfoot valgus deformity and
excessive forefoot pronation
The presence of small vessels in inflammatory diseases
intratendinosis can simulate a fissuration tendon confusion can be ignored using colour Doppler Another possible diagnostic difficulty is when the undamaged tendon flexor digitorum longus (FLD) moves back and simulates the TP unbroken but it is smaller and in this case we only see in the groove retromalleolar 1 only tendon
Ultrasound has also proven to be an effective resource for identifying alterations associated tendon tenosynovitis serosa and hypertrophicSubluxation and dislocation anteriorly and medial TP relative to internal
malleolus is rare and valued sonographically placing the foot in dorsiflexion with forced supination
Thickening moderate amount of fluid surrounding calcifications and
hyperemia affecting the sheath and the posterior tibial tendon related
to chronic tenosynovitis in patient affects rheumatoid arthritis
Thickening moderate amount of surrounding fluid and calcifications (arrow) affecting the
posterior tibial tendon related to chronic tenosynovitis in patient affects rheumatoid arthritis
Tenosynovitis of the posterior tibial tendon caused by a bony ridge at the insertion of the retinaculum The retinaculum is thickened and the tendon subluxates
Psoriatic arthritis Ankle Grayscale examination Posterior tibial tendon on longitudinal (a) and transverse (b) scan Marked tendon sheath widening with homogeneous anechoic aspect (asterisks) of the content indicating an exudative tenosynovitis Note as the normal fibrillar echotexture is conserved Hand Flexor tendons of second finger The volar longitudinal (c) and transverse scan (d) shows a tendon sheath widening with signs of synovial proliferation presence of intense power Doppler signal surrounding the tendon and micro interruption of the margin (arrow) e Wrist Extensor carpi ulnaris tendon (sixth compartment of the extensor tendons ecu) on lateral longitudinal (e) and transverse (f) scan Chronic tenosynovitis with clear areas of low of echogenicity and loss of the continuity of tendon fibrils indicative of partial tendon tear (arrows) Moreover note the presence of power Doppler signal within the interruption indicating still activity of the inflammatory process g Dactylitis Volar longitudinal scan using the ldquoextended viewrdquo technique showing proliferative tenosynovitis of the finger flexor tendon (circle) exudative synovitis of both proximal and distal interphalangeal joint (white asterisks) and edema of the peritendinous tissue (black asterisks) TP posterior tibial tendon mm medial malleolus DP distal phalanx mp middle phalanx cu cubital bone ft flexor tendons
Tenosynovitis of the posterior tibial (1) and flexor digitorum longus tendon (2)
Tibialis Posterior Tendon rupture
Tenosynovitis of the posterior tibial tendon the flexor digitorum tendon and flexor hallucis longus tendon
Tenosynovitis of the tendons on the medial side in the left ankle
bullLIGAMENT INJURIESThe ligament partial tear ligament shows a hypoechoic
areas swollen with internal focal or diffuse In the complete
ruptures within the substance of the divided ligament rift is
observed corresponding to the hematoma hypoechoic and
the free ends of the divided ligament can be and retracted
appreciated corrugated in contrast with normal
appearance straight
Grade I Mild stretching of the ligament without breakage
or instability
Grade II Partial tearing of the ligament
Grade III Complete tearing
Degrees depending on the severity of the injury and the
place of employment
LATERAL COMPARTMENTThese injuries occur secondary to inversion sprains with internal rotation of
the foot combined with ankle plantar flexion
The anterior talar fibular ligament tears (ATFL) usually occur as isolated
involvement (70) or associated with calcaneal fibular ligament (CFL) (20-40)
but the posterior talar fibular ligament (PTFL) affects only major trauma
involving ankle dislocation
ATFL breaks is associated with breakage of the joint capsule and synovial fluid
extravasation into the anterolateral soft ankle whereas the complete tearing of
CFL can communicate the ankle joint and synovial sheath peroneal tendons
Rupture of CFL is rarely associated with superior peroneal retinaculum tear
The CFL is tensioned during dorsiflexion pulling on peroneal tendons laterally
so that absence of its displacement is sign of a complete tear
Within a damaged ligament can also observe calcifications that often
correspond to fragments of avulsion bone
During the ultrasound can be performed forced maneuvers to detect to joint
laxity and ligament injuries The anterior drawer test is performed with the feet
hanging over the edge of the examination table while the forefoot is pulled
anteriorly when the foot is in plantar flexion and inversion This maneuver
helps differentiate partial tears (grade II) of the ATFL to complete (grade III)
where the anterior displacement of the talus on the tibia open a crack in the
substance becoming more visible the ligament injury
The sindesmosys sprains are up to 10 of ankle
injuries happening in eversion and pronation
movements (like the deltoid ligament injury) and
primarily affect the anterior tibiofibular ligament (ATFL)
the failure is frequently associated with fracture of the
fibula
According to the place of employment are 4 degrees
useful for prognostic evaluation and therapeutic strategy
choice
Grade I stretch or partial tear of the ATFL
Grade II complete tearing but only the ATFL
Grade III complete tear of the ATFL and partial CFL
Grade IV complete tear of the ATFL and CFL
The grade I and II injuries usually scarred without any
significant instability whereas grade III and IV injuries
can cause chronic pain and require surgical treatment
Thickened but continued ATFL right in relation to the partial rupture
Grade 111 sprain of right ATFL
Thickened anterior talofibular ligament with calcifications and a partial rupture
Thickened tibiofibular ligament after trauma
Anterior Talofibular Ligament Partial Tear and Elastography
Tibio fibular ligament rupture with bony avulsion
Complete rupture of right ATFL
Bony avulsion with radiographic evidence as visible calcification in a grade III sprain ATFL
Moderately thickened and hypoechoic ATFL
Discontinuity of the ATFL with fluid surrounding the torn ends (arrow)
Thickening and hypoechogenicity of the fibular end of the ligament seen here passing over the subtalar joint which contains a small of fluid
Complete disruption to the tibiofibular ligament with bony irregularity of particularly the tibial margin and fluid in the gap
MEDIAL COMPARTMENTBecause of the low incidence of eversion ankle
sprains and the thickness of the deltoid ligament
is rarely injured in isolation and when the injury
does not usually full thickness Usually
accompanied by lesions of the medial malleolus
and lateral displacement of the talus with
consequent widening of the ankle mortise
Ultrasound is useful for differentiating ligament
injury of the posterior tibial tendon injury
(TP) adjacent they have similar symptoms
The inability to visualize the deltoid ligament may
indicate tear but this is not considered a reliable
sign as its full ultrasound is not always possible
Partial medial ligament rupture
Thickened heterogeneous abnormal deltoid demonstrating hyperemia
Ultrasonogram showing a disrupted deltoid ligament with the probe in the coronal plane The white arrow indicates the medial malleolus the blue arrow indicates the talus and the red arrows indicate the disrupted deltoid ligament (A) Radiograph showing the same injury (B)
bullJOINT AND BONE DISORDERSUltrasound reliably detect spills mild (gt 2 ml) inside
of the ankle joint by exploring the front and rear
recess as well as areas of synovial proliferation and
may even display using the colour Doppler
hyperemic areas in arthritis patients
The intraarticular joints are displayed surrounded
fluid in one of the recesses of the ankle or subtalar
joint Sonographically diagnosed when changing position to perform flexion and extension Fracture of the lateral process of the talus is overlooked up to 50 of cases with plain radiography Ultrasound may suspect the presence of focal cortical disruption helping further to exclude concomitant ligament injury
Rheumatoid arthritis with synovial thickening (1) and erosion of the tibia (2)
Infectious arthritis with a pus filled anterior recess of the ankle
Arthritis and tenosynovitis of the ankle in a patient with rheumatoid arthritis
bullTUMOURSUltrasound can differentiate between a mass complex
and solid and a cystic in addition to verifying the
existence of accessory muscles (peroneus fourth
accessory flexor digitorum longus and accessory
soleus) As in any other location can be found
neoformative soft tissue tumors inflammatory
infectious etc
Ganglions of this location are more often symptomatic
and larger with multiple partitions
branched and lobed edges Differential diagnosis must
be made with tenosynovitis abscesses seromas and
varicosities
Neurogenic tumours are described as pathognomonic
homogeneous hypoechoic oval mass in continuity with
a nerve of origin
Ganglion cysts are non-malignant cystic masses that occur in association with musculoskeletal structures They are sometimes also simply referred to as ganglia or a ganglion but should not be confused with the anatomical term ganglion UltrasoundThe vast majority are anechoic to hypoechoic on ultrasound and have well defined margins Many demonstrate internal septations as well as acoustic enhancement A synovial cyst is a small fluid-filled sac or pouch that can develop over a tendon or joint creating a mass under the skin Synovial cyst is rare in ankle joint A synovial cyst may or may not be painful depending on their size and location
Ganglion cyst in the foot with bony erosion between navicular and cuneiform bones
Tarsal synovial cyst
Anechoic ganglion situated in the sinus tarsi fat between the talus and calcaneous
Plantar fasciitis (PF) refers to inflammation of the
plantar fascia of the foot It is considered the most common cause of heel pain
Clinical presentation Pain on the undersurface of the heel on weight bearing is the principal complaint It can be worse when weight is borne after a period of rest (eg in the morning) and eases with walking Passive dorsiflexion of the toes may exacerbates discomfort
UltrasoundOften the initial imaging modality of choice Ultrasound typically shows increased thickness of the fascia and a hypoechoic fascia
Thickened hypoechoic origin of the plantar fascia which has a convex superior margin
Complete avulsion of the plantar fascia from the calcaneal tubercle
Plantar fasciitis
bull LOCATING FOREIGN BODIES AND FRACTURES
As in any other location the ankle
area is also subsidiary host foreign
whose classification location and
existence can be defined perfectly by
ultrasound Being a focused study to
the area of interest and with great
resolution for surface structures can
be considered more resolute
examination to screen these cases
Osseous diseases and fractures | Sonography discovered Medial Malleolus Fracture
Ultrasound examination of left ankle A Longitudinal sonogram left ankle demonstrates a wooden foreign body B Transverse view left ankle Note the hypervascularity in the inflamed area C Corresponding X-ray of left ankle Note the swelling on the lateral aspect No foreign body is visible
Thank You
Tenosynovitis of the anterior tibial tendon with effusion
Anterior tibial tendon tenosynovitis with intratendinous ruptures
Anterior tibial tendon rupture with retraction of the tendon
Tenosynovitis of the extensor digitorum tendons with a synovial effusion
Tenosynovitis of the extensor digitorum tendon with hypervascularized thickened tendon and synovium and synovial fluid
Rheumatoid arthritis with tenosynovitis of the extensor digitorum and peroneal tendons
Thickening of the extensor hallucis longus tendon caused by osteosynthesis material
Multicystic non vascularized intramuscular mass in the extensor digitorum brevis muscle
LATERAL COMPARTMENTTENOSYNOVITIS OF THE PERONEAL TENDONSThe main sign of ultrasound is the presence of liquid inside the
common synovial sheath whereas usually tendinous
morphology is preserved We must differentiate tenosynovitis of
a spill within the common peroneal sheath secondary to a tear of
calcaneofibular ligament (PCL) The ultrasound diagnosis is the detection of the tendons in a lateral plane relative to the distal portion of the lateral malleolus instead of behind it The dynamic exploration foot dorsiflexion as both eversion may help identify cases of intermittent subluxation In long-standing disease can be observed fusiform thickening
of the peroneal tendons at the tip of the malleolus The complete tears of the peroneus brevis tendon (PC) and peroneus longus (PL) are rare occurring in the area of the lateral malleolus or midfoot Seen in patients with ankle sprains or history of chronic instability especially if they suffer widespread diseases (RA DM) or treated with corticosteroids The peroneal tendon ruptures causing the inability to eversion of the foot and cavus foot varus
Important thickening of both peroneal tendons (longus and brevis) associated
with moderate amount of fluid and thickening of the synovial sheath
Discreet amount of fluid in the common sheath of the peroneal tendons
associated with disorganization and a heterogeneous appearance
peroneus brevis tendon related to longitudinal rupture
Peroneal tenosynovitis and osteosynthesis
Tenosynovitis of the peroneal tendons and an intratendinous rupture of the short peroneal tendon
Intratendinous rupture and cyst in the peroneus brevis tendon
Peroneus quartus with an accessory muscle next to the peroneus longus and brevis tendons
Tumor next to the peroneal tendons that proved to be a benign fibrous mass
MEDIAL COMPARTMENT
ANOMALIES POSTERIOR TIBIAL TENDON (TP)
It is the most frequently injured in this compartment with ruptures
in asymptomatic middle-aged obese women as a result of
widespread disease (RA seronegative Spondyloarthropathy) or
associated with bone fractures It causes a gradual collapse of the
medial longitudinal arch with hindfoot valgus deformity and
excessive forefoot pronation
The presence of small vessels in inflammatory diseases
intratendinosis can simulate a fissuration tendon confusion can be ignored using colour Doppler Another possible diagnostic difficulty is when the undamaged tendon flexor digitorum longus (FLD) moves back and simulates the TP unbroken but it is smaller and in this case we only see in the groove retromalleolar 1 only tendon
Ultrasound has also proven to be an effective resource for identifying alterations associated tendon tenosynovitis serosa and hypertrophicSubluxation and dislocation anteriorly and medial TP relative to internal
malleolus is rare and valued sonographically placing the foot in dorsiflexion with forced supination
Thickening moderate amount of fluid surrounding calcifications and
hyperemia affecting the sheath and the posterior tibial tendon related
to chronic tenosynovitis in patient affects rheumatoid arthritis
Thickening moderate amount of surrounding fluid and calcifications (arrow) affecting the
posterior tibial tendon related to chronic tenosynovitis in patient affects rheumatoid arthritis
Tenosynovitis of the posterior tibial tendon caused by a bony ridge at the insertion of the retinaculum The retinaculum is thickened and the tendon subluxates
Psoriatic arthritis Ankle Grayscale examination Posterior tibial tendon on longitudinal (a) and transverse (b) scan Marked tendon sheath widening with homogeneous anechoic aspect (asterisks) of the content indicating an exudative tenosynovitis Note as the normal fibrillar echotexture is conserved Hand Flexor tendons of second finger The volar longitudinal (c) and transverse scan (d) shows a tendon sheath widening with signs of synovial proliferation presence of intense power Doppler signal surrounding the tendon and micro interruption of the margin (arrow) e Wrist Extensor carpi ulnaris tendon (sixth compartment of the extensor tendons ecu) on lateral longitudinal (e) and transverse (f) scan Chronic tenosynovitis with clear areas of low of echogenicity and loss of the continuity of tendon fibrils indicative of partial tendon tear (arrows) Moreover note the presence of power Doppler signal within the interruption indicating still activity of the inflammatory process g Dactylitis Volar longitudinal scan using the ldquoextended viewrdquo technique showing proliferative tenosynovitis of the finger flexor tendon (circle) exudative synovitis of both proximal and distal interphalangeal joint (white asterisks) and edema of the peritendinous tissue (black asterisks) TP posterior tibial tendon mm medial malleolus DP distal phalanx mp middle phalanx cu cubital bone ft flexor tendons
Tenosynovitis of the posterior tibial (1) and flexor digitorum longus tendon (2)
Tibialis Posterior Tendon rupture
Tenosynovitis of the posterior tibial tendon the flexor digitorum tendon and flexor hallucis longus tendon
Tenosynovitis of the tendons on the medial side in the left ankle
bullLIGAMENT INJURIESThe ligament partial tear ligament shows a hypoechoic
areas swollen with internal focal or diffuse In the complete
ruptures within the substance of the divided ligament rift is
observed corresponding to the hematoma hypoechoic and
the free ends of the divided ligament can be and retracted
appreciated corrugated in contrast with normal
appearance straight
Grade I Mild stretching of the ligament without breakage
or instability
Grade II Partial tearing of the ligament
Grade III Complete tearing
Degrees depending on the severity of the injury and the
place of employment
LATERAL COMPARTMENTThese injuries occur secondary to inversion sprains with internal rotation of
the foot combined with ankle plantar flexion
The anterior talar fibular ligament tears (ATFL) usually occur as isolated
involvement (70) or associated with calcaneal fibular ligament (CFL) (20-40)
but the posterior talar fibular ligament (PTFL) affects only major trauma
involving ankle dislocation
ATFL breaks is associated with breakage of the joint capsule and synovial fluid
extravasation into the anterolateral soft ankle whereas the complete tearing of
CFL can communicate the ankle joint and synovial sheath peroneal tendons
Rupture of CFL is rarely associated with superior peroneal retinaculum tear
The CFL is tensioned during dorsiflexion pulling on peroneal tendons laterally
so that absence of its displacement is sign of a complete tear
Within a damaged ligament can also observe calcifications that often
correspond to fragments of avulsion bone
During the ultrasound can be performed forced maneuvers to detect to joint
laxity and ligament injuries The anterior drawer test is performed with the feet
hanging over the edge of the examination table while the forefoot is pulled
anteriorly when the foot is in plantar flexion and inversion This maneuver
helps differentiate partial tears (grade II) of the ATFL to complete (grade III)
where the anterior displacement of the talus on the tibia open a crack in the
substance becoming more visible the ligament injury
The sindesmosys sprains are up to 10 of ankle
injuries happening in eversion and pronation
movements (like the deltoid ligament injury) and
primarily affect the anterior tibiofibular ligament (ATFL)
the failure is frequently associated with fracture of the
fibula
According to the place of employment are 4 degrees
useful for prognostic evaluation and therapeutic strategy
choice
Grade I stretch or partial tear of the ATFL
Grade II complete tearing but only the ATFL
Grade III complete tear of the ATFL and partial CFL
Grade IV complete tear of the ATFL and CFL
The grade I and II injuries usually scarred without any
significant instability whereas grade III and IV injuries
can cause chronic pain and require surgical treatment
Thickened but continued ATFL right in relation to the partial rupture
Grade 111 sprain of right ATFL
Thickened anterior talofibular ligament with calcifications and a partial rupture
Thickened tibiofibular ligament after trauma
Anterior Talofibular Ligament Partial Tear and Elastography
Tibio fibular ligament rupture with bony avulsion
Complete rupture of right ATFL
Bony avulsion with radiographic evidence as visible calcification in a grade III sprain ATFL
Moderately thickened and hypoechoic ATFL
Discontinuity of the ATFL with fluid surrounding the torn ends (arrow)
Thickening and hypoechogenicity of the fibular end of the ligament seen here passing over the subtalar joint which contains a small of fluid
Complete disruption to the tibiofibular ligament with bony irregularity of particularly the tibial margin and fluid in the gap
MEDIAL COMPARTMENTBecause of the low incidence of eversion ankle
sprains and the thickness of the deltoid ligament
is rarely injured in isolation and when the injury
does not usually full thickness Usually
accompanied by lesions of the medial malleolus
and lateral displacement of the talus with
consequent widening of the ankle mortise
Ultrasound is useful for differentiating ligament
injury of the posterior tibial tendon injury
(TP) adjacent they have similar symptoms
The inability to visualize the deltoid ligament may
indicate tear but this is not considered a reliable
sign as its full ultrasound is not always possible
Partial medial ligament rupture
Thickened heterogeneous abnormal deltoid demonstrating hyperemia
Ultrasonogram showing a disrupted deltoid ligament with the probe in the coronal plane The white arrow indicates the medial malleolus the blue arrow indicates the talus and the red arrows indicate the disrupted deltoid ligament (A) Radiograph showing the same injury (B)
bullJOINT AND BONE DISORDERSUltrasound reliably detect spills mild (gt 2 ml) inside
of the ankle joint by exploring the front and rear
recess as well as areas of synovial proliferation and
may even display using the colour Doppler
hyperemic areas in arthritis patients
The intraarticular joints are displayed surrounded
fluid in one of the recesses of the ankle or subtalar
joint Sonographically diagnosed when changing position to perform flexion and extension Fracture of the lateral process of the talus is overlooked up to 50 of cases with plain radiography Ultrasound may suspect the presence of focal cortical disruption helping further to exclude concomitant ligament injury
Rheumatoid arthritis with synovial thickening (1) and erosion of the tibia (2)
Infectious arthritis with a pus filled anterior recess of the ankle
Arthritis and tenosynovitis of the ankle in a patient with rheumatoid arthritis
bullTUMOURSUltrasound can differentiate between a mass complex
and solid and a cystic in addition to verifying the
existence of accessory muscles (peroneus fourth
accessory flexor digitorum longus and accessory
soleus) As in any other location can be found
neoformative soft tissue tumors inflammatory
infectious etc
Ganglions of this location are more often symptomatic
and larger with multiple partitions
branched and lobed edges Differential diagnosis must
be made with tenosynovitis abscesses seromas and
varicosities
Neurogenic tumours are described as pathognomonic
homogeneous hypoechoic oval mass in continuity with
a nerve of origin
Ganglion cysts are non-malignant cystic masses that occur in association with musculoskeletal structures They are sometimes also simply referred to as ganglia or a ganglion but should not be confused with the anatomical term ganglion UltrasoundThe vast majority are anechoic to hypoechoic on ultrasound and have well defined margins Many demonstrate internal septations as well as acoustic enhancement A synovial cyst is a small fluid-filled sac or pouch that can develop over a tendon or joint creating a mass under the skin Synovial cyst is rare in ankle joint A synovial cyst may or may not be painful depending on their size and location
Ganglion cyst in the foot with bony erosion between navicular and cuneiform bones
Tarsal synovial cyst
Anechoic ganglion situated in the sinus tarsi fat between the talus and calcaneous
Plantar fasciitis (PF) refers to inflammation of the
plantar fascia of the foot It is considered the most common cause of heel pain
Clinical presentation Pain on the undersurface of the heel on weight bearing is the principal complaint It can be worse when weight is borne after a period of rest (eg in the morning) and eases with walking Passive dorsiflexion of the toes may exacerbates discomfort
UltrasoundOften the initial imaging modality of choice Ultrasound typically shows increased thickness of the fascia and a hypoechoic fascia
Thickened hypoechoic origin of the plantar fascia which has a convex superior margin
Complete avulsion of the plantar fascia from the calcaneal tubercle
Plantar fasciitis
bull LOCATING FOREIGN BODIES AND FRACTURES
As in any other location the ankle
area is also subsidiary host foreign
whose classification location and
existence can be defined perfectly by
ultrasound Being a focused study to
the area of interest and with great
resolution for surface structures can
be considered more resolute
examination to screen these cases
Osseous diseases and fractures | Sonography discovered Medial Malleolus Fracture
Ultrasound examination of left ankle A Longitudinal sonogram left ankle demonstrates a wooden foreign body B Transverse view left ankle Note the hypervascularity in the inflamed area C Corresponding X-ray of left ankle Note the swelling on the lateral aspect No foreign body is visible
Thank You
Anterior tibial tendon tenosynovitis with intratendinous ruptures
Anterior tibial tendon rupture with retraction of the tendon
Tenosynovitis of the extensor digitorum tendons with a synovial effusion
Tenosynovitis of the extensor digitorum tendon with hypervascularized thickened tendon and synovium and synovial fluid
Rheumatoid arthritis with tenosynovitis of the extensor digitorum and peroneal tendons
Thickening of the extensor hallucis longus tendon caused by osteosynthesis material
Multicystic non vascularized intramuscular mass in the extensor digitorum brevis muscle
LATERAL COMPARTMENTTENOSYNOVITIS OF THE PERONEAL TENDONSThe main sign of ultrasound is the presence of liquid inside the
common synovial sheath whereas usually tendinous
morphology is preserved We must differentiate tenosynovitis of
a spill within the common peroneal sheath secondary to a tear of
calcaneofibular ligament (PCL) The ultrasound diagnosis is the detection of the tendons in a lateral plane relative to the distal portion of the lateral malleolus instead of behind it The dynamic exploration foot dorsiflexion as both eversion may help identify cases of intermittent subluxation In long-standing disease can be observed fusiform thickening
of the peroneal tendons at the tip of the malleolus The complete tears of the peroneus brevis tendon (PC) and peroneus longus (PL) are rare occurring in the area of the lateral malleolus or midfoot Seen in patients with ankle sprains or history of chronic instability especially if they suffer widespread diseases (RA DM) or treated with corticosteroids The peroneal tendon ruptures causing the inability to eversion of the foot and cavus foot varus
Important thickening of both peroneal tendons (longus and brevis) associated
with moderate amount of fluid and thickening of the synovial sheath
Discreet amount of fluid in the common sheath of the peroneal tendons
associated with disorganization and a heterogeneous appearance
peroneus brevis tendon related to longitudinal rupture
Peroneal tenosynovitis and osteosynthesis
Tenosynovitis of the peroneal tendons and an intratendinous rupture of the short peroneal tendon
Intratendinous rupture and cyst in the peroneus brevis tendon
Peroneus quartus with an accessory muscle next to the peroneus longus and brevis tendons
Tumor next to the peroneal tendons that proved to be a benign fibrous mass
MEDIAL COMPARTMENT
ANOMALIES POSTERIOR TIBIAL TENDON (TP)
It is the most frequently injured in this compartment with ruptures
in asymptomatic middle-aged obese women as a result of
widespread disease (RA seronegative Spondyloarthropathy) or
associated with bone fractures It causes a gradual collapse of the
medial longitudinal arch with hindfoot valgus deformity and
excessive forefoot pronation
The presence of small vessels in inflammatory diseases
intratendinosis can simulate a fissuration tendon confusion can be ignored using colour Doppler Another possible diagnostic difficulty is when the undamaged tendon flexor digitorum longus (FLD) moves back and simulates the TP unbroken but it is smaller and in this case we only see in the groove retromalleolar 1 only tendon
Ultrasound has also proven to be an effective resource for identifying alterations associated tendon tenosynovitis serosa and hypertrophicSubluxation and dislocation anteriorly and medial TP relative to internal
malleolus is rare and valued sonographically placing the foot in dorsiflexion with forced supination
Thickening moderate amount of fluid surrounding calcifications and
hyperemia affecting the sheath and the posterior tibial tendon related
to chronic tenosynovitis in patient affects rheumatoid arthritis
Thickening moderate amount of surrounding fluid and calcifications (arrow) affecting the
posterior tibial tendon related to chronic tenosynovitis in patient affects rheumatoid arthritis
Tenosynovitis of the posterior tibial tendon caused by a bony ridge at the insertion of the retinaculum The retinaculum is thickened and the tendon subluxates
Psoriatic arthritis Ankle Grayscale examination Posterior tibial tendon on longitudinal (a) and transverse (b) scan Marked tendon sheath widening with homogeneous anechoic aspect (asterisks) of the content indicating an exudative tenosynovitis Note as the normal fibrillar echotexture is conserved Hand Flexor tendons of second finger The volar longitudinal (c) and transverse scan (d) shows a tendon sheath widening with signs of synovial proliferation presence of intense power Doppler signal surrounding the tendon and micro interruption of the margin (arrow) e Wrist Extensor carpi ulnaris tendon (sixth compartment of the extensor tendons ecu) on lateral longitudinal (e) and transverse (f) scan Chronic tenosynovitis with clear areas of low of echogenicity and loss of the continuity of tendon fibrils indicative of partial tendon tear (arrows) Moreover note the presence of power Doppler signal within the interruption indicating still activity of the inflammatory process g Dactylitis Volar longitudinal scan using the ldquoextended viewrdquo technique showing proliferative tenosynovitis of the finger flexor tendon (circle) exudative synovitis of both proximal and distal interphalangeal joint (white asterisks) and edema of the peritendinous tissue (black asterisks) TP posterior tibial tendon mm medial malleolus DP distal phalanx mp middle phalanx cu cubital bone ft flexor tendons
Tenosynovitis of the posterior tibial (1) and flexor digitorum longus tendon (2)
Tibialis Posterior Tendon rupture
Tenosynovitis of the posterior tibial tendon the flexor digitorum tendon and flexor hallucis longus tendon
Tenosynovitis of the tendons on the medial side in the left ankle
bullLIGAMENT INJURIESThe ligament partial tear ligament shows a hypoechoic
areas swollen with internal focal or diffuse In the complete
ruptures within the substance of the divided ligament rift is
observed corresponding to the hematoma hypoechoic and
the free ends of the divided ligament can be and retracted
appreciated corrugated in contrast with normal
appearance straight
Grade I Mild stretching of the ligament without breakage
or instability
Grade II Partial tearing of the ligament
Grade III Complete tearing
Degrees depending on the severity of the injury and the
place of employment
LATERAL COMPARTMENTThese injuries occur secondary to inversion sprains with internal rotation of
the foot combined with ankle plantar flexion
The anterior talar fibular ligament tears (ATFL) usually occur as isolated
involvement (70) or associated with calcaneal fibular ligament (CFL) (20-40)
but the posterior talar fibular ligament (PTFL) affects only major trauma
involving ankle dislocation
ATFL breaks is associated with breakage of the joint capsule and synovial fluid
extravasation into the anterolateral soft ankle whereas the complete tearing of
CFL can communicate the ankle joint and synovial sheath peroneal tendons
Rupture of CFL is rarely associated with superior peroneal retinaculum tear
The CFL is tensioned during dorsiflexion pulling on peroneal tendons laterally
so that absence of its displacement is sign of a complete tear
Within a damaged ligament can also observe calcifications that often
correspond to fragments of avulsion bone
During the ultrasound can be performed forced maneuvers to detect to joint
laxity and ligament injuries The anterior drawer test is performed with the feet
hanging over the edge of the examination table while the forefoot is pulled
anteriorly when the foot is in plantar flexion and inversion This maneuver
helps differentiate partial tears (grade II) of the ATFL to complete (grade III)
where the anterior displacement of the talus on the tibia open a crack in the
substance becoming more visible the ligament injury
The sindesmosys sprains are up to 10 of ankle
injuries happening in eversion and pronation
movements (like the deltoid ligament injury) and
primarily affect the anterior tibiofibular ligament (ATFL)
the failure is frequently associated with fracture of the
fibula
According to the place of employment are 4 degrees
useful for prognostic evaluation and therapeutic strategy
choice
Grade I stretch or partial tear of the ATFL
Grade II complete tearing but only the ATFL
Grade III complete tear of the ATFL and partial CFL
Grade IV complete tear of the ATFL and CFL
The grade I and II injuries usually scarred without any
significant instability whereas grade III and IV injuries
can cause chronic pain and require surgical treatment
Thickened but continued ATFL right in relation to the partial rupture
Grade 111 sprain of right ATFL
Thickened anterior talofibular ligament with calcifications and a partial rupture
Thickened tibiofibular ligament after trauma
Anterior Talofibular Ligament Partial Tear and Elastography
Tibio fibular ligament rupture with bony avulsion
Complete rupture of right ATFL
Bony avulsion with radiographic evidence as visible calcification in a grade III sprain ATFL
Moderately thickened and hypoechoic ATFL
Discontinuity of the ATFL with fluid surrounding the torn ends (arrow)
Thickening and hypoechogenicity of the fibular end of the ligament seen here passing over the subtalar joint which contains a small of fluid
Complete disruption to the tibiofibular ligament with bony irregularity of particularly the tibial margin and fluid in the gap
MEDIAL COMPARTMENTBecause of the low incidence of eversion ankle
sprains and the thickness of the deltoid ligament
is rarely injured in isolation and when the injury
does not usually full thickness Usually
accompanied by lesions of the medial malleolus
and lateral displacement of the talus with
consequent widening of the ankle mortise
Ultrasound is useful for differentiating ligament
injury of the posterior tibial tendon injury
(TP) adjacent they have similar symptoms
The inability to visualize the deltoid ligament may
indicate tear but this is not considered a reliable
sign as its full ultrasound is not always possible
Partial medial ligament rupture
Thickened heterogeneous abnormal deltoid demonstrating hyperemia
Ultrasonogram showing a disrupted deltoid ligament with the probe in the coronal plane The white arrow indicates the medial malleolus the blue arrow indicates the talus and the red arrows indicate the disrupted deltoid ligament (A) Radiograph showing the same injury (B)
bullJOINT AND BONE DISORDERSUltrasound reliably detect spills mild (gt 2 ml) inside
of the ankle joint by exploring the front and rear
recess as well as areas of synovial proliferation and
may even display using the colour Doppler
hyperemic areas in arthritis patients
The intraarticular joints are displayed surrounded
fluid in one of the recesses of the ankle or subtalar
joint Sonographically diagnosed when changing position to perform flexion and extension Fracture of the lateral process of the talus is overlooked up to 50 of cases with plain radiography Ultrasound may suspect the presence of focal cortical disruption helping further to exclude concomitant ligament injury
Rheumatoid arthritis with synovial thickening (1) and erosion of the tibia (2)
Infectious arthritis with a pus filled anterior recess of the ankle
Arthritis and tenosynovitis of the ankle in a patient with rheumatoid arthritis
bullTUMOURSUltrasound can differentiate between a mass complex
and solid and a cystic in addition to verifying the
existence of accessory muscles (peroneus fourth
accessory flexor digitorum longus and accessory
soleus) As in any other location can be found
neoformative soft tissue tumors inflammatory
infectious etc
Ganglions of this location are more often symptomatic
and larger with multiple partitions
branched and lobed edges Differential diagnosis must
be made with tenosynovitis abscesses seromas and
varicosities
Neurogenic tumours are described as pathognomonic
homogeneous hypoechoic oval mass in continuity with
a nerve of origin
Ganglion cysts are non-malignant cystic masses that occur in association with musculoskeletal structures They are sometimes also simply referred to as ganglia or a ganglion but should not be confused with the anatomical term ganglion UltrasoundThe vast majority are anechoic to hypoechoic on ultrasound and have well defined margins Many demonstrate internal septations as well as acoustic enhancement A synovial cyst is a small fluid-filled sac or pouch that can develop over a tendon or joint creating a mass under the skin Synovial cyst is rare in ankle joint A synovial cyst may or may not be painful depending on their size and location
Ganglion cyst in the foot with bony erosion between navicular and cuneiform bones
Tarsal synovial cyst
Anechoic ganglion situated in the sinus tarsi fat between the talus and calcaneous
Plantar fasciitis (PF) refers to inflammation of the
plantar fascia of the foot It is considered the most common cause of heel pain
Clinical presentation Pain on the undersurface of the heel on weight bearing is the principal complaint It can be worse when weight is borne after a period of rest (eg in the morning) and eases with walking Passive dorsiflexion of the toes may exacerbates discomfort
UltrasoundOften the initial imaging modality of choice Ultrasound typically shows increased thickness of the fascia and a hypoechoic fascia
Thickened hypoechoic origin of the plantar fascia which has a convex superior margin
Complete avulsion of the plantar fascia from the calcaneal tubercle
Plantar fasciitis
bull LOCATING FOREIGN BODIES AND FRACTURES
As in any other location the ankle
area is also subsidiary host foreign
whose classification location and
existence can be defined perfectly by
ultrasound Being a focused study to
the area of interest and with great
resolution for surface structures can
be considered more resolute
examination to screen these cases
Osseous diseases and fractures | Sonography discovered Medial Malleolus Fracture
Ultrasound examination of left ankle A Longitudinal sonogram left ankle demonstrates a wooden foreign body B Transverse view left ankle Note the hypervascularity in the inflamed area C Corresponding X-ray of left ankle Note the swelling on the lateral aspect No foreign body is visible
Thank You
Anterior tibial tendon rupture with retraction of the tendon
Tenosynovitis of the extensor digitorum tendons with a synovial effusion
Tenosynovitis of the extensor digitorum tendon with hypervascularized thickened tendon and synovium and synovial fluid
Rheumatoid arthritis with tenosynovitis of the extensor digitorum and peroneal tendons
Thickening of the extensor hallucis longus tendon caused by osteosynthesis material
Multicystic non vascularized intramuscular mass in the extensor digitorum brevis muscle
LATERAL COMPARTMENTTENOSYNOVITIS OF THE PERONEAL TENDONSThe main sign of ultrasound is the presence of liquid inside the
common synovial sheath whereas usually tendinous
morphology is preserved We must differentiate tenosynovitis of
a spill within the common peroneal sheath secondary to a tear of
calcaneofibular ligament (PCL) The ultrasound diagnosis is the detection of the tendons in a lateral plane relative to the distal portion of the lateral malleolus instead of behind it The dynamic exploration foot dorsiflexion as both eversion may help identify cases of intermittent subluxation In long-standing disease can be observed fusiform thickening
of the peroneal tendons at the tip of the malleolus The complete tears of the peroneus brevis tendon (PC) and peroneus longus (PL) are rare occurring in the area of the lateral malleolus or midfoot Seen in patients with ankle sprains or history of chronic instability especially if they suffer widespread diseases (RA DM) or treated with corticosteroids The peroneal tendon ruptures causing the inability to eversion of the foot and cavus foot varus
Important thickening of both peroneal tendons (longus and brevis) associated
with moderate amount of fluid and thickening of the synovial sheath
Discreet amount of fluid in the common sheath of the peroneal tendons
associated with disorganization and a heterogeneous appearance
peroneus brevis tendon related to longitudinal rupture
Peroneal tenosynovitis and osteosynthesis
Tenosynovitis of the peroneal tendons and an intratendinous rupture of the short peroneal tendon
Intratendinous rupture and cyst in the peroneus brevis tendon
Peroneus quartus with an accessory muscle next to the peroneus longus and brevis tendons
Tumor next to the peroneal tendons that proved to be a benign fibrous mass
MEDIAL COMPARTMENT
ANOMALIES POSTERIOR TIBIAL TENDON (TP)
It is the most frequently injured in this compartment with ruptures
in asymptomatic middle-aged obese women as a result of
widespread disease (RA seronegative Spondyloarthropathy) or
associated with bone fractures It causes a gradual collapse of the
medial longitudinal arch with hindfoot valgus deformity and
excessive forefoot pronation
The presence of small vessels in inflammatory diseases
intratendinosis can simulate a fissuration tendon confusion can be ignored using colour Doppler Another possible diagnostic difficulty is when the undamaged tendon flexor digitorum longus (FLD) moves back and simulates the TP unbroken but it is smaller and in this case we only see in the groove retromalleolar 1 only tendon
Ultrasound has also proven to be an effective resource for identifying alterations associated tendon tenosynovitis serosa and hypertrophicSubluxation and dislocation anteriorly and medial TP relative to internal
malleolus is rare and valued sonographically placing the foot in dorsiflexion with forced supination
Thickening moderate amount of fluid surrounding calcifications and
hyperemia affecting the sheath and the posterior tibial tendon related
to chronic tenosynovitis in patient affects rheumatoid arthritis
Thickening moderate amount of surrounding fluid and calcifications (arrow) affecting the
posterior tibial tendon related to chronic tenosynovitis in patient affects rheumatoid arthritis
Tenosynovitis of the posterior tibial tendon caused by a bony ridge at the insertion of the retinaculum The retinaculum is thickened and the tendon subluxates
Psoriatic arthritis Ankle Grayscale examination Posterior tibial tendon on longitudinal (a) and transverse (b) scan Marked tendon sheath widening with homogeneous anechoic aspect (asterisks) of the content indicating an exudative tenosynovitis Note as the normal fibrillar echotexture is conserved Hand Flexor tendons of second finger The volar longitudinal (c) and transverse scan (d) shows a tendon sheath widening with signs of synovial proliferation presence of intense power Doppler signal surrounding the tendon and micro interruption of the margin (arrow) e Wrist Extensor carpi ulnaris tendon (sixth compartment of the extensor tendons ecu) on lateral longitudinal (e) and transverse (f) scan Chronic tenosynovitis with clear areas of low of echogenicity and loss of the continuity of tendon fibrils indicative of partial tendon tear (arrows) Moreover note the presence of power Doppler signal within the interruption indicating still activity of the inflammatory process g Dactylitis Volar longitudinal scan using the ldquoextended viewrdquo technique showing proliferative tenosynovitis of the finger flexor tendon (circle) exudative synovitis of both proximal and distal interphalangeal joint (white asterisks) and edema of the peritendinous tissue (black asterisks) TP posterior tibial tendon mm medial malleolus DP distal phalanx mp middle phalanx cu cubital bone ft flexor tendons
Tenosynovitis of the posterior tibial (1) and flexor digitorum longus tendon (2)
Tibialis Posterior Tendon rupture
Tenosynovitis of the posterior tibial tendon the flexor digitorum tendon and flexor hallucis longus tendon
Tenosynovitis of the tendons on the medial side in the left ankle
bullLIGAMENT INJURIESThe ligament partial tear ligament shows a hypoechoic
areas swollen with internal focal or diffuse In the complete
ruptures within the substance of the divided ligament rift is
observed corresponding to the hematoma hypoechoic and
the free ends of the divided ligament can be and retracted
appreciated corrugated in contrast with normal
appearance straight
Grade I Mild stretching of the ligament without breakage
or instability
Grade II Partial tearing of the ligament
Grade III Complete tearing
Degrees depending on the severity of the injury and the
place of employment
LATERAL COMPARTMENTThese injuries occur secondary to inversion sprains with internal rotation of
the foot combined with ankle plantar flexion
The anterior talar fibular ligament tears (ATFL) usually occur as isolated
involvement (70) or associated with calcaneal fibular ligament (CFL) (20-40)
but the posterior talar fibular ligament (PTFL) affects only major trauma
involving ankle dislocation
ATFL breaks is associated with breakage of the joint capsule and synovial fluid
extravasation into the anterolateral soft ankle whereas the complete tearing of
CFL can communicate the ankle joint and synovial sheath peroneal tendons
Rupture of CFL is rarely associated with superior peroneal retinaculum tear
The CFL is tensioned during dorsiflexion pulling on peroneal tendons laterally
so that absence of its displacement is sign of a complete tear
Within a damaged ligament can also observe calcifications that often
correspond to fragments of avulsion bone
During the ultrasound can be performed forced maneuvers to detect to joint
laxity and ligament injuries The anterior drawer test is performed with the feet
hanging over the edge of the examination table while the forefoot is pulled
anteriorly when the foot is in plantar flexion and inversion This maneuver
helps differentiate partial tears (grade II) of the ATFL to complete (grade III)
where the anterior displacement of the talus on the tibia open a crack in the
substance becoming more visible the ligament injury
The sindesmosys sprains are up to 10 of ankle
injuries happening in eversion and pronation
movements (like the deltoid ligament injury) and
primarily affect the anterior tibiofibular ligament (ATFL)
the failure is frequently associated with fracture of the
fibula
According to the place of employment are 4 degrees
useful for prognostic evaluation and therapeutic strategy
choice
Grade I stretch or partial tear of the ATFL
Grade II complete tearing but only the ATFL
Grade III complete tear of the ATFL and partial CFL
Grade IV complete tear of the ATFL and CFL
The grade I and II injuries usually scarred without any
significant instability whereas grade III and IV injuries
can cause chronic pain and require surgical treatment
Thickened but continued ATFL right in relation to the partial rupture
Grade 111 sprain of right ATFL
Thickened anterior talofibular ligament with calcifications and a partial rupture
Thickened tibiofibular ligament after trauma
Anterior Talofibular Ligament Partial Tear and Elastography
Tibio fibular ligament rupture with bony avulsion
Complete rupture of right ATFL
Bony avulsion with radiographic evidence as visible calcification in a grade III sprain ATFL
Moderately thickened and hypoechoic ATFL
Discontinuity of the ATFL with fluid surrounding the torn ends (arrow)
Thickening and hypoechogenicity of the fibular end of the ligament seen here passing over the subtalar joint which contains a small of fluid
Complete disruption to the tibiofibular ligament with bony irregularity of particularly the tibial margin and fluid in the gap
MEDIAL COMPARTMENTBecause of the low incidence of eversion ankle
sprains and the thickness of the deltoid ligament
is rarely injured in isolation and when the injury
does not usually full thickness Usually
accompanied by lesions of the medial malleolus
and lateral displacement of the talus with
consequent widening of the ankle mortise
Ultrasound is useful for differentiating ligament
injury of the posterior tibial tendon injury
(TP) adjacent they have similar symptoms
The inability to visualize the deltoid ligament may
indicate tear but this is not considered a reliable
sign as its full ultrasound is not always possible
Partial medial ligament rupture
Thickened heterogeneous abnormal deltoid demonstrating hyperemia
Ultrasonogram showing a disrupted deltoid ligament with the probe in the coronal plane The white arrow indicates the medial malleolus the blue arrow indicates the talus and the red arrows indicate the disrupted deltoid ligament (A) Radiograph showing the same injury (B)
bullJOINT AND BONE DISORDERSUltrasound reliably detect spills mild (gt 2 ml) inside
of the ankle joint by exploring the front and rear
recess as well as areas of synovial proliferation and
may even display using the colour Doppler
hyperemic areas in arthritis patients
The intraarticular joints are displayed surrounded
fluid in one of the recesses of the ankle or subtalar
joint Sonographically diagnosed when changing position to perform flexion and extension Fracture of the lateral process of the talus is overlooked up to 50 of cases with plain radiography Ultrasound may suspect the presence of focal cortical disruption helping further to exclude concomitant ligament injury
Rheumatoid arthritis with synovial thickening (1) and erosion of the tibia (2)
Infectious arthritis with a pus filled anterior recess of the ankle
Arthritis and tenosynovitis of the ankle in a patient with rheumatoid arthritis
bullTUMOURSUltrasound can differentiate between a mass complex
and solid and a cystic in addition to verifying the
existence of accessory muscles (peroneus fourth
accessory flexor digitorum longus and accessory
soleus) As in any other location can be found
neoformative soft tissue tumors inflammatory
infectious etc
Ganglions of this location are more often symptomatic
and larger with multiple partitions
branched and lobed edges Differential diagnosis must
be made with tenosynovitis abscesses seromas and
varicosities
Neurogenic tumours are described as pathognomonic
homogeneous hypoechoic oval mass in continuity with
a nerve of origin
Ganglion cysts are non-malignant cystic masses that occur in association with musculoskeletal structures They are sometimes also simply referred to as ganglia or a ganglion but should not be confused with the anatomical term ganglion UltrasoundThe vast majority are anechoic to hypoechoic on ultrasound and have well defined margins Many demonstrate internal septations as well as acoustic enhancement A synovial cyst is a small fluid-filled sac or pouch that can develop over a tendon or joint creating a mass under the skin Synovial cyst is rare in ankle joint A synovial cyst may or may not be painful depending on their size and location
Ganglion cyst in the foot with bony erosion between navicular and cuneiform bones
Tarsal synovial cyst
Anechoic ganglion situated in the sinus tarsi fat between the talus and calcaneous
Plantar fasciitis (PF) refers to inflammation of the
plantar fascia of the foot It is considered the most common cause of heel pain
Clinical presentation Pain on the undersurface of the heel on weight bearing is the principal complaint It can be worse when weight is borne after a period of rest (eg in the morning) and eases with walking Passive dorsiflexion of the toes may exacerbates discomfort
UltrasoundOften the initial imaging modality of choice Ultrasound typically shows increased thickness of the fascia and a hypoechoic fascia
Thickened hypoechoic origin of the plantar fascia which has a convex superior margin
Complete avulsion of the plantar fascia from the calcaneal tubercle
Plantar fasciitis
bull LOCATING FOREIGN BODIES AND FRACTURES
As in any other location the ankle
area is also subsidiary host foreign
whose classification location and
existence can be defined perfectly by
ultrasound Being a focused study to
the area of interest and with great
resolution for surface structures can
be considered more resolute
examination to screen these cases
Osseous diseases and fractures | Sonography discovered Medial Malleolus Fracture
Ultrasound examination of left ankle A Longitudinal sonogram left ankle demonstrates a wooden foreign body B Transverse view left ankle Note the hypervascularity in the inflamed area C Corresponding X-ray of left ankle Note the swelling on the lateral aspect No foreign body is visible
Thank You
Tenosynovitis of the extensor digitorum tendons with a synovial effusion
Tenosynovitis of the extensor digitorum tendon with hypervascularized thickened tendon and synovium and synovial fluid
Rheumatoid arthritis with tenosynovitis of the extensor digitorum and peroneal tendons
Thickening of the extensor hallucis longus tendon caused by osteosynthesis material
Multicystic non vascularized intramuscular mass in the extensor digitorum brevis muscle
LATERAL COMPARTMENTTENOSYNOVITIS OF THE PERONEAL TENDONSThe main sign of ultrasound is the presence of liquid inside the
common synovial sheath whereas usually tendinous
morphology is preserved We must differentiate tenosynovitis of
a spill within the common peroneal sheath secondary to a tear of
calcaneofibular ligament (PCL) The ultrasound diagnosis is the detection of the tendons in a lateral plane relative to the distal portion of the lateral malleolus instead of behind it The dynamic exploration foot dorsiflexion as both eversion may help identify cases of intermittent subluxation In long-standing disease can be observed fusiform thickening
of the peroneal tendons at the tip of the malleolus The complete tears of the peroneus brevis tendon (PC) and peroneus longus (PL) are rare occurring in the area of the lateral malleolus or midfoot Seen in patients with ankle sprains or history of chronic instability especially if they suffer widespread diseases (RA DM) or treated with corticosteroids The peroneal tendon ruptures causing the inability to eversion of the foot and cavus foot varus
Important thickening of both peroneal tendons (longus and brevis) associated
with moderate amount of fluid and thickening of the synovial sheath
Discreet amount of fluid in the common sheath of the peroneal tendons
associated with disorganization and a heterogeneous appearance
peroneus brevis tendon related to longitudinal rupture
Peroneal tenosynovitis and osteosynthesis
Tenosynovitis of the peroneal tendons and an intratendinous rupture of the short peroneal tendon
Intratendinous rupture and cyst in the peroneus brevis tendon
Peroneus quartus with an accessory muscle next to the peroneus longus and brevis tendons
Tumor next to the peroneal tendons that proved to be a benign fibrous mass
MEDIAL COMPARTMENT
ANOMALIES POSTERIOR TIBIAL TENDON (TP)
It is the most frequently injured in this compartment with ruptures
in asymptomatic middle-aged obese women as a result of
widespread disease (RA seronegative Spondyloarthropathy) or
associated with bone fractures It causes a gradual collapse of the
medial longitudinal arch with hindfoot valgus deformity and
excessive forefoot pronation
The presence of small vessels in inflammatory diseases
intratendinosis can simulate a fissuration tendon confusion can be ignored using colour Doppler Another possible diagnostic difficulty is when the undamaged tendon flexor digitorum longus (FLD) moves back and simulates the TP unbroken but it is smaller and in this case we only see in the groove retromalleolar 1 only tendon
Ultrasound has also proven to be an effective resource for identifying alterations associated tendon tenosynovitis serosa and hypertrophicSubluxation and dislocation anteriorly and medial TP relative to internal
malleolus is rare and valued sonographically placing the foot in dorsiflexion with forced supination
Thickening moderate amount of fluid surrounding calcifications and
hyperemia affecting the sheath and the posterior tibial tendon related
to chronic tenosynovitis in patient affects rheumatoid arthritis
Thickening moderate amount of surrounding fluid and calcifications (arrow) affecting the
posterior tibial tendon related to chronic tenosynovitis in patient affects rheumatoid arthritis
Tenosynovitis of the posterior tibial tendon caused by a bony ridge at the insertion of the retinaculum The retinaculum is thickened and the tendon subluxates
Psoriatic arthritis Ankle Grayscale examination Posterior tibial tendon on longitudinal (a) and transverse (b) scan Marked tendon sheath widening with homogeneous anechoic aspect (asterisks) of the content indicating an exudative tenosynovitis Note as the normal fibrillar echotexture is conserved Hand Flexor tendons of second finger The volar longitudinal (c) and transverse scan (d) shows a tendon sheath widening with signs of synovial proliferation presence of intense power Doppler signal surrounding the tendon and micro interruption of the margin (arrow) e Wrist Extensor carpi ulnaris tendon (sixth compartment of the extensor tendons ecu) on lateral longitudinal (e) and transverse (f) scan Chronic tenosynovitis with clear areas of low of echogenicity and loss of the continuity of tendon fibrils indicative of partial tendon tear (arrows) Moreover note the presence of power Doppler signal within the interruption indicating still activity of the inflammatory process g Dactylitis Volar longitudinal scan using the ldquoextended viewrdquo technique showing proliferative tenosynovitis of the finger flexor tendon (circle) exudative synovitis of both proximal and distal interphalangeal joint (white asterisks) and edema of the peritendinous tissue (black asterisks) TP posterior tibial tendon mm medial malleolus DP distal phalanx mp middle phalanx cu cubital bone ft flexor tendons
Tenosynovitis of the posterior tibial (1) and flexor digitorum longus tendon (2)
Tibialis Posterior Tendon rupture
Tenosynovitis of the posterior tibial tendon the flexor digitorum tendon and flexor hallucis longus tendon
Tenosynovitis of the tendons on the medial side in the left ankle
bullLIGAMENT INJURIESThe ligament partial tear ligament shows a hypoechoic
areas swollen with internal focal or diffuse In the complete
ruptures within the substance of the divided ligament rift is
observed corresponding to the hematoma hypoechoic and
the free ends of the divided ligament can be and retracted
appreciated corrugated in contrast with normal
appearance straight
Grade I Mild stretching of the ligament without breakage
or instability
Grade II Partial tearing of the ligament
Grade III Complete tearing
Degrees depending on the severity of the injury and the
place of employment
LATERAL COMPARTMENTThese injuries occur secondary to inversion sprains with internal rotation of
the foot combined with ankle plantar flexion
The anterior talar fibular ligament tears (ATFL) usually occur as isolated
involvement (70) or associated with calcaneal fibular ligament (CFL) (20-40)
but the posterior talar fibular ligament (PTFL) affects only major trauma
involving ankle dislocation
ATFL breaks is associated with breakage of the joint capsule and synovial fluid
extravasation into the anterolateral soft ankle whereas the complete tearing of
CFL can communicate the ankle joint and synovial sheath peroneal tendons
Rupture of CFL is rarely associated with superior peroneal retinaculum tear
The CFL is tensioned during dorsiflexion pulling on peroneal tendons laterally
so that absence of its displacement is sign of a complete tear
Within a damaged ligament can also observe calcifications that often
correspond to fragments of avulsion bone
During the ultrasound can be performed forced maneuvers to detect to joint
laxity and ligament injuries The anterior drawer test is performed with the feet
hanging over the edge of the examination table while the forefoot is pulled
anteriorly when the foot is in plantar flexion and inversion This maneuver
helps differentiate partial tears (grade II) of the ATFL to complete (grade III)
where the anterior displacement of the talus on the tibia open a crack in the
substance becoming more visible the ligament injury
The sindesmosys sprains are up to 10 of ankle
injuries happening in eversion and pronation
movements (like the deltoid ligament injury) and
primarily affect the anterior tibiofibular ligament (ATFL)
the failure is frequently associated with fracture of the
fibula
According to the place of employment are 4 degrees
useful for prognostic evaluation and therapeutic strategy
choice
Grade I stretch or partial tear of the ATFL
Grade II complete tearing but only the ATFL
Grade III complete tear of the ATFL and partial CFL
Grade IV complete tear of the ATFL and CFL
The grade I and II injuries usually scarred without any
significant instability whereas grade III and IV injuries
can cause chronic pain and require surgical treatment
Thickened but continued ATFL right in relation to the partial rupture
Grade 111 sprain of right ATFL
Thickened anterior talofibular ligament with calcifications and a partial rupture
Thickened tibiofibular ligament after trauma
Anterior Talofibular Ligament Partial Tear and Elastography
Tibio fibular ligament rupture with bony avulsion
Complete rupture of right ATFL
Bony avulsion with radiographic evidence as visible calcification in a grade III sprain ATFL
Moderately thickened and hypoechoic ATFL
Discontinuity of the ATFL with fluid surrounding the torn ends (arrow)
Thickening and hypoechogenicity of the fibular end of the ligament seen here passing over the subtalar joint which contains a small of fluid
Complete disruption to the tibiofibular ligament with bony irregularity of particularly the tibial margin and fluid in the gap
MEDIAL COMPARTMENTBecause of the low incidence of eversion ankle
sprains and the thickness of the deltoid ligament
is rarely injured in isolation and when the injury
does not usually full thickness Usually
accompanied by lesions of the medial malleolus
and lateral displacement of the talus with
consequent widening of the ankle mortise
Ultrasound is useful for differentiating ligament
injury of the posterior tibial tendon injury
(TP) adjacent they have similar symptoms
The inability to visualize the deltoid ligament may
indicate tear but this is not considered a reliable
sign as its full ultrasound is not always possible
Partial medial ligament rupture
Thickened heterogeneous abnormal deltoid demonstrating hyperemia
Ultrasonogram showing a disrupted deltoid ligament with the probe in the coronal plane The white arrow indicates the medial malleolus the blue arrow indicates the talus and the red arrows indicate the disrupted deltoid ligament (A) Radiograph showing the same injury (B)
bullJOINT AND BONE DISORDERSUltrasound reliably detect spills mild (gt 2 ml) inside
of the ankle joint by exploring the front and rear
recess as well as areas of synovial proliferation and
may even display using the colour Doppler
hyperemic areas in arthritis patients
The intraarticular joints are displayed surrounded
fluid in one of the recesses of the ankle or subtalar
joint Sonographically diagnosed when changing position to perform flexion and extension Fracture of the lateral process of the talus is overlooked up to 50 of cases with plain radiography Ultrasound may suspect the presence of focal cortical disruption helping further to exclude concomitant ligament injury
Rheumatoid arthritis with synovial thickening (1) and erosion of the tibia (2)
Infectious arthritis with a pus filled anterior recess of the ankle
Arthritis and tenosynovitis of the ankle in a patient with rheumatoid arthritis
bullTUMOURSUltrasound can differentiate between a mass complex
and solid and a cystic in addition to verifying the
existence of accessory muscles (peroneus fourth
accessory flexor digitorum longus and accessory
soleus) As in any other location can be found
neoformative soft tissue tumors inflammatory
infectious etc
Ganglions of this location are more often symptomatic
and larger with multiple partitions
branched and lobed edges Differential diagnosis must
be made with tenosynovitis abscesses seromas and
varicosities
Neurogenic tumours are described as pathognomonic
homogeneous hypoechoic oval mass in continuity with
a nerve of origin
Ganglion cysts are non-malignant cystic masses that occur in association with musculoskeletal structures They are sometimes also simply referred to as ganglia or a ganglion but should not be confused with the anatomical term ganglion UltrasoundThe vast majority are anechoic to hypoechoic on ultrasound and have well defined margins Many demonstrate internal septations as well as acoustic enhancement A synovial cyst is a small fluid-filled sac or pouch that can develop over a tendon or joint creating a mass under the skin Synovial cyst is rare in ankle joint A synovial cyst may or may not be painful depending on their size and location
Ganglion cyst in the foot with bony erosion between navicular and cuneiform bones
Tarsal synovial cyst
Anechoic ganglion situated in the sinus tarsi fat between the talus and calcaneous
Plantar fasciitis (PF) refers to inflammation of the
plantar fascia of the foot It is considered the most common cause of heel pain
Clinical presentation Pain on the undersurface of the heel on weight bearing is the principal complaint It can be worse when weight is borne after a period of rest (eg in the morning) and eases with walking Passive dorsiflexion of the toes may exacerbates discomfort
UltrasoundOften the initial imaging modality of choice Ultrasound typically shows increased thickness of the fascia and a hypoechoic fascia
Thickened hypoechoic origin of the plantar fascia which has a convex superior margin
Complete avulsion of the plantar fascia from the calcaneal tubercle
Plantar fasciitis
bull LOCATING FOREIGN BODIES AND FRACTURES
As in any other location the ankle
area is also subsidiary host foreign
whose classification location and
existence can be defined perfectly by
ultrasound Being a focused study to
the area of interest and with great
resolution for surface structures can
be considered more resolute
examination to screen these cases
Osseous diseases and fractures | Sonography discovered Medial Malleolus Fracture
Ultrasound examination of left ankle A Longitudinal sonogram left ankle demonstrates a wooden foreign body B Transverse view left ankle Note the hypervascularity in the inflamed area C Corresponding X-ray of left ankle Note the swelling on the lateral aspect No foreign body is visible
Thank You
Tenosynovitis of the extensor digitorum tendon with hypervascularized thickened tendon and synovium and synovial fluid
Rheumatoid arthritis with tenosynovitis of the extensor digitorum and peroneal tendons
Thickening of the extensor hallucis longus tendon caused by osteosynthesis material
Multicystic non vascularized intramuscular mass in the extensor digitorum brevis muscle
LATERAL COMPARTMENTTENOSYNOVITIS OF THE PERONEAL TENDONSThe main sign of ultrasound is the presence of liquid inside the
common synovial sheath whereas usually tendinous
morphology is preserved We must differentiate tenosynovitis of
a spill within the common peroneal sheath secondary to a tear of
calcaneofibular ligament (PCL) The ultrasound diagnosis is the detection of the tendons in a lateral plane relative to the distal portion of the lateral malleolus instead of behind it The dynamic exploration foot dorsiflexion as both eversion may help identify cases of intermittent subluxation In long-standing disease can be observed fusiform thickening
of the peroneal tendons at the tip of the malleolus The complete tears of the peroneus brevis tendon (PC) and peroneus longus (PL) are rare occurring in the area of the lateral malleolus or midfoot Seen in patients with ankle sprains or history of chronic instability especially if they suffer widespread diseases (RA DM) or treated with corticosteroids The peroneal tendon ruptures causing the inability to eversion of the foot and cavus foot varus
Important thickening of both peroneal tendons (longus and brevis) associated
with moderate amount of fluid and thickening of the synovial sheath
Discreet amount of fluid in the common sheath of the peroneal tendons
associated with disorganization and a heterogeneous appearance
peroneus brevis tendon related to longitudinal rupture
Peroneal tenosynovitis and osteosynthesis
Tenosynovitis of the peroneal tendons and an intratendinous rupture of the short peroneal tendon
Intratendinous rupture and cyst in the peroneus brevis tendon
Peroneus quartus with an accessory muscle next to the peroneus longus and brevis tendons
Tumor next to the peroneal tendons that proved to be a benign fibrous mass
MEDIAL COMPARTMENT
ANOMALIES POSTERIOR TIBIAL TENDON (TP)
It is the most frequently injured in this compartment with ruptures
in asymptomatic middle-aged obese women as a result of
widespread disease (RA seronegative Spondyloarthropathy) or
associated with bone fractures It causes a gradual collapse of the
medial longitudinal arch with hindfoot valgus deformity and
excessive forefoot pronation
The presence of small vessels in inflammatory diseases
intratendinosis can simulate a fissuration tendon confusion can be ignored using colour Doppler Another possible diagnostic difficulty is when the undamaged tendon flexor digitorum longus (FLD) moves back and simulates the TP unbroken but it is smaller and in this case we only see in the groove retromalleolar 1 only tendon
Ultrasound has also proven to be an effective resource for identifying alterations associated tendon tenosynovitis serosa and hypertrophicSubluxation and dislocation anteriorly and medial TP relative to internal
malleolus is rare and valued sonographically placing the foot in dorsiflexion with forced supination
Thickening moderate amount of fluid surrounding calcifications and
hyperemia affecting the sheath and the posterior tibial tendon related
to chronic tenosynovitis in patient affects rheumatoid arthritis
Thickening moderate amount of surrounding fluid and calcifications (arrow) affecting the
posterior tibial tendon related to chronic tenosynovitis in patient affects rheumatoid arthritis
Tenosynovitis of the posterior tibial tendon caused by a bony ridge at the insertion of the retinaculum The retinaculum is thickened and the tendon subluxates
Psoriatic arthritis Ankle Grayscale examination Posterior tibial tendon on longitudinal (a) and transverse (b) scan Marked tendon sheath widening with homogeneous anechoic aspect (asterisks) of the content indicating an exudative tenosynovitis Note as the normal fibrillar echotexture is conserved Hand Flexor tendons of second finger The volar longitudinal (c) and transverse scan (d) shows a tendon sheath widening with signs of synovial proliferation presence of intense power Doppler signal surrounding the tendon and micro interruption of the margin (arrow) e Wrist Extensor carpi ulnaris tendon (sixth compartment of the extensor tendons ecu) on lateral longitudinal (e) and transverse (f) scan Chronic tenosynovitis with clear areas of low of echogenicity and loss of the continuity of tendon fibrils indicative of partial tendon tear (arrows) Moreover note the presence of power Doppler signal within the interruption indicating still activity of the inflammatory process g Dactylitis Volar longitudinal scan using the ldquoextended viewrdquo technique showing proliferative tenosynovitis of the finger flexor tendon (circle) exudative synovitis of both proximal and distal interphalangeal joint (white asterisks) and edema of the peritendinous tissue (black asterisks) TP posterior tibial tendon mm medial malleolus DP distal phalanx mp middle phalanx cu cubital bone ft flexor tendons
Tenosynovitis of the posterior tibial (1) and flexor digitorum longus tendon (2)
Tibialis Posterior Tendon rupture
Tenosynovitis of the posterior tibial tendon the flexor digitorum tendon and flexor hallucis longus tendon
Tenosynovitis of the tendons on the medial side in the left ankle
bullLIGAMENT INJURIESThe ligament partial tear ligament shows a hypoechoic
areas swollen with internal focal or diffuse In the complete
ruptures within the substance of the divided ligament rift is
observed corresponding to the hematoma hypoechoic and
the free ends of the divided ligament can be and retracted
appreciated corrugated in contrast with normal
appearance straight
Grade I Mild stretching of the ligament without breakage
or instability
Grade II Partial tearing of the ligament
Grade III Complete tearing
Degrees depending on the severity of the injury and the
place of employment
LATERAL COMPARTMENTThese injuries occur secondary to inversion sprains with internal rotation of
the foot combined with ankle plantar flexion
The anterior talar fibular ligament tears (ATFL) usually occur as isolated
involvement (70) or associated with calcaneal fibular ligament (CFL) (20-40)
but the posterior talar fibular ligament (PTFL) affects only major trauma
involving ankle dislocation
ATFL breaks is associated with breakage of the joint capsule and synovial fluid
extravasation into the anterolateral soft ankle whereas the complete tearing of
CFL can communicate the ankle joint and synovial sheath peroneal tendons
Rupture of CFL is rarely associated with superior peroneal retinaculum tear
The CFL is tensioned during dorsiflexion pulling on peroneal tendons laterally
so that absence of its displacement is sign of a complete tear
Within a damaged ligament can also observe calcifications that often
correspond to fragments of avulsion bone
During the ultrasound can be performed forced maneuvers to detect to joint
laxity and ligament injuries The anterior drawer test is performed with the feet
hanging over the edge of the examination table while the forefoot is pulled
anteriorly when the foot is in plantar flexion and inversion This maneuver
helps differentiate partial tears (grade II) of the ATFL to complete (grade III)
where the anterior displacement of the talus on the tibia open a crack in the
substance becoming more visible the ligament injury
The sindesmosys sprains are up to 10 of ankle
injuries happening in eversion and pronation
movements (like the deltoid ligament injury) and
primarily affect the anterior tibiofibular ligament (ATFL)
the failure is frequently associated with fracture of the
fibula
According to the place of employment are 4 degrees
useful for prognostic evaluation and therapeutic strategy
choice
Grade I stretch or partial tear of the ATFL
Grade II complete tearing but only the ATFL
Grade III complete tear of the ATFL and partial CFL
Grade IV complete tear of the ATFL and CFL
The grade I and II injuries usually scarred without any
significant instability whereas grade III and IV injuries
can cause chronic pain and require surgical treatment
Thickened but continued ATFL right in relation to the partial rupture
Grade 111 sprain of right ATFL
Thickened anterior talofibular ligament with calcifications and a partial rupture
Thickened tibiofibular ligament after trauma
Anterior Talofibular Ligament Partial Tear and Elastography
Tibio fibular ligament rupture with bony avulsion
Complete rupture of right ATFL
Bony avulsion with radiographic evidence as visible calcification in a grade III sprain ATFL
Moderately thickened and hypoechoic ATFL
Discontinuity of the ATFL with fluid surrounding the torn ends (arrow)
Thickening and hypoechogenicity of the fibular end of the ligament seen here passing over the subtalar joint which contains a small of fluid
Complete disruption to the tibiofibular ligament with bony irregularity of particularly the tibial margin and fluid in the gap
MEDIAL COMPARTMENTBecause of the low incidence of eversion ankle
sprains and the thickness of the deltoid ligament
is rarely injured in isolation and when the injury
does not usually full thickness Usually
accompanied by lesions of the medial malleolus
and lateral displacement of the talus with
consequent widening of the ankle mortise
Ultrasound is useful for differentiating ligament
injury of the posterior tibial tendon injury
(TP) adjacent they have similar symptoms
The inability to visualize the deltoid ligament may
indicate tear but this is not considered a reliable
sign as its full ultrasound is not always possible
Partial medial ligament rupture
Thickened heterogeneous abnormal deltoid demonstrating hyperemia
Ultrasonogram showing a disrupted deltoid ligament with the probe in the coronal plane The white arrow indicates the medial malleolus the blue arrow indicates the talus and the red arrows indicate the disrupted deltoid ligament (A) Radiograph showing the same injury (B)
bullJOINT AND BONE DISORDERSUltrasound reliably detect spills mild (gt 2 ml) inside
of the ankle joint by exploring the front and rear
recess as well as areas of synovial proliferation and
may even display using the colour Doppler
hyperemic areas in arthritis patients
The intraarticular joints are displayed surrounded
fluid in one of the recesses of the ankle or subtalar
joint Sonographically diagnosed when changing position to perform flexion and extension Fracture of the lateral process of the talus is overlooked up to 50 of cases with plain radiography Ultrasound may suspect the presence of focal cortical disruption helping further to exclude concomitant ligament injury
Rheumatoid arthritis with synovial thickening (1) and erosion of the tibia (2)
Infectious arthritis with a pus filled anterior recess of the ankle
Arthritis and tenosynovitis of the ankle in a patient with rheumatoid arthritis
bullTUMOURSUltrasound can differentiate between a mass complex
and solid and a cystic in addition to verifying the
existence of accessory muscles (peroneus fourth
accessory flexor digitorum longus and accessory
soleus) As in any other location can be found
neoformative soft tissue tumors inflammatory
infectious etc
Ganglions of this location are more often symptomatic
and larger with multiple partitions
branched and lobed edges Differential diagnosis must
be made with tenosynovitis abscesses seromas and
varicosities
Neurogenic tumours are described as pathognomonic
homogeneous hypoechoic oval mass in continuity with
a nerve of origin
Ganglion cysts are non-malignant cystic masses that occur in association with musculoskeletal structures They are sometimes also simply referred to as ganglia or a ganglion but should not be confused with the anatomical term ganglion UltrasoundThe vast majority are anechoic to hypoechoic on ultrasound and have well defined margins Many demonstrate internal septations as well as acoustic enhancement A synovial cyst is a small fluid-filled sac or pouch that can develop over a tendon or joint creating a mass under the skin Synovial cyst is rare in ankle joint A synovial cyst may or may not be painful depending on their size and location
Ganglion cyst in the foot with bony erosion between navicular and cuneiform bones
Tarsal synovial cyst
Anechoic ganglion situated in the sinus tarsi fat between the talus and calcaneous
Plantar fasciitis (PF) refers to inflammation of the
plantar fascia of the foot It is considered the most common cause of heel pain
Clinical presentation Pain on the undersurface of the heel on weight bearing is the principal complaint It can be worse when weight is borne after a period of rest (eg in the morning) and eases with walking Passive dorsiflexion of the toes may exacerbates discomfort
UltrasoundOften the initial imaging modality of choice Ultrasound typically shows increased thickness of the fascia and a hypoechoic fascia
Thickened hypoechoic origin of the plantar fascia which has a convex superior margin
Complete avulsion of the plantar fascia from the calcaneal tubercle
Plantar fasciitis
bull LOCATING FOREIGN BODIES AND FRACTURES
As in any other location the ankle
area is also subsidiary host foreign
whose classification location and
existence can be defined perfectly by
ultrasound Being a focused study to
the area of interest and with great
resolution for surface structures can
be considered more resolute
examination to screen these cases
Osseous diseases and fractures | Sonography discovered Medial Malleolus Fracture
Ultrasound examination of left ankle A Longitudinal sonogram left ankle demonstrates a wooden foreign body B Transverse view left ankle Note the hypervascularity in the inflamed area C Corresponding X-ray of left ankle Note the swelling on the lateral aspect No foreign body is visible
Thank You
Rheumatoid arthritis with tenosynovitis of the extensor digitorum and peroneal tendons
Thickening of the extensor hallucis longus tendon caused by osteosynthesis material
Multicystic non vascularized intramuscular mass in the extensor digitorum brevis muscle
LATERAL COMPARTMENTTENOSYNOVITIS OF THE PERONEAL TENDONSThe main sign of ultrasound is the presence of liquid inside the
common synovial sheath whereas usually tendinous
morphology is preserved We must differentiate tenosynovitis of
a spill within the common peroneal sheath secondary to a tear of
calcaneofibular ligament (PCL) The ultrasound diagnosis is the detection of the tendons in a lateral plane relative to the distal portion of the lateral malleolus instead of behind it The dynamic exploration foot dorsiflexion as both eversion may help identify cases of intermittent subluxation In long-standing disease can be observed fusiform thickening
of the peroneal tendons at the tip of the malleolus The complete tears of the peroneus brevis tendon (PC) and peroneus longus (PL) are rare occurring in the area of the lateral malleolus or midfoot Seen in patients with ankle sprains or history of chronic instability especially if they suffer widespread diseases (RA DM) or treated with corticosteroids The peroneal tendon ruptures causing the inability to eversion of the foot and cavus foot varus
Important thickening of both peroneal tendons (longus and brevis) associated
with moderate amount of fluid and thickening of the synovial sheath
Discreet amount of fluid in the common sheath of the peroneal tendons
associated with disorganization and a heterogeneous appearance
peroneus brevis tendon related to longitudinal rupture
Peroneal tenosynovitis and osteosynthesis
Tenosynovitis of the peroneal tendons and an intratendinous rupture of the short peroneal tendon
Intratendinous rupture and cyst in the peroneus brevis tendon
Peroneus quartus with an accessory muscle next to the peroneus longus and brevis tendons
Tumor next to the peroneal tendons that proved to be a benign fibrous mass
MEDIAL COMPARTMENT
ANOMALIES POSTERIOR TIBIAL TENDON (TP)
It is the most frequently injured in this compartment with ruptures
in asymptomatic middle-aged obese women as a result of
widespread disease (RA seronegative Spondyloarthropathy) or
associated with bone fractures It causes a gradual collapse of the
medial longitudinal arch with hindfoot valgus deformity and
excessive forefoot pronation
The presence of small vessels in inflammatory diseases
intratendinosis can simulate a fissuration tendon confusion can be ignored using colour Doppler Another possible diagnostic difficulty is when the undamaged tendon flexor digitorum longus (FLD) moves back and simulates the TP unbroken but it is smaller and in this case we only see in the groove retromalleolar 1 only tendon
Ultrasound has also proven to be an effective resource for identifying alterations associated tendon tenosynovitis serosa and hypertrophicSubluxation and dislocation anteriorly and medial TP relative to internal
malleolus is rare and valued sonographically placing the foot in dorsiflexion with forced supination
Thickening moderate amount of fluid surrounding calcifications and
hyperemia affecting the sheath and the posterior tibial tendon related
to chronic tenosynovitis in patient affects rheumatoid arthritis
Thickening moderate amount of surrounding fluid and calcifications (arrow) affecting the
posterior tibial tendon related to chronic tenosynovitis in patient affects rheumatoid arthritis
Tenosynovitis of the posterior tibial tendon caused by a bony ridge at the insertion of the retinaculum The retinaculum is thickened and the tendon subluxates
Psoriatic arthritis Ankle Grayscale examination Posterior tibial tendon on longitudinal (a) and transverse (b) scan Marked tendon sheath widening with homogeneous anechoic aspect (asterisks) of the content indicating an exudative tenosynovitis Note as the normal fibrillar echotexture is conserved Hand Flexor tendons of second finger The volar longitudinal (c) and transverse scan (d) shows a tendon sheath widening with signs of synovial proliferation presence of intense power Doppler signal surrounding the tendon and micro interruption of the margin (arrow) e Wrist Extensor carpi ulnaris tendon (sixth compartment of the extensor tendons ecu) on lateral longitudinal (e) and transverse (f) scan Chronic tenosynovitis with clear areas of low of echogenicity and loss of the continuity of tendon fibrils indicative of partial tendon tear (arrows) Moreover note the presence of power Doppler signal within the interruption indicating still activity of the inflammatory process g Dactylitis Volar longitudinal scan using the ldquoextended viewrdquo technique showing proliferative tenosynovitis of the finger flexor tendon (circle) exudative synovitis of both proximal and distal interphalangeal joint (white asterisks) and edema of the peritendinous tissue (black asterisks) TP posterior tibial tendon mm medial malleolus DP distal phalanx mp middle phalanx cu cubital bone ft flexor tendons
Tenosynovitis of the posterior tibial (1) and flexor digitorum longus tendon (2)
Tibialis Posterior Tendon rupture
Tenosynovitis of the posterior tibial tendon the flexor digitorum tendon and flexor hallucis longus tendon
Tenosynovitis of the tendons on the medial side in the left ankle
bullLIGAMENT INJURIESThe ligament partial tear ligament shows a hypoechoic
areas swollen with internal focal or diffuse In the complete
ruptures within the substance of the divided ligament rift is
observed corresponding to the hematoma hypoechoic and
the free ends of the divided ligament can be and retracted
appreciated corrugated in contrast with normal
appearance straight
Grade I Mild stretching of the ligament without breakage
or instability
Grade II Partial tearing of the ligament
Grade III Complete tearing
Degrees depending on the severity of the injury and the
place of employment
LATERAL COMPARTMENTThese injuries occur secondary to inversion sprains with internal rotation of
the foot combined with ankle plantar flexion
The anterior talar fibular ligament tears (ATFL) usually occur as isolated
involvement (70) or associated with calcaneal fibular ligament (CFL) (20-40)
but the posterior talar fibular ligament (PTFL) affects only major trauma
involving ankle dislocation
ATFL breaks is associated with breakage of the joint capsule and synovial fluid
extravasation into the anterolateral soft ankle whereas the complete tearing of
CFL can communicate the ankle joint and synovial sheath peroneal tendons
Rupture of CFL is rarely associated with superior peroneal retinaculum tear
The CFL is tensioned during dorsiflexion pulling on peroneal tendons laterally
so that absence of its displacement is sign of a complete tear
Within a damaged ligament can also observe calcifications that often
correspond to fragments of avulsion bone
During the ultrasound can be performed forced maneuvers to detect to joint
laxity and ligament injuries The anterior drawer test is performed with the feet
hanging over the edge of the examination table while the forefoot is pulled
anteriorly when the foot is in plantar flexion and inversion This maneuver
helps differentiate partial tears (grade II) of the ATFL to complete (grade III)
where the anterior displacement of the talus on the tibia open a crack in the
substance becoming more visible the ligament injury
The sindesmosys sprains are up to 10 of ankle
injuries happening in eversion and pronation
movements (like the deltoid ligament injury) and
primarily affect the anterior tibiofibular ligament (ATFL)
the failure is frequently associated with fracture of the
fibula
According to the place of employment are 4 degrees
useful for prognostic evaluation and therapeutic strategy
choice
Grade I stretch or partial tear of the ATFL
Grade II complete tearing but only the ATFL
Grade III complete tear of the ATFL and partial CFL
Grade IV complete tear of the ATFL and CFL
The grade I and II injuries usually scarred without any
significant instability whereas grade III and IV injuries
can cause chronic pain and require surgical treatment
Thickened but continued ATFL right in relation to the partial rupture
Grade 111 sprain of right ATFL
Thickened anterior talofibular ligament with calcifications and a partial rupture
Thickened tibiofibular ligament after trauma
Anterior Talofibular Ligament Partial Tear and Elastography
Tibio fibular ligament rupture with bony avulsion
Complete rupture of right ATFL
Bony avulsion with radiographic evidence as visible calcification in a grade III sprain ATFL
Moderately thickened and hypoechoic ATFL
Discontinuity of the ATFL with fluid surrounding the torn ends (arrow)
Thickening and hypoechogenicity of the fibular end of the ligament seen here passing over the subtalar joint which contains a small of fluid
Complete disruption to the tibiofibular ligament with bony irregularity of particularly the tibial margin and fluid in the gap
MEDIAL COMPARTMENTBecause of the low incidence of eversion ankle
sprains and the thickness of the deltoid ligament
is rarely injured in isolation and when the injury
does not usually full thickness Usually
accompanied by lesions of the medial malleolus
and lateral displacement of the talus with
consequent widening of the ankle mortise
Ultrasound is useful for differentiating ligament
injury of the posterior tibial tendon injury
(TP) adjacent they have similar symptoms
The inability to visualize the deltoid ligament may
indicate tear but this is not considered a reliable
sign as its full ultrasound is not always possible
Partial medial ligament rupture
Thickened heterogeneous abnormal deltoid demonstrating hyperemia
Ultrasonogram showing a disrupted deltoid ligament with the probe in the coronal plane The white arrow indicates the medial malleolus the blue arrow indicates the talus and the red arrows indicate the disrupted deltoid ligament (A) Radiograph showing the same injury (B)
bullJOINT AND BONE DISORDERSUltrasound reliably detect spills mild (gt 2 ml) inside
of the ankle joint by exploring the front and rear
recess as well as areas of synovial proliferation and
may even display using the colour Doppler
hyperemic areas in arthritis patients
The intraarticular joints are displayed surrounded
fluid in one of the recesses of the ankle or subtalar
joint Sonographically diagnosed when changing position to perform flexion and extension Fracture of the lateral process of the talus is overlooked up to 50 of cases with plain radiography Ultrasound may suspect the presence of focal cortical disruption helping further to exclude concomitant ligament injury
Rheumatoid arthritis with synovial thickening (1) and erosion of the tibia (2)
Infectious arthritis with a pus filled anterior recess of the ankle
Arthritis and tenosynovitis of the ankle in a patient with rheumatoid arthritis
bullTUMOURSUltrasound can differentiate between a mass complex
and solid and a cystic in addition to verifying the
existence of accessory muscles (peroneus fourth
accessory flexor digitorum longus and accessory
soleus) As in any other location can be found
neoformative soft tissue tumors inflammatory
infectious etc
Ganglions of this location are more often symptomatic
and larger with multiple partitions
branched and lobed edges Differential diagnosis must
be made with tenosynovitis abscesses seromas and
varicosities
Neurogenic tumours are described as pathognomonic
homogeneous hypoechoic oval mass in continuity with
a nerve of origin
Ganglion cysts are non-malignant cystic masses that occur in association with musculoskeletal structures They are sometimes also simply referred to as ganglia or a ganglion but should not be confused with the anatomical term ganglion UltrasoundThe vast majority are anechoic to hypoechoic on ultrasound and have well defined margins Many demonstrate internal septations as well as acoustic enhancement A synovial cyst is a small fluid-filled sac or pouch that can develop over a tendon or joint creating a mass under the skin Synovial cyst is rare in ankle joint A synovial cyst may or may not be painful depending on their size and location
Ganglion cyst in the foot with bony erosion between navicular and cuneiform bones
Tarsal synovial cyst
Anechoic ganglion situated in the sinus tarsi fat between the talus and calcaneous
Plantar fasciitis (PF) refers to inflammation of the
plantar fascia of the foot It is considered the most common cause of heel pain
Clinical presentation Pain on the undersurface of the heel on weight bearing is the principal complaint It can be worse when weight is borne after a period of rest (eg in the morning) and eases with walking Passive dorsiflexion of the toes may exacerbates discomfort
UltrasoundOften the initial imaging modality of choice Ultrasound typically shows increased thickness of the fascia and a hypoechoic fascia
Thickened hypoechoic origin of the plantar fascia which has a convex superior margin
Complete avulsion of the plantar fascia from the calcaneal tubercle
Plantar fasciitis
bull LOCATING FOREIGN BODIES AND FRACTURES
As in any other location the ankle
area is also subsidiary host foreign
whose classification location and
existence can be defined perfectly by
ultrasound Being a focused study to
the area of interest and with great
resolution for surface structures can
be considered more resolute
examination to screen these cases
Osseous diseases and fractures | Sonography discovered Medial Malleolus Fracture
Ultrasound examination of left ankle A Longitudinal sonogram left ankle demonstrates a wooden foreign body B Transverse view left ankle Note the hypervascularity in the inflamed area C Corresponding X-ray of left ankle Note the swelling on the lateral aspect No foreign body is visible
Thank You
Thickening of the extensor hallucis longus tendon caused by osteosynthesis material
Multicystic non vascularized intramuscular mass in the extensor digitorum brevis muscle
LATERAL COMPARTMENTTENOSYNOVITIS OF THE PERONEAL TENDONSThe main sign of ultrasound is the presence of liquid inside the
common synovial sheath whereas usually tendinous
morphology is preserved We must differentiate tenosynovitis of
a spill within the common peroneal sheath secondary to a tear of
calcaneofibular ligament (PCL) The ultrasound diagnosis is the detection of the tendons in a lateral plane relative to the distal portion of the lateral malleolus instead of behind it The dynamic exploration foot dorsiflexion as both eversion may help identify cases of intermittent subluxation In long-standing disease can be observed fusiform thickening
of the peroneal tendons at the tip of the malleolus The complete tears of the peroneus brevis tendon (PC) and peroneus longus (PL) are rare occurring in the area of the lateral malleolus or midfoot Seen in patients with ankle sprains or history of chronic instability especially if they suffer widespread diseases (RA DM) or treated with corticosteroids The peroneal tendon ruptures causing the inability to eversion of the foot and cavus foot varus
Important thickening of both peroneal tendons (longus and brevis) associated
with moderate amount of fluid and thickening of the synovial sheath
Discreet amount of fluid in the common sheath of the peroneal tendons
associated with disorganization and a heterogeneous appearance
peroneus brevis tendon related to longitudinal rupture
Peroneal tenosynovitis and osteosynthesis
Tenosynovitis of the peroneal tendons and an intratendinous rupture of the short peroneal tendon
Intratendinous rupture and cyst in the peroneus brevis tendon
Peroneus quartus with an accessory muscle next to the peroneus longus and brevis tendons
Tumor next to the peroneal tendons that proved to be a benign fibrous mass
MEDIAL COMPARTMENT
ANOMALIES POSTERIOR TIBIAL TENDON (TP)
It is the most frequently injured in this compartment with ruptures
in asymptomatic middle-aged obese women as a result of
widespread disease (RA seronegative Spondyloarthropathy) or
associated with bone fractures It causes a gradual collapse of the
medial longitudinal arch with hindfoot valgus deformity and
excessive forefoot pronation
The presence of small vessels in inflammatory diseases
intratendinosis can simulate a fissuration tendon confusion can be ignored using colour Doppler Another possible diagnostic difficulty is when the undamaged tendon flexor digitorum longus (FLD) moves back and simulates the TP unbroken but it is smaller and in this case we only see in the groove retromalleolar 1 only tendon
Ultrasound has also proven to be an effective resource for identifying alterations associated tendon tenosynovitis serosa and hypertrophicSubluxation and dislocation anteriorly and medial TP relative to internal
malleolus is rare and valued sonographically placing the foot in dorsiflexion with forced supination
Thickening moderate amount of fluid surrounding calcifications and
hyperemia affecting the sheath and the posterior tibial tendon related
to chronic tenosynovitis in patient affects rheumatoid arthritis
Thickening moderate amount of surrounding fluid and calcifications (arrow) affecting the
posterior tibial tendon related to chronic tenosynovitis in patient affects rheumatoid arthritis
Tenosynovitis of the posterior tibial tendon caused by a bony ridge at the insertion of the retinaculum The retinaculum is thickened and the tendon subluxates
Psoriatic arthritis Ankle Grayscale examination Posterior tibial tendon on longitudinal (a) and transverse (b) scan Marked tendon sheath widening with homogeneous anechoic aspect (asterisks) of the content indicating an exudative tenosynovitis Note as the normal fibrillar echotexture is conserved Hand Flexor tendons of second finger The volar longitudinal (c) and transverse scan (d) shows a tendon sheath widening with signs of synovial proliferation presence of intense power Doppler signal surrounding the tendon and micro interruption of the margin (arrow) e Wrist Extensor carpi ulnaris tendon (sixth compartment of the extensor tendons ecu) on lateral longitudinal (e) and transverse (f) scan Chronic tenosynovitis with clear areas of low of echogenicity and loss of the continuity of tendon fibrils indicative of partial tendon tear (arrows) Moreover note the presence of power Doppler signal within the interruption indicating still activity of the inflammatory process g Dactylitis Volar longitudinal scan using the ldquoextended viewrdquo technique showing proliferative tenosynovitis of the finger flexor tendon (circle) exudative synovitis of both proximal and distal interphalangeal joint (white asterisks) and edema of the peritendinous tissue (black asterisks) TP posterior tibial tendon mm medial malleolus DP distal phalanx mp middle phalanx cu cubital bone ft flexor tendons
Tenosynovitis of the posterior tibial (1) and flexor digitorum longus tendon (2)
Tibialis Posterior Tendon rupture
Tenosynovitis of the posterior tibial tendon the flexor digitorum tendon and flexor hallucis longus tendon
Tenosynovitis of the tendons on the medial side in the left ankle
bullLIGAMENT INJURIESThe ligament partial tear ligament shows a hypoechoic
areas swollen with internal focal or diffuse In the complete
ruptures within the substance of the divided ligament rift is
observed corresponding to the hematoma hypoechoic and
the free ends of the divided ligament can be and retracted
appreciated corrugated in contrast with normal
appearance straight
Grade I Mild stretching of the ligament without breakage
or instability
Grade II Partial tearing of the ligament
Grade III Complete tearing
Degrees depending on the severity of the injury and the
place of employment
LATERAL COMPARTMENTThese injuries occur secondary to inversion sprains with internal rotation of
the foot combined with ankle plantar flexion
The anterior talar fibular ligament tears (ATFL) usually occur as isolated
involvement (70) or associated with calcaneal fibular ligament (CFL) (20-40)
but the posterior talar fibular ligament (PTFL) affects only major trauma
involving ankle dislocation
ATFL breaks is associated with breakage of the joint capsule and synovial fluid
extravasation into the anterolateral soft ankle whereas the complete tearing of
CFL can communicate the ankle joint and synovial sheath peroneal tendons
Rupture of CFL is rarely associated with superior peroneal retinaculum tear
The CFL is tensioned during dorsiflexion pulling on peroneal tendons laterally
so that absence of its displacement is sign of a complete tear
Within a damaged ligament can also observe calcifications that often
correspond to fragments of avulsion bone
During the ultrasound can be performed forced maneuvers to detect to joint
laxity and ligament injuries The anterior drawer test is performed with the feet
hanging over the edge of the examination table while the forefoot is pulled
anteriorly when the foot is in plantar flexion and inversion This maneuver
helps differentiate partial tears (grade II) of the ATFL to complete (grade III)
where the anterior displacement of the talus on the tibia open a crack in the
substance becoming more visible the ligament injury
The sindesmosys sprains are up to 10 of ankle
injuries happening in eversion and pronation
movements (like the deltoid ligament injury) and
primarily affect the anterior tibiofibular ligament (ATFL)
the failure is frequently associated with fracture of the
fibula
According to the place of employment are 4 degrees
useful for prognostic evaluation and therapeutic strategy
choice
Grade I stretch or partial tear of the ATFL
Grade II complete tearing but only the ATFL
Grade III complete tear of the ATFL and partial CFL
Grade IV complete tear of the ATFL and CFL
The grade I and II injuries usually scarred without any
significant instability whereas grade III and IV injuries
can cause chronic pain and require surgical treatment
Thickened but continued ATFL right in relation to the partial rupture
Grade 111 sprain of right ATFL
Thickened anterior talofibular ligament with calcifications and a partial rupture
Thickened tibiofibular ligament after trauma
Anterior Talofibular Ligament Partial Tear and Elastography
Tibio fibular ligament rupture with bony avulsion
Complete rupture of right ATFL
Bony avulsion with radiographic evidence as visible calcification in a grade III sprain ATFL
Moderately thickened and hypoechoic ATFL
Discontinuity of the ATFL with fluid surrounding the torn ends (arrow)
Thickening and hypoechogenicity of the fibular end of the ligament seen here passing over the subtalar joint which contains a small of fluid
Complete disruption to the tibiofibular ligament with bony irregularity of particularly the tibial margin and fluid in the gap
MEDIAL COMPARTMENTBecause of the low incidence of eversion ankle
sprains and the thickness of the deltoid ligament
is rarely injured in isolation and when the injury
does not usually full thickness Usually
accompanied by lesions of the medial malleolus
and lateral displacement of the talus with
consequent widening of the ankle mortise
Ultrasound is useful for differentiating ligament
injury of the posterior tibial tendon injury
(TP) adjacent they have similar symptoms
The inability to visualize the deltoid ligament may
indicate tear but this is not considered a reliable
sign as its full ultrasound is not always possible
Partial medial ligament rupture
Thickened heterogeneous abnormal deltoid demonstrating hyperemia
Ultrasonogram showing a disrupted deltoid ligament with the probe in the coronal plane The white arrow indicates the medial malleolus the blue arrow indicates the talus and the red arrows indicate the disrupted deltoid ligament (A) Radiograph showing the same injury (B)
bullJOINT AND BONE DISORDERSUltrasound reliably detect spills mild (gt 2 ml) inside
of the ankle joint by exploring the front and rear
recess as well as areas of synovial proliferation and
may even display using the colour Doppler
hyperemic areas in arthritis patients
The intraarticular joints are displayed surrounded
fluid in one of the recesses of the ankle or subtalar
joint Sonographically diagnosed when changing position to perform flexion and extension Fracture of the lateral process of the talus is overlooked up to 50 of cases with plain radiography Ultrasound may suspect the presence of focal cortical disruption helping further to exclude concomitant ligament injury
Rheumatoid arthritis with synovial thickening (1) and erosion of the tibia (2)
Infectious arthritis with a pus filled anterior recess of the ankle
Arthritis and tenosynovitis of the ankle in a patient with rheumatoid arthritis
bullTUMOURSUltrasound can differentiate between a mass complex
and solid and a cystic in addition to verifying the
existence of accessory muscles (peroneus fourth
accessory flexor digitorum longus and accessory
soleus) As in any other location can be found
neoformative soft tissue tumors inflammatory
infectious etc
Ganglions of this location are more often symptomatic
and larger with multiple partitions
branched and lobed edges Differential diagnosis must
be made with tenosynovitis abscesses seromas and
varicosities
Neurogenic tumours are described as pathognomonic
homogeneous hypoechoic oval mass in continuity with
a nerve of origin
Ganglion cysts are non-malignant cystic masses that occur in association with musculoskeletal structures They are sometimes also simply referred to as ganglia or a ganglion but should not be confused with the anatomical term ganglion UltrasoundThe vast majority are anechoic to hypoechoic on ultrasound and have well defined margins Many demonstrate internal septations as well as acoustic enhancement A synovial cyst is a small fluid-filled sac or pouch that can develop over a tendon or joint creating a mass under the skin Synovial cyst is rare in ankle joint A synovial cyst may or may not be painful depending on their size and location
Ganglion cyst in the foot with bony erosion between navicular and cuneiform bones
Tarsal synovial cyst
Anechoic ganglion situated in the sinus tarsi fat between the talus and calcaneous
Plantar fasciitis (PF) refers to inflammation of the
plantar fascia of the foot It is considered the most common cause of heel pain
Clinical presentation Pain on the undersurface of the heel on weight bearing is the principal complaint It can be worse when weight is borne after a period of rest (eg in the morning) and eases with walking Passive dorsiflexion of the toes may exacerbates discomfort
UltrasoundOften the initial imaging modality of choice Ultrasound typically shows increased thickness of the fascia and a hypoechoic fascia
Thickened hypoechoic origin of the plantar fascia which has a convex superior margin
Complete avulsion of the plantar fascia from the calcaneal tubercle
Plantar fasciitis
bull LOCATING FOREIGN BODIES AND FRACTURES
As in any other location the ankle
area is also subsidiary host foreign
whose classification location and
existence can be defined perfectly by
ultrasound Being a focused study to
the area of interest and with great
resolution for surface structures can
be considered more resolute
examination to screen these cases
Osseous diseases and fractures | Sonography discovered Medial Malleolus Fracture
Ultrasound examination of left ankle A Longitudinal sonogram left ankle demonstrates a wooden foreign body B Transverse view left ankle Note the hypervascularity in the inflamed area C Corresponding X-ray of left ankle Note the swelling on the lateral aspect No foreign body is visible
Thank You
Multicystic non vascularized intramuscular mass in the extensor digitorum brevis muscle
LATERAL COMPARTMENTTENOSYNOVITIS OF THE PERONEAL TENDONSThe main sign of ultrasound is the presence of liquid inside the
common synovial sheath whereas usually tendinous
morphology is preserved We must differentiate tenosynovitis of
a spill within the common peroneal sheath secondary to a tear of
calcaneofibular ligament (PCL) The ultrasound diagnosis is the detection of the tendons in a lateral plane relative to the distal portion of the lateral malleolus instead of behind it The dynamic exploration foot dorsiflexion as both eversion may help identify cases of intermittent subluxation In long-standing disease can be observed fusiform thickening
of the peroneal tendons at the tip of the malleolus The complete tears of the peroneus brevis tendon (PC) and peroneus longus (PL) are rare occurring in the area of the lateral malleolus or midfoot Seen in patients with ankle sprains or history of chronic instability especially if they suffer widespread diseases (RA DM) or treated with corticosteroids The peroneal tendon ruptures causing the inability to eversion of the foot and cavus foot varus
Important thickening of both peroneal tendons (longus and brevis) associated
with moderate amount of fluid and thickening of the synovial sheath
Discreet amount of fluid in the common sheath of the peroneal tendons
associated with disorganization and a heterogeneous appearance
peroneus brevis tendon related to longitudinal rupture
Peroneal tenosynovitis and osteosynthesis
Tenosynovitis of the peroneal tendons and an intratendinous rupture of the short peroneal tendon
Intratendinous rupture and cyst in the peroneus brevis tendon
Peroneus quartus with an accessory muscle next to the peroneus longus and brevis tendons
Tumor next to the peroneal tendons that proved to be a benign fibrous mass
MEDIAL COMPARTMENT
ANOMALIES POSTERIOR TIBIAL TENDON (TP)
It is the most frequently injured in this compartment with ruptures
in asymptomatic middle-aged obese women as a result of
widespread disease (RA seronegative Spondyloarthropathy) or
associated with bone fractures It causes a gradual collapse of the
medial longitudinal arch with hindfoot valgus deformity and
excessive forefoot pronation
The presence of small vessels in inflammatory diseases
intratendinosis can simulate a fissuration tendon confusion can be ignored using colour Doppler Another possible diagnostic difficulty is when the undamaged tendon flexor digitorum longus (FLD) moves back and simulates the TP unbroken but it is smaller and in this case we only see in the groove retromalleolar 1 only tendon
Ultrasound has also proven to be an effective resource for identifying alterations associated tendon tenosynovitis serosa and hypertrophicSubluxation and dislocation anteriorly and medial TP relative to internal
malleolus is rare and valued sonographically placing the foot in dorsiflexion with forced supination
Thickening moderate amount of fluid surrounding calcifications and
hyperemia affecting the sheath and the posterior tibial tendon related
to chronic tenosynovitis in patient affects rheumatoid arthritis
Thickening moderate amount of surrounding fluid and calcifications (arrow) affecting the
posterior tibial tendon related to chronic tenosynovitis in patient affects rheumatoid arthritis
Tenosynovitis of the posterior tibial tendon caused by a bony ridge at the insertion of the retinaculum The retinaculum is thickened and the tendon subluxates
Psoriatic arthritis Ankle Grayscale examination Posterior tibial tendon on longitudinal (a) and transverse (b) scan Marked tendon sheath widening with homogeneous anechoic aspect (asterisks) of the content indicating an exudative tenosynovitis Note as the normal fibrillar echotexture is conserved Hand Flexor tendons of second finger The volar longitudinal (c) and transverse scan (d) shows a tendon sheath widening with signs of synovial proliferation presence of intense power Doppler signal surrounding the tendon and micro interruption of the margin (arrow) e Wrist Extensor carpi ulnaris tendon (sixth compartment of the extensor tendons ecu) on lateral longitudinal (e) and transverse (f) scan Chronic tenosynovitis with clear areas of low of echogenicity and loss of the continuity of tendon fibrils indicative of partial tendon tear (arrows) Moreover note the presence of power Doppler signal within the interruption indicating still activity of the inflammatory process g Dactylitis Volar longitudinal scan using the ldquoextended viewrdquo technique showing proliferative tenosynovitis of the finger flexor tendon (circle) exudative synovitis of both proximal and distal interphalangeal joint (white asterisks) and edema of the peritendinous tissue (black asterisks) TP posterior tibial tendon mm medial malleolus DP distal phalanx mp middle phalanx cu cubital bone ft flexor tendons
Tenosynovitis of the posterior tibial (1) and flexor digitorum longus tendon (2)
Tibialis Posterior Tendon rupture
Tenosynovitis of the posterior tibial tendon the flexor digitorum tendon and flexor hallucis longus tendon
Tenosynovitis of the tendons on the medial side in the left ankle
bullLIGAMENT INJURIESThe ligament partial tear ligament shows a hypoechoic
areas swollen with internal focal or diffuse In the complete
ruptures within the substance of the divided ligament rift is
observed corresponding to the hematoma hypoechoic and
the free ends of the divided ligament can be and retracted
appreciated corrugated in contrast with normal
appearance straight
Grade I Mild stretching of the ligament without breakage
or instability
Grade II Partial tearing of the ligament
Grade III Complete tearing
Degrees depending on the severity of the injury and the
place of employment
LATERAL COMPARTMENTThese injuries occur secondary to inversion sprains with internal rotation of
the foot combined with ankle plantar flexion
The anterior talar fibular ligament tears (ATFL) usually occur as isolated
involvement (70) or associated with calcaneal fibular ligament (CFL) (20-40)
but the posterior talar fibular ligament (PTFL) affects only major trauma
involving ankle dislocation
ATFL breaks is associated with breakage of the joint capsule and synovial fluid
extravasation into the anterolateral soft ankle whereas the complete tearing of
CFL can communicate the ankle joint and synovial sheath peroneal tendons
Rupture of CFL is rarely associated with superior peroneal retinaculum tear
The CFL is tensioned during dorsiflexion pulling on peroneal tendons laterally
so that absence of its displacement is sign of a complete tear
Within a damaged ligament can also observe calcifications that often
correspond to fragments of avulsion bone
During the ultrasound can be performed forced maneuvers to detect to joint
laxity and ligament injuries The anterior drawer test is performed with the feet
hanging over the edge of the examination table while the forefoot is pulled
anteriorly when the foot is in plantar flexion and inversion This maneuver
helps differentiate partial tears (grade II) of the ATFL to complete (grade III)
where the anterior displacement of the talus on the tibia open a crack in the
substance becoming more visible the ligament injury
The sindesmosys sprains are up to 10 of ankle
injuries happening in eversion and pronation
movements (like the deltoid ligament injury) and
primarily affect the anterior tibiofibular ligament (ATFL)
the failure is frequently associated with fracture of the
fibula
According to the place of employment are 4 degrees
useful for prognostic evaluation and therapeutic strategy
choice
Grade I stretch or partial tear of the ATFL
Grade II complete tearing but only the ATFL
Grade III complete tear of the ATFL and partial CFL
Grade IV complete tear of the ATFL and CFL
The grade I and II injuries usually scarred without any
significant instability whereas grade III and IV injuries
can cause chronic pain and require surgical treatment
Thickened but continued ATFL right in relation to the partial rupture
Grade 111 sprain of right ATFL
Thickened anterior talofibular ligament with calcifications and a partial rupture
Thickened tibiofibular ligament after trauma
Anterior Talofibular Ligament Partial Tear and Elastography
Tibio fibular ligament rupture with bony avulsion
Complete rupture of right ATFL
Bony avulsion with radiographic evidence as visible calcification in a grade III sprain ATFL
Moderately thickened and hypoechoic ATFL
Discontinuity of the ATFL with fluid surrounding the torn ends (arrow)
Thickening and hypoechogenicity of the fibular end of the ligament seen here passing over the subtalar joint which contains a small of fluid
Complete disruption to the tibiofibular ligament with bony irregularity of particularly the tibial margin and fluid in the gap
MEDIAL COMPARTMENTBecause of the low incidence of eversion ankle
sprains and the thickness of the deltoid ligament
is rarely injured in isolation and when the injury
does not usually full thickness Usually
accompanied by lesions of the medial malleolus
and lateral displacement of the talus with
consequent widening of the ankle mortise
Ultrasound is useful for differentiating ligament
injury of the posterior tibial tendon injury
(TP) adjacent they have similar symptoms
The inability to visualize the deltoid ligament may
indicate tear but this is not considered a reliable
sign as its full ultrasound is not always possible
Partial medial ligament rupture
Thickened heterogeneous abnormal deltoid demonstrating hyperemia
Ultrasonogram showing a disrupted deltoid ligament with the probe in the coronal plane The white arrow indicates the medial malleolus the blue arrow indicates the talus and the red arrows indicate the disrupted deltoid ligament (A) Radiograph showing the same injury (B)
bullJOINT AND BONE DISORDERSUltrasound reliably detect spills mild (gt 2 ml) inside
of the ankle joint by exploring the front and rear
recess as well as areas of synovial proliferation and
may even display using the colour Doppler
hyperemic areas in arthritis patients
The intraarticular joints are displayed surrounded
fluid in one of the recesses of the ankle or subtalar
joint Sonographically diagnosed when changing position to perform flexion and extension Fracture of the lateral process of the talus is overlooked up to 50 of cases with plain radiography Ultrasound may suspect the presence of focal cortical disruption helping further to exclude concomitant ligament injury
Rheumatoid arthritis with synovial thickening (1) and erosion of the tibia (2)
Infectious arthritis with a pus filled anterior recess of the ankle
Arthritis and tenosynovitis of the ankle in a patient with rheumatoid arthritis
bullTUMOURSUltrasound can differentiate between a mass complex
and solid and a cystic in addition to verifying the
existence of accessory muscles (peroneus fourth
accessory flexor digitorum longus and accessory
soleus) As in any other location can be found
neoformative soft tissue tumors inflammatory
infectious etc
Ganglions of this location are more often symptomatic
and larger with multiple partitions
branched and lobed edges Differential diagnosis must
be made with tenosynovitis abscesses seromas and
varicosities
Neurogenic tumours are described as pathognomonic
homogeneous hypoechoic oval mass in continuity with
a nerve of origin
Ganglion cysts are non-malignant cystic masses that occur in association with musculoskeletal structures They are sometimes also simply referred to as ganglia or a ganglion but should not be confused with the anatomical term ganglion UltrasoundThe vast majority are anechoic to hypoechoic on ultrasound and have well defined margins Many demonstrate internal septations as well as acoustic enhancement A synovial cyst is a small fluid-filled sac or pouch that can develop over a tendon or joint creating a mass under the skin Synovial cyst is rare in ankle joint A synovial cyst may or may not be painful depending on their size and location
Ganglion cyst in the foot with bony erosion between navicular and cuneiform bones
Tarsal synovial cyst
Anechoic ganglion situated in the sinus tarsi fat between the talus and calcaneous
Plantar fasciitis (PF) refers to inflammation of the
plantar fascia of the foot It is considered the most common cause of heel pain
Clinical presentation Pain on the undersurface of the heel on weight bearing is the principal complaint It can be worse when weight is borne after a period of rest (eg in the morning) and eases with walking Passive dorsiflexion of the toes may exacerbates discomfort
UltrasoundOften the initial imaging modality of choice Ultrasound typically shows increased thickness of the fascia and a hypoechoic fascia
Thickened hypoechoic origin of the plantar fascia which has a convex superior margin
Complete avulsion of the plantar fascia from the calcaneal tubercle
Plantar fasciitis
bull LOCATING FOREIGN BODIES AND FRACTURES
As in any other location the ankle
area is also subsidiary host foreign
whose classification location and
existence can be defined perfectly by
ultrasound Being a focused study to
the area of interest and with great
resolution for surface structures can
be considered more resolute
examination to screen these cases
Osseous diseases and fractures | Sonography discovered Medial Malleolus Fracture
Ultrasound examination of left ankle A Longitudinal sonogram left ankle demonstrates a wooden foreign body B Transverse view left ankle Note the hypervascularity in the inflamed area C Corresponding X-ray of left ankle Note the swelling on the lateral aspect No foreign body is visible
Thank You
LATERAL COMPARTMENTTENOSYNOVITIS OF THE PERONEAL TENDONSThe main sign of ultrasound is the presence of liquid inside the
common synovial sheath whereas usually tendinous
morphology is preserved We must differentiate tenosynovitis of
a spill within the common peroneal sheath secondary to a tear of
calcaneofibular ligament (PCL) The ultrasound diagnosis is the detection of the tendons in a lateral plane relative to the distal portion of the lateral malleolus instead of behind it The dynamic exploration foot dorsiflexion as both eversion may help identify cases of intermittent subluxation In long-standing disease can be observed fusiform thickening
of the peroneal tendons at the tip of the malleolus The complete tears of the peroneus brevis tendon (PC) and peroneus longus (PL) are rare occurring in the area of the lateral malleolus or midfoot Seen in patients with ankle sprains or history of chronic instability especially if they suffer widespread diseases (RA DM) or treated with corticosteroids The peroneal tendon ruptures causing the inability to eversion of the foot and cavus foot varus
Important thickening of both peroneal tendons (longus and brevis) associated
with moderate amount of fluid and thickening of the synovial sheath
Discreet amount of fluid in the common sheath of the peroneal tendons
associated with disorganization and a heterogeneous appearance
peroneus brevis tendon related to longitudinal rupture
Peroneal tenosynovitis and osteosynthesis
Tenosynovitis of the peroneal tendons and an intratendinous rupture of the short peroneal tendon
Intratendinous rupture and cyst in the peroneus brevis tendon
Peroneus quartus with an accessory muscle next to the peroneus longus and brevis tendons
Tumor next to the peroneal tendons that proved to be a benign fibrous mass
MEDIAL COMPARTMENT
ANOMALIES POSTERIOR TIBIAL TENDON (TP)
It is the most frequently injured in this compartment with ruptures
in asymptomatic middle-aged obese women as a result of
widespread disease (RA seronegative Spondyloarthropathy) or
associated with bone fractures It causes a gradual collapse of the
medial longitudinal arch with hindfoot valgus deformity and
excessive forefoot pronation
The presence of small vessels in inflammatory diseases
intratendinosis can simulate a fissuration tendon confusion can be ignored using colour Doppler Another possible diagnostic difficulty is when the undamaged tendon flexor digitorum longus (FLD) moves back and simulates the TP unbroken but it is smaller and in this case we only see in the groove retromalleolar 1 only tendon
Ultrasound has also proven to be an effective resource for identifying alterations associated tendon tenosynovitis serosa and hypertrophicSubluxation and dislocation anteriorly and medial TP relative to internal
malleolus is rare and valued sonographically placing the foot in dorsiflexion with forced supination
Thickening moderate amount of fluid surrounding calcifications and
hyperemia affecting the sheath and the posterior tibial tendon related
to chronic tenosynovitis in patient affects rheumatoid arthritis
Thickening moderate amount of surrounding fluid and calcifications (arrow) affecting the
posterior tibial tendon related to chronic tenosynovitis in patient affects rheumatoid arthritis
Tenosynovitis of the posterior tibial tendon caused by a bony ridge at the insertion of the retinaculum The retinaculum is thickened and the tendon subluxates
Psoriatic arthritis Ankle Grayscale examination Posterior tibial tendon on longitudinal (a) and transverse (b) scan Marked tendon sheath widening with homogeneous anechoic aspect (asterisks) of the content indicating an exudative tenosynovitis Note as the normal fibrillar echotexture is conserved Hand Flexor tendons of second finger The volar longitudinal (c) and transverse scan (d) shows a tendon sheath widening with signs of synovial proliferation presence of intense power Doppler signal surrounding the tendon and micro interruption of the margin (arrow) e Wrist Extensor carpi ulnaris tendon (sixth compartment of the extensor tendons ecu) on lateral longitudinal (e) and transverse (f) scan Chronic tenosynovitis with clear areas of low of echogenicity and loss of the continuity of tendon fibrils indicative of partial tendon tear (arrows) Moreover note the presence of power Doppler signal within the interruption indicating still activity of the inflammatory process g Dactylitis Volar longitudinal scan using the ldquoextended viewrdquo technique showing proliferative tenosynovitis of the finger flexor tendon (circle) exudative synovitis of both proximal and distal interphalangeal joint (white asterisks) and edema of the peritendinous tissue (black asterisks) TP posterior tibial tendon mm medial malleolus DP distal phalanx mp middle phalanx cu cubital bone ft flexor tendons
Tenosynovitis of the posterior tibial (1) and flexor digitorum longus tendon (2)
Tibialis Posterior Tendon rupture
Tenosynovitis of the posterior tibial tendon the flexor digitorum tendon and flexor hallucis longus tendon
Tenosynovitis of the tendons on the medial side in the left ankle
bullLIGAMENT INJURIESThe ligament partial tear ligament shows a hypoechoic
areas swollen with internal focal or diffuse In the complete
ruptures within the substance of the divided ligament rift is
observed corresponding to the hematoma hypoechoic and
the free ends of the divided ligament can be and retracted
appreciated corrugated in contrast with normal
appearance straight
Grade I Mild stretching of the ligament without breakage
or instability
Grade II Partial tearing of the ligament
Grade III Complete tearing
Degrees depending on the severity of the injury and the
place of employment
LATERAL COMPARTMENTThese injuries occur secondary to inversion sprains with internal rotation of
the foot combined with ankle plantar flexion
The anterior talar fibular ligament tears (ATFL) usually occur as isolated
involvement (70) or associated with calcaneal fibular ligament (CFL) (20-40)
but the posterior talar fibular ligament (PTFL) affects only major trauma
involving ankle dislocation
ATFL breaks is associated with breakage of the joint capsule and synovial fluid
extravasation into the anterolateral soft ankle whereas the complete tearing of
CFL can communicate the ankle joint and synovial sheath peroneal tendons
Rupture of CFL is rarely associated with superior peroneal retinaculum tear
The CFL is tensioned during dorsiflexion pulling on peroneal tendons laterally
so that absence of its displacement is sign of a complete tear
Within a damaged ligament can also observe calcifications that often
correspond to fragments of avulsion bone
During the ultrasound can be performed forced maneuvers to detect to joint
laxity and ligament injuries The anterior drawer test is performed with the feet
hanging over the edge of the examination table while the forefoot is pulled
anteriorly when the foot is in plantar flexion and inversion This maneuver
helps differentiate partial tears (grade II) of the ATFL to complete (grade III)
where the anterior displacement of the talus on the tibia open a crack in the
substance becoming more visible the ligament injury
The sindesmosys sprains are up to 10 of ankle
injuries happening in eversion and pronation
movements (like the deltoid ligament injury) and
primarily affect the anterior tibiofibular ligament (ATFL)
the failure is frequently associated with fracture of the
fibula
According to the place of employment are 4 degrees
useful for prognostic evaluation and therapeutic strategy
choice
Grade I stretch or partial tear of the ATFL
Grade II complete tearing but only the ATFL
Grade III complete tear of the ATFL and partial CFL
Grade IV complete tear of the ATFL and CFL
The grade I and II injuries usually scarred without any
significant instability whereas grade III and IV injuries
can cause chronic pain and require surgical treatment
Thickened but continued ATFL right in relation to the partial rupture
Grade 111 sprain of right ATFL
Thickened anterior talofibular ligament with calcifications and a partial rupture
Thickened tibiofibular ligament after trauma
Anterior Talofibular Ligament Partial Tear and Elastography
Tibio fibular ligament rupture with bony avulsion
Complete rupture of right ATFL
Bony avulsion with radiographic evidence as visible calcification in a grade III sprain ATFL
Moderately thickened and hypoechoic ATFL
Discontinuity of the ATFL with fluid surrounding the torn ends (arrow)
Thickening and hypoechogenicity of the fibular end of the ligament seen here passing over the subtalar joint which contains a small of fluid
Complete disruption to the tibiofibular ligament with bony irregularity of particularly the tibial margin and fluid in the gap
MEDIAL COMPARTMENTBecause of the low incidence of eversion ankle
sprains and the thickness of the deltoid ligament
is rarely injured in isolation and when the injury
does not usually full thickness Usually
accompanied by lesions of the medial malleolus
and lateral displacement of the talus with
consequent widening of the ankle mortise
Ultrasound is useful for differentiating ligament
injury of the posterior tibial tendon injury
(TP) adjacent they have similar symptoms
The inability to visualize the deltoid ligament may
indicate tear but this is not considered a reliable
sign as its full ultrasound is not always possible
Partial medial ligament rupture
Thickened heterogeneous abnormal deltoid demonstrating hyperemia
Ultrasonogram showing a disrupted deltoid ligament with the probe in the coronal plane The white arrow indicates the medial malleolus the blue arrow indicates the talus and the red arrows indicate the disrupted deltoid ligament (A) Radiograph showing the same injury (B)
bullJOINT AND BONE DISORDERSUltrasound reliably detect spills mild (gt 2 ml) inside
of the ankle joint by exploring the front and rear
recess as well as areas of synovial proliferation and
may even display using the colour Doppler
hyperemic areas in arthritis patients
The intraarticular joints are displayed surrounded
fluid in one of the recesses of the ankle or subtalar
joint Sonographically diagnosed when changing position to perform flexion and extension Fracture of the lateral process of the talus is overlooked up to 50 of cases with plain radiography Ultrasound may suspect the presence of focal cortical disruption helping further to exclude concomitant ligament injury
Rheumatoid arthritis with synovial thickening (1) and erosion of the tibia (2)
Infectious arthritis with a pus filled anterior recess of the ankle
Arthritis and tenosynovitis of the ankle in a patient with rheumatoid arthritis
bullTUMOURSUltrasound can differentiate between a mass complex
and solid and a cystic in addition to verifying the
existence of accessory muscles (peroneus fourth
accessory flexor digitorum longus and accessory
soleus) As in any other location can be found
neoformative soft tissue tumors inflammatory
infectious etc
Ganglions of this location are more often symptomatic
and larger with multiple partitions
branched and lobed edges Differential diagnosis must
be made with tenosynovitis abscesses seromas and
varicosities
Neurogenic tumours are described as pathognomonic
homogeneous hypoechoic oval mass in continuity with
a nerve of origin
Ganglion cysts are non-malignant cystic masses that occur in association with musculoskeletal structures They are sometimes also simply referred to as ganglia or a ganglion but should not be confused with the anatomical term ganglion UltrasoundThe vast majority are anechoic to hypoechoic on ultrasound and have well defined margins Many demonstrate internal septations as well as acoustic enhancement A synovial cyst is a small fluid-filled sac or pouch that can develop over a tendon or joint creating a mass under the skin Synovial cyst is rare in ankle joint A synovial cyst may or may not be painful depending on their size and location
Ganglion cyst in the foot with bony erosion between navicular and cuneiform bones
Tarsal synovial cyst
Anechoic ganglion situated in the sinus tarsi fat between the talus and calcaneous
Plantar fasciitis (PF) refers to inflammation of the
plantar fascia of the foot It is considered the most common cause of heel pain
Clinical presentation Pain on the undersurface of the heel on weight bearing is the principal complaint It can be worse when weight is borne after a period of rest (eg in the morning) and eases with walking Passive dorsiflexion of the toes may exacerbates discomfort
UltrasoundOften the initial imaging modality of choice Ultrasound typically shows increased thickness of the fascia and a hypoechoic fascia
Thickened hypoechoic origin of the plantar fascia which has a convex superior margin
Complete avulsion of the plantar fascia from the calcaneal tubercle
Plantar fasciitis
bull LOCATING FOREIGN BODIES AND FRACTURES
As in any other location the ankle
area is also subsidiary host foreign
whose classification location and
existence can be defined perfectly by
ultrasound Being a focused study to
the area of interest and with great
resolution for surface structures can
be considered more resolute
examination to screen these cases
Osseous diseases and fractures | Sonography discovered Medial Malleolus Fracture
Ultrasound examination of left ankle A Longitudinal sonogram left ankle demonstrates a wooden foreign body B Transverse view left ankle Note the hypervascularity in the inflamed area C Corresponding X-ray of left ankle Note the swelling on the lateral aspect No foreign body is visible
Thank You
Important thickening of both peroneal tendons (longus and brevis) associated
with moderate amount of fluid and thickening of the synovial sheath
Discreet amount of fluid in the common sheath of the peroneal tendons
associated with disorganization and a heterogeneous appearance
peroneus brevis tendon related to longitudinal rupture
Peroneal tenosynovitis and osteosynthesis
Tenosynovitis of the peroneal tendons and an intratendinous rupture of the short peroneal tendon
Intratendinous rupture and cyst in the peroneus brevis tendon
Peroneus quartus with an accessory muscle next to the peroneus longus and brevis tendons
Tumor next to the peroneal tendons that proved to be a benign fibrous mass
MEDIAL COMPARTMENT
ANOMALIES POSTERIOR TIBIAL TENDON (TP)
It is the most frequently injured in this compartment with ruptures
in asymptomatic middle-aged obese women as a result of
widespread disease (RA seronegative Spondyloarthropathy) or
associated with bone fractures It causes a gradual collapse of the
medial longitudinal arch with hindfoot valgus deformity and
excessive forefoot pronation
The presence of small vessels in inflammatory diseases
intratendinosis can simulate a fissuration tendon confusion can be ignored using colour Doppler Another possible diagnostic difficulty is when the undamaged tendon flexor digitorum longus (FLD) moves back and simulates the TP unbroken but it is smaller and in this case we only see in the groove retromalleolar 1 only tendon
Ultrasound has also proven to be an effective resource for identifying alterations associated tendon tenosynovitis serosa and hypertrophicSubluxation and dislocation anteriorly and medial TP relative to internal
malleolus is rare and valued sonographically placing the foot in dorsiflexion with forced supination
Thickening moderate amount of fluid surrounding calcifications and
hyperemia affecting the sheath and the posterior tibial tendon related
to chronic tenosynovitis in patient affects rheumatoid arthritis
Thickening moderate amount of surrounding fluid and calcifications (arrow) affecting the
posterior tibial tendon related to chronic tenosynovitis in patient affects rheumatoid arthritis
Tenosynovitis of the posterior tibial tendon caused by a bony ridge at the insertion of the retinaculum The retinaculum is thickened and the tendon subluxates
Psoriatic arthritis Ankle Grayscale examination Posterior tibial tendon on longitudinal (a) and transverse (b) scan Marked tendon sheath widening with homogeneous anechoic aspect (asterisks) of the content indicating an exudative tenosynovitis Note as the normal fibrillar echotexture is conserved Hand Flexor tendons of second finger The volar longitudinal (c) and transverse scan (d) shows a tendon sheath widening with signs of synovial proliferation presence of intense power Doppler signal surrounding the tendon and micro interruption of the margin (arrow) e Wrist Extensor carpi ulnaris tendon (sixth compartment of the extensor tendons ecu) on lateral longitudinal (e) and transverse (f) scan Chronic tenosynovitis with clear areas of low of echogenicity and loss of the continuity of tendon fibrils indicative of partial tendon tear (arrows) Moreover note the presence of power Doppler signal within the interruption indicating still activity of the inflammatory process g Dactylitis Volar longitudinal scan using the ldquoextended viewrdquo technique showing proliferative tenosynovitis of the finger flexor tendon (circle) exudative synovitis of both proximal and distal interphalangeal joint (white asterisks) and edema of the peritendinous tissue (black asterisks) TP posterior tibial tendon mm medial malleolus DP distal phalanx mp middle phalanx cu cubital bone ft flexor tendons
Tenosynovitis of the posterior tibial (1) and flexor digitorum longus tendon (2)
Tibialis Posterior Tendon rupture
Tenosynovitis of the posterior tibial tendon the flexor digitorum tendon and flexor hallucis longus tendon
Tenosynovitis of the tendons on the medial side in the left ankle
bullLIGAMENT INJURIESThe ligament partial tear ligament shows a hypoechoic
areas swollen with internal focal or diffuse In the complete
ruptures within the substance of the divided ligament rift is
observed corresponding to the hematoma hypoechoic and
the free ends of the divided ligament can be and retracted
appreciated corrugated in contrast with normal
appearance straight
Grade I Mild stretching of the ligament without breakage
or instability
Grade II Partial tearing of the ligament
Grade III Complete tearing
Degrees depending on the severity of the injury and the
place of employment
LATERAL COMPARTMENTThese injuries occur secondary to inversion sprains with internal rotation of
the foot combined with ankle plantar flexion
The anterior talar fibular ligament tears (ATFL) usually occur as isolated
involvement (70) or associated with calcaneal fibular ligament (CFL) (20-40)
but the posterior talar fibular ligament (PTFL) affects only major trauma
involving ankle dislocation
ATFL breaks is associated with breakage of the joint capsule and synovial fluid
extravasation into the anterolateral soft ankle whereas the complete tearing of
CFL can communicate the ankle joint and synovial sheath peroneal tendons
Rupture of CFL is rarely associated with superior peroneal retinaculum tear
The CFL is tensioned during dorsiflexion pulling on peroneal tendons laterally
so that absence of its displacement is sign of a complete tear
Within a damaged ligament can also observe calcifications that often
correspond to fragments of avulsion bone
During the ultrasound can be performed forced maneuvers to detect to joint
laxity and ligament injuries The anterior drawer test is performed with the feet
hanging over the edge of the examination table while the forefoot is pulled
anteriorly when the foot is in plantar flexion and inversion This maneuver
helps differentiate partial tears (grade II) of the ATFL to complete (grade III)
where the anterior displacement of the talus on the tibia open a crack in the
substance becoming more visible the ligament injury
The sindesmosys sprains are up to 10 of ankle
injuries happening in eversion and pronation
movements (like the deltoid ligament injury) and
primarily affect the anterior tibiofibular ligament (ATFL)
the failure is frequently associated with fracture of the
fibula
According to the place of employment are 4 degrees
useful for prognostic evaluation and therapeutic strategy
choice
Grade I stretch or partial tear of the ATFL
Grade II complete tearing but only the ATFL
Grade III complete tear of the ATFL and partial CFL
Grade IV complete tear of the ATFL and CFL
The grade I and II injuries usually scarred without any
significant instability whereas grade III and IV injuries
can cause chronic pain and require surgical treatment
Thickened but continued ATFL right in relation to the partial rupture
Grade 111 sprain of right ATFL
Thickened anterior talofibular ligament with calcifications and a partial rupture
Thickened tibiofibular ligament after trauma
Anterior Talofibular Ligament Partial Tear and Elastography
Tibio fibular ligament rupture with bony avulsion
Complete rupture of right ATFL
Bony avulsion with radiographic evidence as visible calcification in a grade III sprain ATFL
Moderately thickened and hypoechoic ATFL
Discontinuity of the ATFL with fluid surrounding the torn ends (arrow)
Thickening and hypoechogenicity of the fibular end of the ligament seen here passing over the subtalar joint which contains a small of fluid
Complete disruption to the tibiofibular ligament with bony irregularity of particularly the tibial margin and fluid in the gap
MEDIAL COMPARTMENTBecause of the low incidence of eversion ankle
sprains and the thickness of the deltoid ligament
is rarely injured in isolation and when the injury
does not usually full thickness Usually
accompanied by lesions of the medial malleolus
and lateral displacement of the talus with
consequent widening of the ankle mortise
Ultrasound is useful for differentiating ligament
injury of the posterior tibial tendon injury
(TP) adjacent they have similar symptoms
The inability to visualize the deltoid ligament may
indicate tear but this is not considered a reliable
sign as its full ultrasound is not always possible
Partial medial ligament rupture
Thickened heterogeneous abnormal deltoid demonstrating hyperemia
Ultrasonogram showing a disrupted deltoid ligament with the probe in the coronal plane The white arrow indicates the medial malleolus the blue arrow indicates the talus and the red arrows indicate the disrupted deltoid ligament (A) Radiograph showing the same injury (B)
bullJOINT AND BONE DISORDERSUltrasound reliably detect spills mild (gt 2 ml) inside
of the ankle joint by exploring the front and rear
recess as well as areas of synovial proliferation and
may even display using the colour Doppler
hyperemic areas in arthritis patients
The intraarticular joints are displayed surrounded
fluid in one of the recesses of the ankle or subtalar
joint Sonographically diagnosed when changing position to perform flexion and extension Fracture of the lateral process of the talus is overlooked up to 50 of cases with plain radiography Ultrasound may suspect the presence of focal cortical disruption helping further to exclude concomitant ligament injury
Rheumatoid arthritis with synovial thickening (1) and erosion of the tibia (2)
Infectious arthritis with a pus filled anterior recess of the ankle
Arthritis and tenosynovitis of the ankle in a patient with rheumatoid arthritis
bullTUMOURSUltrasound can differentiate between a mass complex
and solid and a cystic in addition to verifying the
existence of accessory muscles (peroneus fourth
accessory flexor digitorum longus and accessory
soleus) As in any other location can be found
neoformative soft tissue tumors inflammatory
infectious etc
Ganglions of this location are more often symptomatic
and larger with multiple partitions
branched and lobed edges Differential diagnosis must
be made with tenosynovitis abscesses seromas and
varicosities
Neurogenic tumours are described as pathognomonic
homogeneous hypoechoic oval mass in continuity with
a nerve of origin
Ganglion cysts are non-malignant cystic masses that occur in association with musculoskeletal structures They are sometimes also simply referred to as ganglia or a ganglion but should not be confused with the anatomical term ganglion UltrasoundThe vast majority are anechoic to hypoechoic on ultrasound and have well defined margins Many demonstrate internal septations as well as acoustic enhancement A synovial cyst is a small fluid-filled sac or pouch that can develop over a tendon or joint creating a mass under the skin Synovial cyst is rare in ankle joint A synovial cyst may or may not be painful depending on their size and location
Ganglion cyst in the foot with bony erosion between navicular and cuneiform bones
Tarsal synovial cyst
Anechoic ganglion situated in the sinus tarsi fat between the talus and calcaneous
Plantar fasciitis (PF) refers to inflammation of the
plantar fascia of the foot It is considered the most common cause of heel pain
Clinical presentation Pain on the undersurface of the heel on weight bearing is the principal complaint It can be worse when weight is borne after a period of rest (eg in the morning) and eases with walking Passive dorsiflexion of the toes may exacerbates discomfort
UltrasoundOften the initial imaging modality of choice Ultrasound typically shows increased thickness of the fascia and a hypoechoic fascia
Thickened hypoechoic origin of the plantar fascia which has a convex superior margin
Complete avulsion of the plantar fascia from the calcaneal tubercle
Plantar fasciitis
bull LOCATING FOREIGN BODIES AND FRACTURES
As in any other location the ankle
area is also subsidiary host foreign
whose classification location and
existence can be defined perfectly by
ultrasound Being a focused study to
the area of interest and with great
resolution for surface structures can
be considered more resolute
examination to screen these cases
Osseous diseases and fractures | Sonography discovered Medial Malleolus Fracture
Ultrasound examination of left ankle A Longitudinal sonogram left ankle demonstrates a wooden foreign body B Transverse view left ankle Note the hypervascularity in the inflamed area C Corresponding X-ray of left ankle Note the swelling on the lateral aspect No foreign body is visible
Thank You
Discreet amount of fluid in the common sheath of the peroneal tendons
associated with disorganization and a heterogeneous appearance
peroneus brevis tendon related to longitudinal rupture
Peroneal tenosynovitis and osteosynthesis
Tenosynovitis of the peroneal tendons and an intratendinous rupture of the short peroneal tendon
Intratendinous rupture and cyst in the peroneus brevis tendon
Peroneus quartus with an accessory muscle next to the peroneus longus and brevis tendons
Tumor next to the peroneal tendons that proved to be a benign fibrous mass
MEDIAL COMPARTMENT
ANOMALIES POSTERIOR TIBIAL TENDON (TP)
It is the most frequently injured in this compartment with ruptures
in asymptomatic middle-aged obese women as a result of
widespread disease (RA seronegative Spondyloarthropathy) or
associated with bone fractures It causes a gradual collapse of the
medial longitudinal arch with hindfoot valgus deformity and
excessive forefoot pronation
The presence of small vessels in inflammatory diseases
intratendinosis can simulate a fissuration tendon confusion can be ignored using colour Doppler Another possible diagnostic difficulty is when the undamaged tendon flexor digitorum longus (FLD) moves back and simulates the TP unbroken but it is smaller and in this case we only see in the groove retromalleolar 1 only tendon
Ultrasound has also proven to be an effective resource for identifying alterations associated tendon tenosynovitis serosa and hypertrophicSubluxation and dislocation anteriorly and medial TP relative to internal
malleolus is rare and valued sonographically placing the foot in dorsiflexion with forced supination
Thickening moderate amount of fluid surrounding calcifications and
hyperemia affecting the sheath and the posterior tibial tendon related
to chronic tenosynovitis in patient affects rheumatoid arthritis
Thickening moderate amount of surrounding fluid and calcifications (arrow) affecting the
posterior tibial tendon related to chronic tenosynovitis in patient affects rheumatoid arthritis
Tenosynovitis of the posterior tibial tendon caused by a bony ridge at the insertion of the retinaculum The retinaculum is thickened and the tendon subluxates
Psoriatic arthritis Ankle Grayscale examination Posterior tibial tendon on longitudinal (a) and transverse (b) scan Marked tendon sheath widening with homogeneous anechoic aspect (asterisks) of the content indicating an exudative tenosynovitis Note as the normal fibrillar echotexture is conserved Hand Flexor tendons of second finger The volar longitudinal (c) and transverse scan (d) shows a tendon sheath widening with signs of synovial proliferation presence of intense power Doppler signal surrounding the tendon and micro interruption of the margin (arrow) e Wrist Extensor carpi ulnaris tendon (sixth compartment of the extensor tendons ecu) on lateral longitudinal (e) and transverse (f) scan Chronic tenosynovitis with clear areas of low of echogenicity and loss of the continuity of tendon fibrils indicative of partial tendon tear (arrows) Moreover note the presence of power Doppler signal within the interruption indicating still activity of the inflammatory process g Dactylitis Volar longitudinal scan using the ldquoextended viewrdquo technique showing proliferative tenosynovitis of the finger flexor tendon (circle) exudative synovitis of both proximal and distal interphalangeal joint (white asterisks) and edema of the peritendinous tissue (black asterisks) TP posterior tibial tendon mm medial malleolus DP distal phalanx mp middle phalanx cu cubital bone ft flexor tendons
Tenosynovitis of the posterior tibial (1) and flexor digitorum longus tendon (2)
Tibialis Posterior Tendon rupture
Tenosynovitis of the posterior tibial tendon the flexor digitorum tendon and flexor hallucis longus tendon
Tenosynovitis of the tendons on the medial side in the left ankle
bullLIGAMENT INJURIESThe ligament partial tear ligament shows a hypoechoic
areas swollen with internal focal or diffuse In the complete
ruptures within the substance of the divided ligament rift is
observed corresponding to the hematoma hypoechoic and
the free ends of the divided ligament can be and retracted
appreciated corrugated in contrast with normal
appearance straight
Grade I Mild stretching of the ligament without breakage
or instability
Grade II Partial tearing of the ligament
Grade III Complete tearing
Degrees depending on the severity of the injury and the
place of employment
LATERAL COMPARTMENTThese injuries occur secondary to inversion sprains with internal rotation of
the foot combined with ankle plantar flexion
The anterior talar fibular ligament tears (ATFL) usually occur as isolated
involvement (70) or associated with calcaneal fibular ligament (CFL) (20-40)
but the posterior talar fibular ligament (PTFL) affects only major trauma
involving ankle dislocation
ATFL breaks is associated with breakage of the joint capsule and synovial fluid
extravasation into the anterolateral soft ankle whereas the complete tearing of
CFL can communicate the ankle joint and synovial sheath peroneal tendons
Rupture of CFL is rarely associated with superior peroneal retinaculum tear
The CFL is tensioned during dorsiflexion pulling on peroneal tendons laterally
so that absence of its displacement is sign of a complete tear
Within a damaged ligament can also observe calcifications that often
correspond to fragments of avulsion bone
During the ultrasound can be performed forced maneuvers to detect to joint
laxity and ligament injuries The anterior drawer test is performed with the feet
hanging over the edge of the examination table while the forefoot is pulled
anteriorly when the foot is in plantar flexion and inversion This maneuver
helps differentiate partial tears (grade II) of the ATFL to complete (grade III)
where the anterior displacement of the talus on the tibia open a crack in the
substance becoming more visible the ligament injury
The sindesmosys sprains are up to 10 of ankle
injuries happening in eversion and pronation
movements (like the deltoid ligament injury) and
primarily affect the anterior tibiofibular ligament (ATFL)
the failure is frequently associated with fracture of the
fibula
According to the place of employment are 4 degrees
useful for prognostic evaluation and therapeutic strategy
choice
Grade I stretch or partial tear of the ATFL
Grade II complete tearing but only the ATFL
Grade III complete tear of the ATFL and partial CFL
Grade IV complete tear of the ATFL and CFL
The grade I and II injuries usually scarred without any
significant instability whereas grade III and IV injuries
can cause chronic pain and require surgical treatment
Thickened but continued ATFL right in relation to the partial rupture
Grade 111 sprain of right ATFL
Thickened anterior talofibular ligament with calcifications and a partial rupture
Thickened tibiofibular ligament after trauma
Anterior Talofibular Ligament Partial Tear and Elastography
Tibio fibular ligament rupture with bony avulsion
Complete rupture of right ATFL
Bony avulsion with radiographic evidence as visible calcification in a grade III sprain ATFL
Moderately thickened and hypoechoic ATFL
Discontinuity of the ATFL with fluid surrounding the torn ends (arrow)
Thickening and hypoechogenicity of the fibular end of the ligament seen here passing over the subtalar joint which contains a small of fluid
Complete disruption to the tibiofibular ligament with bony irregularity of particularly the tibial margin and fluid in the gap
MEDIAL COMPARTMENTBecause of the low incidence of eversion ankle
sprains and the thickness of the deltoid ligament
is rarely injured in isolation and when the injury
does not usually full thickness Usually
accompanied by lesions of the medial malleolus
and lateral displacement of the talus with
consequent widening of the ankle mortise
Ultrasound is useful for differentiating ligament
injury of the posterior tibial tendon injury
(TP) adjacent they have similar symptoms
The inability to visualize the deltoid ligament may
indicate tear but this is not considered a reliable
sign as its full ultrasound is not always possible
Partial medial ligament rupture
Thickened heterogeneous abnormal deltoid demonstrating hyperemia
Ultrasonogram showing a disrupted deltoid ligament with the probe in the coronal plane The white arrow indicates the medial malleolus the blue arrow indicates the talus and the red arrows indicate the disrupted deltoid ligament (A) Radiograph showing the same injury (B)
bullJOINT AND BONE DISORDERSUltrasound reliably detect spills mild (gt 2 ml) inside
of the ankle joint by exploring the front and rear
recess as well as areas of synovial proliferation and
may even display using the colour Doppler
hyperemic areas in arthritis patients
The intraarticular joints are displayed surrounded
fluid in one of the recesses of the ankle or subtalar
joint Sonographically diagnosed when changing position to perform flexion and extension Fracture of the lateral process of the talus is overlooked up to 50 of cases with plain radiography Ultrasound may suspect the presence of focal cortical disruption helping further to exclude concomitant ligament injury
Rheumatoid arthritis with synovial thickening (1) and erosion of the tibia (2)
Infectious arthritis with a pus filled anterior recess of the ankle
Arthritis and tenosynovitis of the ankle in a patient with rheumatoid arthritis
bullTUMOURSUltrasound can differentiate between a mass complex
and solid and a cystic in addition to verifying the
existence of accessory muscles (peroneus fourth
accessory flexor digitorum longus and accessory
soleus) As in any other location can be found
neoformative soft tissue tumors inflammatory
infectious etc
Ganglions of this location are more often symptomatic
and larger with multiple partitions
branched and lobed edges Differential diagnosis must
be made with tenosynovitis abscesses seromas and
varicosities
Neurogenic tumours are described as pathognomonic
homogeneous hypoechoic oval mass in continuity with
a nerve of origin
Ganglion cysts are non-malignant cystic masses that occur in association with musculoskeletal structures They are sometimes also simply referred to as ganglia or a ganglion but should not be confused with the anatomical term ganglion UltrasoundThe vast majority are anechoic to hypoechoic on ultrasound and have well defined margins Many demonstrate internal septations as well as acoustic enhancement A synovial cyst is a small fluid-filled sac or pouch that can develop over a tendon or joint creating a mass under the skin Synovial cyst is rare in ankle joint A synovial cyst may or may not be painful depending on their size and location
Ganglion cyst in the foot with bony erosion between navicular and cuneiform bones
Tarsal synovial cyst
Anechoic ganglion situated in the sinus tarsi fat between the talus and calcaneous
Plantar fasciitis (PF) refers to inflammation of the
plantar fascia of the foot It is considered the most common cause of heel pain
Clinical presentation Pain on the undersurface of the heel on weight bearing is the principal complaint It can be worse when weight is borne after a period of rest (eg in the morning) and eases with walking Passive dorsiflexion of the toes may exacerbates discomfort
UltrasoundOften the initial imaging modality of choice Ultrasound typically shows increased thickness of the fascia and a hypoechoic fascia
Thickened hypoechoic origin of the plantar fascia which has a convex superior margin
Complete avulsion of the plantar fascia from the calcaneal tubercle
Plantar fasciitis
bull LOCATING FOREIGN BODIES AND FRACTURES
As in any other location the ankle
area is also subsidiary host foreign
whose classification location and
existence can be defined perfectly by
ultrasound Being a focused study to
the area of interest and with great
resolution for surface structures can
be considered more resolute
examination to screen these cases
Osseous diseases and fractures | Sonography discovered Medial Malleolus Fracture
Ultrasound examination of left ankle A Longitudinal sonogram left ankle demonstrates a wooden foreign body B Transverse view left ankle Note the hypervascularity in the inflamed area C Corresponding X-ray of left ankle Note the swelling on the lateral aspect No foreign body is visible
Thank You
Peroneal tenosynovitis and osteosynthesis
Tenosynovitis of the peroneal tendons and an intratendinous rupture of the short peroneal tendon
Intratendinous rupture and cyst in the peroneus brevis tendon
Peroneus quartus with an accessory muscle next to the peroneus longus and brevis tendons
Tumor next to the peroneal tendons that proved to be a benign fibrous mass
MEDIAL COMPARTMENT
ANOMALIES POSTERIOR TIBIAL TENDON (TP)
It is the most frequently injured in this compartment with ruptures
in asymptomatic middle-aged obese women as a result of
widespread disease (RA seronegative Spondyloarthropathy) or
associated with bone fractures It causes a gradual collapse of the
medial longitudinal arch with hindfoot valgus deformity and
excessive forefoot pronation
The presence of small vessels in inflammatory diseases
intratendinosis can simulate a fissuration tendon confusion can be ignored using colour Doppler Another possible diagnostic difficulty is when the undamaged tendon flexor digitorum longus (FLD) moves back and simulates the TP unbroken but it is smaller and in this case we only see in the groove retromalleolar 1 only tendon
Ultrasound has also proven to be an effective resource for identifying alterations associated tendon tenosynovitis serosa and hypertrophicSubluxation and dislocation anteriorly and medial TP relative to internal
malleolus is rare and valued sonographically placing the foot in dorsiflexion with forced supination
Thickening moderate amount of fluid surrounding calcifications and
hyperemia affecting the sheath and the posterior tibial tendon related
to chronic tenosynovitis in patient affects rheumatoid arthritis
Thickening moderate amount of surrounding fluid and calcifications (arrow) affecting the
posterior tibial tendon related to chronic tenosynovitis in patient affects rheumatoid arthritis
Tenosynovitis of the posterior tibial tendon caused by a bony ridge at the insertion of the retinaculum The retinaculum is thickened and the tendon subluxates
Psoriatic arthritis Ankle Grayscale examination Posterior tibial tendon on longitudinal (a) and transverse (b) scan Marked tendon sheath widening with homogeneous anechoic aspect (asterisks) of the content indicating an exudative tenosynovitis Note as the normal fibrillar echotexture is conserved Hand Flexor tendons of second finger The volar longitudinal (c) and transverse scan (d) shows a tendon sheath widening with signs of synovial proliferation presence of intense power Doppler signal surrounding the tendon and micro interruption of the margin (arrow) e Wrist Extensor carpi ulnaris tendon (sixth compartment of the extensor tendons ecu) on lateral longitudinal (e) and transverse (f) scan Chronic tenosynovitis with clear areas of low of echogenicity and loss of the continuity of tendon fibrils indicative of partial tendon tear (arrows) Moreover note the presence of power Doppler signal within the interruption indicating still activity of the inflammatory process g Dactylitis Volar longitudinal scan using the ldquoextended viewrdquo technique showing proliferative tenosynovitis of the finger flexor tendon (circle) exudative synovitis of both proximal and distal interphalangeal joint (white asterisks) and edema of the peritendinous tissue (black asterisks) TP posterior tibial tendon mm medial malleolus DP distal phalanx mp middle phalanx cu cubital bone ft flexor tendons
Tenosynovitis of the posterior tibial (1) and flexor digitorum longus tendon (2)
Tibialis Posterior Tendon rupture
Tenosynovitis of the posterior tibial tendon the flexor digitorum tendon and flexor hallucis longus tendon
Tenosynovitis of the tendons on the medial side in the left ankle
bullLIGAMENT INJURIESThe ligament partial tear ligament shows a hypoechoic
areas swollen with internal focal or diffuse In the complete
ruptures within the substance of the divided ligament rift is
observed corresponding to the hematoma hypoechoic and
the free ends of the divided ligament can be and retracted
appreciated corrugated in contrast with normal
appearance straight
Grade I Mild stretching of the ligament without breakage
or instability
Grade II Partial tearing of the ligament
Grade III Complete tearing
Degrees depending on the severity of the injury and the
place of employment
LATERAL COMPARTMENTThese injuries occur secondary to inversion sprains with internal rotation of
the foot combined with ankle plantar flexion
The anterior talar fibular ligament tears (ATFL) usually occur as isolated
involvement (70) or associated with calcaneal fibular ligament (CFL) (20-40)
but the posterior talar fibular ligament (PTFL) affects only major trauma
involving ankle dislocation
ATFL breaks is associated with breakage of the joint capsule and synovial fluid
extravasation into the anterolateral soft ankle whereas the complete tearing of
CFL can communicate the ankle joint and synovial sheath peroneal tendons
Rupture of CFL is rarely associated with superior peroneal retinaculum tear
The CFL is tensioned during dorsiflexion pulling on peroneal tendons laterally
so that absence of its displacement is sign of a complete tear
Within a damaged ligament can also observe calcifications that often
correspond to fragments of avulsion bone
During the ultrasound can be performed forced maneuvers to detect to joint
laxity and ligament injuries The anterior drawer test is performed with the feet
hanging over the edge of the examination table while the forefoot is pulled
anteriorly when the foot is in plantar flexion and inversion This maneuver
helps differentiate partial tears (grade II) of the ATFL to complete (grade III)
where the anterior displacement of the talus on the tibia open a crack in the
substance becoming more visible the ligament injury
The sindesmosys sprains are up to 10 of ankle
injuries happening in eversion and pronation
movements (like the deltoid ligament injury) and
primarily affect the anterior tibiofibular ligament (ATFL)
the failure is frequently associated with fracture of the
fibula
According to the place of employment are 4 degrees
useful for prognostic evaluation and therapeutic strategy
choice
Grade I stretch or partial tear of the ATFL
Grade II complete tearing but only the ATFL
Grade III complete tear of the ATFL and partial CFL
Grade IV complete tear of the ATFL and CFL
The grade I and II injuries usually scarred without any
significant instability whereas grade III and IV injuries
can cause chronic pain and require surgical treatment
Thickened but continued ATFL right in relation to the partial rupture
Grade 111 sprain of right ATFL
Thickened anterior talofibular ligament with calcifications and a partial rupture
Thickened tibiofibular ligament after trauma
Anterior Talofibular Ligament Partial Tear and Elastography
Tibio fibular ligament rupture with bony avulsion
Complete rupture of right ATFL
Bony avulsion with radiographic evidence as visible calcification in a grade III sprain ATFL
Moderately thickened and hypoechoic ATFL
Discontinuity of the ATFL with fluid surrounding the torn ends (arrow)
Thickening and hypoechogenicity of the fibular end of the ligament seen here passing over the subtalar joint which contains a small of fluid
Complete disruption to the tibiofibular ligament with bony irregularity of particularly the tibial margin and fluid in the gap
MEDIAL COMPARTMENTBecause of the low incidence of eversion ankle
sprains and the thickness of the deltoid ligament
is rarely injured in isolation and when the injury
does not usually full thickness Usually
accompanied by lesions of the medial malleolus
and lateral displacement of the talus with
consequent widening of the ankle mortise
Ultrasound is useful for differentiating ligament
injury of the posterior tibial tendon injury
(TP) adjacent they have similar symptoms
The inability to visualize the deltoid ligament may
indicate tear but this is not considered a reliable
sign as its full ultrasound is not always possible
Partial medial ligament rupture
Thickened heterogeneous abnormal deltoid demonstrating hyperemia
Ultrasonogram showing a disrupted deltoid ligament with the probe in the coronal plane The white arrow indicates the medial malleolus the blue arrow indicates the talus and the red arrows indicate the disrupted deltoid ligament (A) Radiograph showing the same injury (B)
bullJOINT AND BONE DISORDERSUltrasound reliably detect spills mild (gt 2 ml) inside
of the ankle joint by exploring the front and rear
recess as well as areas of synovial proliferation and
may even display using the colour Doppler
hyperemic areas in arthritis patients
The intraarticular joints are displayed surrounded
fluid in one of the recesses of the ankle or subtalar
joint Sonographically diagnosed when changing position to perform flexion and extension Fracture of the lateral process of the talus is overlooked up to 50 of cases with plain radiography Ultrasound may suspect the presence of focal cortical disruption helping further to exclude concomitant ligament injury
Rheumatoid arthritis with synovial thickening (1) and erosion of the tibia (2)
Infectious arthritis with a pus filled anterior recess of the ankle
Arthritis and tenosynovitis of the ankle in a patient with rheumatoid arthritis
bullTUMOURSUltrasound can differentiate between a mass complex
and solid and a cystic in addition to verifying the
existence of accessory muscles (peroneus fourth
accessory flexor digitorum longus and accessory
soleus) As in any other location can be found
neoformative soft tissue tumors inflammatory
infectious etc
Ganglions of this location are more often symptomatic
and larger with multiple partitions
branched and lobed edges Differential diagnosis must
be made with tenosynovitis abscesses seromas and
varicosities
Neurogenic tumours are described as pathognomonic
homogeneous hypoechoic oval mass in continuity with
a nerve of origin
Ganglion cysts are non-malignant cystic masses that occur in association with musculoskeletal structures They are sometimes also simply referred to as ganglia or a ganglion but should not be confused with the anatomical term ganglion UltrasoundThe vast majority are anechoic to hypoechoic on ultrasound and have well defined margins Many demonstrate internal septations as well as acoustic enhancement A synovial cyst is a small fluid-filled sac or pouch that can develop over a tendon or joint creating a mass under the skin Synovial cyst is rare in ankle joint A synovial cyst may or may not be painful depending on their size and location
Ganglion cyst in the foot with bony erosion between navicular and cuneiform bones
Tarsal synovial cyst
Anechoic ganglion situated in the sinus tarsi fat between the talus and calcaneous
Plantar fasciitis (PF) refers to inflammation of the
plantar fascia of the foot It is considered the most common cause of heel pain
Clinical presentation Pain on the undersurface of the heel on weight bearing is the principal complaint It can be worse when weight is borne after a period of rest (eg in the morning) and eases with walking Passive dorsiflexion of the toes may exacerbates discomfort
UltrasoundOften the initial imaging modality of choice Ultrasound typically shows increased thickness of the fascia and a hypoechoic fascia
Thickened hypoechoic origin of the plantar fascia which has a convex superior margin
Complete avulsion of the plantar fascia from the calcaneal tubercle
Plantar fasciitis
bull LOCATING FOREIGN BODIES AND FRACTURES
As in any other location the ankle
area is also subsidiary host foreign
whose classification location and
existence can be defined perfectly by
ultrasound Being a focused study to
the area of interest and with great
resolution for surface structures can
be considered more resolute
examination to screen these cases
Osseous diseases and fractures | Sonography discovered Medial Malleolus Fracture
Ultrasound examination of left ankle A Longitudinal sonogram left ankle demonstrates a wooden foreign body B Transverse view left ankle Note the hypervascularity in the inflamed area C Corresponding X-ray of left ankle Note the swelling on the lateral aspect No foreign body is visible
Thank You
Tenosynovitis of the peroneal tendons and an intratendinous rupture of the short peroneal tendon
Intratendinous rupture and cyst in the peroneus brevis tendon
Peroneus quartus with an accessory muscle next to the peroneus longus and brevis tendons
Tumor next to the peroneal tendons that proved to be a benign fibrous mass
MEDIAL COMPARTMENT
ANOMALIES POSTERIOR TIBIAL TENDON (TP)
It is the most frequently injured in this compartment with ruptures
in asymptomatic middle-aged obese women as a result of
widespread disease (RA seronegative Spondyloarthropathy) or
associated with bone fractures It causes a gradual collapse of the
medial longitudinal arch with hindfoot valgus deformity and
excessive forefoot pronation
The presence of small vessels in inflammatory diseases
intratendinosis can simulate a fissuration tendon confusion can be ignored using colour Doppler Another possible diagnostic difficulty is when the undamaged tendon flexor digitorum longus (FLD) moves back and simulates the TP unbroken but it is smaller and in this case we only see in the groove retromalleolar 1 only tendon
Ultrasound has also proven to be an effective resource for identifying alterations associated tendon tenosynovitis serosa and hypertrophicSubluxation and dislocation anteriorly and medial TP relative to internal
malleolus is rare and valued sonographically placing the foot in dorsiflexion with forced supination
Thickening moderate amount of fluid surrounding calcifications and
hyperemia affecting the sheath and the posterior tibial tendon related
to chronic tenosynovitis in patient affects rheumatoid arthritis
Thickening moderate amount of surrounding fluid and calcifications (arrow) affecting the
posterior tibial tendon related to chronic tenosynovitis in patient affects rheumatoid arthritis
Tenosynovitis of the posterior tibial tendon caused by a bony ridge at the insertion of the retinaculum The retinaculum is thickened and the tendon subluxates
Psoriatic arthritis Ankle Grayscale examination Posterior tibial tendon on longitudinal (a) and transverse (b) scan Marked tendon sheath widening with homogeneous anechoic aspect (asterisks) of the content indicating an exudative tenosynovitis Note as the normal fibrillar echotexture is conserved Hand Flexor tendons of second finger The volar longitudinal (c) and transverse scan (d) shows a tendon sheath widening with signs of synovial proliferation presence of intense power Doppler signal surrounding the tendon and micro interruption of the margin (arrow) e Wrist Extensor carpi ulnaris tendon (sixth compartment of the extensor tendons ecu) on lateral longitudinal (e) and transverse (f) scan Chronic tenosynovitis with clear areas of low of echogenicity and loss of the continuity of tendon fibrils indicative of partial tendon tear (arrows) Moreover note the presence of power Doppler signal within the interruption indicating still activity of the inflammatory process g Dactylitis Volar longitudinal scan using the ldquoextended viewrdquo technique showing proliferative tenosynovitis of the finger flexor tendon (circle) exudative synovitis of both proximal and distal interphalangeal joint (white asterisks) and edema of the peritendinous tissue (black asterisks) TP posterior tibial tendon mm medial malleolus DP distal phalanx mp middle phalanx cu cubital bone ft flexor tendons
Tenosynovitis of the posterior tibial (1) and flexor digitorum longus tendon (2)
Tibialis Posterior Tendon rupture
Tenosynovitis of the posterior tibial tendon the flexor digitorum tendon and flexor hallucis longus tendon
Tenosynovitis of the tendons on the medial side in the left ankle
bullLIGAMENT INJURIESThe ligament partial tear ligament shows a hypoechoic
areas swollen with internal focal or diffuse In the complete
ruptures within the substance of the divided ligament rift is
observed corresponding to the hematoma hypoechoic and
the free ends of the divided ligament can be and retracted
appreciated corrugated in contrast with normal
appearance straight
Grade I Mild stretching of the ligament without breakage
or instability
Grade II Partial tearing of the ligament
Grade III Complete tearing
Degrees depending on the severity of the injury and the
place of employment
LATERAL COMPARTMENTThese injuries occur secondary to inversion sprains with internal rotation of
the foot combined with ankle plantar flexion
The anterior talar fibular ligament tears (ATFL) usually occur as isolated
involvement (70) or associated with calcaneal fibular ligament (CFL) (20-40)
but the posterior talar fibular ligament (PTFL) affects only major trauma
involving ankle dislocation
ATFL breaks is associated with breakage of the joint capsule and synovial fluid
extravasation into the anterolateral soft ankle whereas the complete tearing of
CFL can communicate the ankle joint and synovial sheath peroneal tendons
Rupture of CFL is rarely associated with superior peroneal retinaculum tear
The CFL is tensioned during dorsiflexion pulling on peroneal tendons laterally
so that absence of its displacement is sign of a complete tear
Within a damaged ligament can also observe calcifications that often
correspond to fragments of avulsion bone
During the ultrasound can be performed forced maneuvers to detect to joint
laxity and ligament injuries The anterior drawer test is performed with the feet
hanging over the edge of the examination table while the forefoot is pulled
anteriorly when the foot is in plantar flexion and inversion This maneuver
helps differentiate partial tears (grade II) of the ATFL to complete (grade III)
where the anterior displacement of the talus on the tibia open a crack in the
substance becoming more visible the ligament injury
The sindesmosys sprains are up to 10 of ankle
injuries happening in eversion and pronation
movements (like the deltoid ligament injury) and
primarily affect the anterior tibiofibular ligament (ATFL)
the failure is frequently associated with fracture of the
fibula
According to the place of employment are 4 degrees
useful for prognostic evaluation and therapeutic strategy
choice
Grade I stretch or partial tear of the ATFL
Grade II complete tearing but only the ATFL
Grade III complete tear of the ATFL and partial CFL
Grade IV complete tear of the ATFL and CFL
The grade I and II injuries usually scarred without any
significant instability whereas grade III and IV injuries
can cause chronic pain and require surgical treatment
Thickened but continued ATFL right in relation to the partial rupture
Grade 111 sprain of right ATFL
Thickened anterior talofibular ligament with calcifications and a partial rupture
Thickened tibiofibular ligament after trauma
Anterior Talofibular Ligament Partial Tear and Elastography
Tibio fibular ligament rupture with bony avulsion
Complete rupture of right ATFL
Bony avulsion with radiographic evidence as visible calcification in a grade III sprain ATFL
Moderately thickened and hypoechoic ATFL
Discontinuity of the ATFL with fluid surrounding the torn ends (arrow)
Thickening and hypoechogenicity of the fibular end of the ligament seen here passing over the subtalar joint which contains a small of fluid
Complete disruption to the tibiofibular ligament with bony irregularity of particularly the tibial margin and fluid in the gap
MEDIAL COMPARTMENTBecause of the low incidence of eversion ankle
sprains and the thickness of the deltoid ligament
is rarely injured in isolation and when the injury
does not usually full thickness Usually
accompanied by lesions of the medial malleolus
and lateral displacement of the talus with
consequent widening of the ankle mortise
Ultrasound is useful for differentiating ligament
injury of the posterior tibial tendon injury
(TP) adjacent they have similar symptoms
The inability to visualize the deltoid ligament may
indicate tear but this is not considered a reliable
sign as its full ultrasound is not always possible
Partial medial ligament rupture
Thickened heterogeneous abnormal deltoid demonstrating hyperemia
Ultrasonogram showing a disrupted deltoid ligament with the probe in the coronal plane The white arrow indicates the medial malleolus the blue arrow indicates the talus and the red arrows indicate the disrupted deltoid ligament (A) Radiograph showing the same injury (B)
bullJOINT AND BONE DISORDERSUltrasound reliably detect spills mild (gt 2 ml) inside
of the ankle joint by exploring the front and rear
recess as well as areas of synovial proliferation and
may even display using the colour Doppler
hyperemic areas in arthritis patients
The intraarticular joints are displayed surrounded
fluid in one of the recesses of the ankle or subtalar
joint Sonographically diagnosed when changing position to perform flexion and extension Fracture of the lateral process of the talus is overlooked up to 50 of cases with plain radiography Ultrasound may suspect the presence of focal cortical disruption helping further to exclude concomitant ligament injury
Rheumatoid arthritis with synovial thickening (1) and erosion of the tibia (2)
Infectious arthritis with a pus filled anterior recess of the ankle
Arthritis and tenosynovitis of the ankle in a patient with rheumatoid arthritis
bullTUMOURSUltrasound can differentiate between a mass complex
and solid and a cystic in addition to verifying the
existence of accessory muscles (peroneus fourth
accessory flexor digitorum longus and accessory
soleus) As in any other location can be found
neoformative soft tissue tumors inflammatory
infectious etc
Ganglions of this location are more often symptomatic
and larger with multiple partitions
branched and lobed edges Differential diagnosis must
be made with tenosynovitis abscesses seromas and
varicosities
Neurogenic tumours are described as pathognomonic
homogeneous hypoechoic oval mass in continuity with
a nerve of origin
Ganglion cysts are non-malignant cystic masses that occur in association with musculoskeletal structures They are sometimes also simply referred to as ganglia or a ganglion but should not be confused with the anatomical term ganglion UltrasoundThe vast majority are anechoic to hypoechoic on ultrasound and have well defined margins Many demonstrate internal septations as well as acoustic enhancement A synovial cyst is a small fluid-filled sac or pouch that can develop over a tendon or joint creating a mass under the skin Synovial cyst is rare in ankle joint A synovial cyst may or may not be painful depending on their size and location
Ganglion cyst in the foot with bony erosion between navicular and cuneiform bones
Tarsal synovial cyst
Anechoic ganglion situated in the sinus tarsi fat between the talus and calcaneous
Plantar fasciitis (PF) refers to inflammation of the
plantar fascia of the foot It is considered the most common cause of heel pain
Clinical presentation Pain on the undersurface of the heel on weight bearing is the principal complaint It can be worse when weight is borne after a period of rest (eg in the morning) and eases with walking Passive dorsiflexion of the toes may exacerbates discomfort
UltrasoundOften the initial imaging modality of choice Ultrasound typically shows increased thickness of the fascia and a hypoechoic fascia
Thickened hypoechoic origin of the plantar fascia which has a convex superior margin
Complete avulsion of the plantar fascia from the calcaneal tubercle
Plantar fasciitis
bull LOCATING FOREIGN BODIES AND FRACTURES
As in any other location the ankle
area is also subsidiary host foreign
whose classification location and
existence can be defined perfectly by
ultrasound Being a focused study to
the area of interest and with great
resolution for surface structures can
be considered more resolute
examination to screen these cases
Osseous diseases and fractures | Sonography discovered Medial Malleolus Fracture
Ultrasound examination of left ankle A Longitudinal sonogram left ankle demonstrates a wooden foreign body B Transverse view left ankle Note the hypervascularity in the inflamed area C Corresponding X-ray of left ankle Note the swelling on the lateral aspect No foreign body is visible
Thank You
Intratendinous rupture and cyst in the peroneus brevis tendon
Peroneus quartus with an accessory muscle next to the peroneus longus and brevis tendons
Tumor next to the peroneal tendons that proved to be a benign fibrous mass
MEDIAL COMPARTMENT
ANOMALIES POSTERIOR TIBIAL TENDON (TP)
It is the most frequently injured in this compartment with ruptures
in asymptomatic middle-aged obese women as a result of
widespread disease (RA seronegative Spondyloarthropathy) or
associated with bone fractures It causes a gradual collapse of the
medial longitudinal arch with hindfoot valgus deformity and
excessive forefoot pronation
The presence of small vessels in inflammatory diseases
intratendinosis can simulate a fissuration tendon confusion can be ignored using colour Doppler Another possible diagnostic difficulty is when the undamaged tendon flexor digitorum longus (FLD) moves back and simulates the TP unbroken but it is smaller and in this case we only see in the groove retromalleolar 1 only tendon
Ultrasound has also proven to be an effective resource for identifying alterations associated tendon tenosynovitis serosa and hypertrophicSubluxation and dislocation anteriorly and medial TP relative to internal
malleolus is rare and valued sonographically placing the foot in dorsiflexion with forced supination
Thickening moderate amount of fluid surrounding calcifications and
hyperemia affecting the sheath and the posterior tibial tendon related
to chronic tenosynovitis in patient affects rheumatoid arthritis
Thickening moderate amount of surrounding fluid and calcifications (arrow) affecting the
posterior tibial tendon related to chronic tenosynovitis in patient affects rheumatoid arthritis
Tenosynovitis of the posterior tibial tendon caused by a bony ridge at the insertion of the retinaculum The retinaculum is thickened and the tendon subluxates
Psoriatic arthritis Ankle Grayscale examination Posterior tibial tendon on longitudinal (a) and transverse (b) scan Marked tendon sheath widening with homogeneous anechoic aspect (asterisks) of the content indicating an exudative tenosynovitis Note as the normal fibrillar echotexture is conserved Hand Flexor tendons of second finger The volar longitudinal (c) and transverse scan (d) shows a tendon sheath widening with signs of synovial proliferation presence of intense power Doppler signal surrounding the tendon and micro interruption of the margin (arrow) e Wrist Extensor carpi ulnaris tendon (sixth compartment of the extensor tendons ecu) on lateral longitudinal (e) and transverse (f) scan Chronic tenosynovitis with clear areas of low of echogenicity and loss of the continuity of tendon fibrils indicative of partial tendon tear (arrows) Moreover note the presence of power Doppler signal within the interruption indicating still activity of the inflammatory process g Dactylitis Volar longitudinal scan using the ldquoextended viewrdquo technique showing proliferative tenosynovitis of the finger flexor tendon (circle) exudative synovitis of both proximal and distal interphalangeal joint (white asterisks) and edema of the peritendinous tissue (black asterisks) TP posterior tibial tendon mm medial malleolus DP distal phalanx mp middle phalanx cu cubital bone ft flexor tendons
Tenosynovitis of the posterior tibial (1) and flexor digitorum longus tendon (2)
Tibialis Posterior Tendon rupture
Tenosynovitis of the posterior tibial tendon the flexor digitorum tendon and flexor hallucis longus tendon
Tenosynovitis of the tendons on the medial side in the left ankle
bullLIGAMENT INJURIESThe ligament partial tear ligament shows a hypoechoic
areas swollen with internal focal or diffuse In the complete
ruptures within the substance of the divided ligament rift is
observed corresponding to the hematoma hypoechoic and
the free ends of the divided ligament can be and retracted
appreciated corrugated in contrast with normal
appearance straight
Grade I Mild stretching of the ligament without breakage
or instability
Grade II Partial tearing of the ligament
Grade III Complete tearing
Degrees depending on the severity of the injury and the
place of employment
LATERAL COMPARTMENTThese injuries occur secondary to inversion sprains with internal rotation of
the foot combined with ankle plantar flexion
The anterior talar fibular ligament tears (ATFL) usually occur as isolated
involvement (70) or associated with calcaneal fibular ligament (CFL) (20-40)
but the posterior talar fibular ligament (PTFL) affects only major trauma
involving ankle dislocation
ATFL breaks is associated with breakage of the joint capsule and synovial fluid
extravasation into the anterolateral soft ankle whereas the complete tearing of
CFL can communicate the ankle joint and synovial sheath peroneal tendons
Rupture of CFL is rarely associated with superior peroneal retinaculum tear
The CFL is tensioned during dorsiflexion pulling on peroneal tendons laterally
so that absence of its displacement is sign of a complete tear
Within a damaged ligament can also observe calcifications that often
correspond to fragments of avulsion bone
During the ultrasound can be performed forced maneuvers to detect to joint
laxity and ligament injuries The anterior drawer test is performed with the feet
hanging over the edge of the examination table while the forefoot is pulled
anteriorly when the foot is in plantar flexion and inversion This maneuver
helps differentiate partial tears (grade II) of the ATFL to complete (grade III)
where the anterior displacement of the talus on the tibia open a crack in the
substance becoming more visible the ligament injury
The sindesmosys sprains are up to 10 of ankle
injuries happening in eversion and pronation
movements (like the deltoid ligament injury) and
primarily affect the anterior tibiofibular ligament (ATFL)
the failure is frequently associated with fracture of the
fibula
According to the place of employment are 4 degrees
useful for prognostic evaluation and therapeutic strategy
choice
Grade I stretch or partial tear of the ATFL
Grade II complete tearing but only the ATFL
Grade III complete tear of the ATFL and partial CFL
Grade IV complete tear of the ATFL and CFL
The grade I and II injuries usually scarred without any
significant instability whereas grade III and IV injuries
can cause chronic pain and require surgical treatment
Thickened but continued ATFL right in relation to the partial rupture
Grade 111 sprain of right ATFL
Thickened anterior talofibular ligament with calcifications and a partial rupture
Thickened tibiofibular ligament after trauma
Anterior Talofibular Ligament Partial Tear and Elastography
Tibio fibular ligament rupture with bony avulsion
Complete rupture of right ATFL
Bony avulsion with radiographic evidence as visible calcification in a grade III sprain ATFL
Moderately thickened and hypoechoic ATFL
Discontinuity of the ATFL with fluid surrounding the torn ends (arrow)
Thickening and hypoechogenicity of the fibular end of the ligament seen here passing over the subtalar joint which contains a small of fluid
Complete disruption to the tibiofibular ligament with bony irregularity of particularly the tibial margin and fluid in the gap
MEDIAL COMPARTMENTBecause of the low incidence of eversion ankle
sprains and the thickness of the deltoid ligament
is rarely injured in isolation and when the injury
does not usually full thickness Usually
accompanied by lesions of the medial malleolus
and lateral displacement of the talus with
consequent widening of the ankle mortise
Ultrasound is useful for differentiating ligament
injury of the posterior tibial tendon injury
(TP) adjacent they have similar symptoms
The inability to visualize the deltoid ligament may
indicate tear but this is not considered a reliable
sign as its full ultrasound is not always possible
Partial medial ligament rupture
Thickened heterogeneous abnormal deltoid demonstrating hyperemia
Ultrasonogram showing a disrupted deltoid ligament with the probe in the coronal plane The white arrow indicates the medial malleolus the blue arrow indicates the talus and the red arrows indicate the disrupted deltoid ligament (A) Radiograph showing the same injury (B)
bullJOINT AND BONE DISORDERSUltrasound reliably detect spills mild (gt 2 ml) inside
of the ankle joint by exploring the front and rear
recess as well as areas of synovial proliferation and
may even display using the colour Doppler
hyperemic areas in arthritis patients
The intraarticular joints are displayed surrounded
fluid in one of the recesses of the ankle or subtalar
joint Sonographically diagnosed when changing position to perform flexion and extension Fracture of the lateral process of the talus is overlooked up to 50 of cases with plain radiography Ultrasound may suspect the presence of focal cortical disruption helping further to exclude concomitant ligament injury
Rheumatoid arthritis with synovial thickening (1) and erosion of the tibia (2)
Infectious arthritis with a pus filled anterior recess of the ankle
Arthritis and tenosynovitis of the ankle in a patient with rheumatoid arthritis
bullTUMOURSUltrasound can differentiate between a mass complex
and solid and a cystic in addition to verifying the
existence of accessory muscles (peroneus fourth
accessory flexor digitorum longus and accessory
soleus) As in any other location can be found
neoformative soft tissue tumors inflammatory
infectious etc
Ganglions of this location are more often symptomatic
and larger with multiple partitions
branched and lobed edges Differential diagnosis must
be made with tenosynovitis abscesses seromas and
varicosities
Neurogenic tumours are described as pathognomonic
homogeneous hypoechoic oval mass in continuity with
a nerve of origin
Ganglion cysts are non-malignant cystic masses that occur in association with musculoskeletal structures They are sometimes also simply referred to as ganglia or a ganglion but should not be confused with the anatomical term ganglion UltrasoundThe vast majority are anechoic to hypoechoic on ultrasound and have well defined margins Many demonstrate internal septations as well as acoustic enhancement A synovial cyst is a small fluid-filled sac or pouch that can develop over a tendon or joint creating a mass under the skin Synovial cyst is rare in ankle joint A synovial cyst may or may not be painful depending on their size and location
Ganglion cyst in the foot with bony erosion between navicular and cuneiform bones
Tarsal synovial cyst
Anechoic ganglion situated in the sinus tarsi fat between the talus and calcaneous
Plantar fasciitis (PF) refers to inflammation of the
plantar fascia of the foot It is considered the most common cause of heel pain
Clinical presentation Pain on the undersurface of the heel on weight bearing is the principal complaint It can be worse when weight is borne after a period of rest (eg in the morning) and eases with walking Passive dorsiflexion of the toes may exacerbates discomfort
UltrasoundOften the initial imaging modality of choice Ultrasound typically shows increased thickness of the fascia and a hypoechoic fascia
Thickened hypoechoic origin of the plantar fascia which has a convex superior margin
Complete avulsion of the plantar fascia from the calcaneal tubercle
Plantar fasciitis
bull LOCATING FOREIGN BODIES AND FRACTURES
As in any other location the ankle
area is also subsidiary host foreign
whose classification location and
existence can be defined perfectly by
ultrasound Being a focused study to
the area of interest and with great
resolution for surface structures can
be considered more resolute
examination to screen these cases
Osseous diseases and fractures | Sonography discovered Medial Malleolus Fracture
Ultrasound examination of left ankle A Longitudinal sonogram left ankle demonstrates a wooden foreign body B Transverse view left ankle Note the hypervascularity in the inflamed area C Corresponding X-ray of left ankle Note the swelling on the lateral aspect No foreign body is visible
Thank You
Peroneus quartus with an accessory muscle next to the peroneus longus and brevis tendons
Tumor next to the peroneal tendons that proved to be a benign fibrous mass
MEDIAL COMPARTMENT
ANOMALIES POSTERIOR TIBIAL TENDON (TP)
It is the most frequently injured in this compartment with ruptures
in asymptomatic middle-aged obese women as a result of
widespread disease (RA seronegative Spondyloarthropathy) or
associated with bone fractures It causes a gradual collapse of the
medial longitudinal arch with hindfoot valgus deformity and
excessive forefoot pronation
The presence of small vessels in inflammatory diseases
intratendinosis can simulate a fissuration tendon confusion can be ignored using colour Doppler Another possible diagnostic difficulty is when the undamaged tendon flexor digitorum longus (FLD) moves back and simulates the TP unbroken but it is smaller and in this case we only see in the groove retromalleolar 1 only tendon
Ultrasound has also proven to be an effective resource for identifying alterations associated tendon tenosynovitis serosa and hypertrophicSubluxation and dislocation anteriorly and medial TP relative to internal
malleolus is rare and valued sonographically placing the foot in dorsiflexion with forced supination
Thickening moderate amount of fluid surrounding calcifications and
hyperemia affecting the sheath and the posterior tibial tendon related
to chronic tenosynovitis in patient affects rheumatoid arthritis
Thickening moderate amount of surrounding fluid and calcifications (arrow) affecting the
posterior tibial tendon related to chronic tenosynovitis in patient affects rheumatoid arthritis
Tenosynovitis of the posterior tibial tendon caused by a bony ridge at the insertion of the retinaculum The retinaculum is thickened and the tendon subluxates
Psoriatic arthritis Ankle Grayscale examination Posterior tibial tendon on longitudinal (a) and transverse (b) scan Marked tendon sheath widening with homogeneous anechoic aspect (asterisks) of the content indicating an exudative tenosynovitis Note as the normal fibrillar echotexture is conserved Hand Flexor tendons of second finger The volar longitudinal (c) and transverse scan (d) shows a tendon sheath widening with signs of synovial proliferation presence of intense power Doppler signal surrounding the tendon and micro interruption of the margin (arrow) e Wrist Extensor carpi ulnaris tendon (sixth compartment of the extensor tendons ecu) on lateral longitudinal (e) and transverse (f) scan Chronic tenosynovitis with clear areas of low of echogenicity and loss of the continuity of tendon fibrils indicative of partial tendon tear (arrows) Moreover note the presence of power Doppler signal within the interruption indicating still activity of the inflammatory process g Dactylitis Volar longitudinal scan using the ldquoextended viewrdquo technique showing proliferative tenosynovitis of the finger flexor tendon (circle) exudative synovitis of both proximal and distal interphalangeal joint (white asterisks) and edema of the peritendinous tissue (black asterisks) TP posterior tibial tendon mm medial malleolus DP distal phalanx mp middle phalanx cu cubital bone ft flexor tendons
Tenosynovitis of the posterior tibial (1) and flexor digitorum longus tendon (2)
Tibialis Posterior Tendon rupture
Tenosynovitis of the posterior tibial tendon the flexor digitorum tendon and flexor hallucis longus tendon
Tenosynovitis of the tendons on the medial side in the left ankle
bullLIGAMENT INJURIESThe ligament partial tear ligament shows a hypoechoic
areas swollen with internal focal or diffuse In the complete
ruptures within the substance of the divided ligament rift is
observed corresponding to the hematoma hypoechoic and
the free ends of the divided ligament can be and retracted
appreciated corrugated in contrast with normal
appearance straight
Grade I Mild stretching of the ligament without breakage
or instability
Grade II Partial tearing of the ligament
Grade III Complete tearing
Degrees depending on the severity of the injury and the
place of employment
LATERAL COMPARTMENTThese injuries occur secondary to inversion sprains with internal rotation of
the foot combined with ankle plantar flexion
The anterior talar fibular ligament tears (ATFL) usually occur as isolated
involvement (70) or associated with calcaneal fibular ligament (CFL) (20-40)
but the posterior talar fibular ligament (PTFL) affects only major trauma
involving ankle dislocation
ATFL breaks is associated with breakage of the joint capsule and synovial fluid
extravasation into the anterolateral soft ankle whereas the complete tearing of
CFL can communicate the ankle joint and synovial sheath peroneal tendons
Rupture of CFL is rarely associated with superior peroneal retinaculum tear
The CFL is tensioned during dorsiflexion pulling on peroneal tendons laterally
so that absence of its displacement is sign of a complete tear
Within a damaged ligament can also observe calcifications that often
correspond to fragments of avulsion bone
During the ultrasound can be performed forced maneuvers to detect to joint
laxity and ligament injuries The anterior drawer test is performed with the feet
hanging over the edge of the examination table while the forefoot is pulled
anteriorly when the foot is in plantar flexion and inversion This maneuver
helps differentiate partial tears (grade II) of the ATFL to complete (grade III)
where the anterior displacement of the talus on the tibia open a crack in the
substance becoming more visible the ligament injury
The sindesmosys sprains are up to 10 of ankle
injuries happening in eversion and pronation
movements (like the deltoid ligament injury) and
primarily affect the anterior tibiofibular ligament (ATFL)
the failure is frequently associated with fracture of the
fibula
According to the place of employment are 4 degrees
useful for prognostic evaluation and therapeutic strategy
choice
Grade I stretch or partial tear of the ATFL
Grade II complete tearing but only the ATFL
Grade III complete tear of the ATFL and partial CFL
Grade IV complete tear of the ATFL and CFL
The grade I and II injuries usually scarred without any
significant instability whereas grade III and IV injuries
can cause chronic pain and require surgical treatment
Thickened but continued ATFL right in relation to the partial rupture
Grade 111 sprain of right ATFL
Thickened anterior talofibular ligament with calcifications and a partial rupture
Thickened tibiofibular ligament after trauma
Anterior Talofibular Ligament Partial Tear and Elastography
Tibio fibular ligament rupture with bony avulsion
Complete rupture of right ATFL
Bony avulsion with radiographic evidence as visible calcification in a grade III sprain ATFL
Moderately thickened and hypoechoic ATFL
Discontinuity of the ATFL with fluid surrounding the torn ends (arrow)
Thickening and hypoechogenicity of the fibular end of the ligament seen here passing over the subtalar joint which contains a small of fluid
Complete disruption to the tibiofibular ligament with bony irregularity of particularly the tibial margin and fluid in the gap
MEDIAL COMPARTMENTBecause of the low incidence of eversion ankle
sprains and the thickness of the deltoid ligament
is rarely injured in isolation and when the injury
does not usually full thickness Usually
accompanied by lesions of the medial malleolus
and lateral displacement of the talus with
consequent widening of the ankle mortise
Ultrasound is useful for differentiating ligament
injury of the posterior tibial tendon injury
(TP) adjacent they have similar symptoms
The inability to visualize the deltoid ligament may
indicate tear but this is not considered a reliable
sign as its full ultrasound is not always possible
Partial medial ligament rupture
Thickened heterogeneous abnormal deltoid demonstrating hyperemia
Ultrasonogram showing a disrupted deltoid ligament with the probe in the coronal plane The white arrow indicates the medial malleolus the blue arrow indicates the talus and the red arrows indicate the disrupted deltoid ligament (A) Radiograph showing the same injury (B)
bullJOINT AND BONE DISORDERSUltrasound reliably detect spills mild (gt 2 ml) inside
of the ankle joint by exploring the front and rear
recess as well as areas of synovial proliferation and
may even display using the colour Doppler
hyperemic areas in arthritis patients
The intraarticular joints are displayed surrounded
fluid in one of the recesses of the ankle or subtalar
joint Sonographically diagnosed when changing position to perform flexion and extension Fracture of the lateral process of the talus is overlooked up to 50 of cases with plain radiography Ultrasound may suspect the presence of focal cortical disruption helping further to exclude concomitant ligament injury
Rheumatoid arthritis with synovial thickening (1) and erosion of the tibia (2)
Infectious arthritis with a pus filled anterior recess of the ankle
Arthritis and tenosynovitis of the ankle in a patient with rheumatoid arthritis
bullTUMOURSUltrasound can differentiate between a mass complex
and solid and a cystic in addition to verifying the
existence of accessory muscles (peroneus fourth
accessory flexor digitorum longus and accessory
soleus) As in any other location can be found
neoformative soft tissue tumors inflammatory
infectious etc
Ganglions of this location are more often symptomatic
and larger with multiple partitions
branched and lobed edges Differential diagnosis must
be made with tenosynovitis abscesses seromas and
varicosities
Neurogenic tumours are described as pathognomonic
homogeneous hypoechoic oval mass in continuity with
a nerve of origin
Ganglion cysts are non-malignant cystic masses that occur in association with musculoskeletal structures They are sometimes also simply referred to as ganglia or a ganglion but should not be confused with the anatomical term ganglion UltrasoundThe vast majority are anechoic to hypoechoic on ultrasound and have well defined margins Many demonstrate internal septations as well as acoustic enhancement A synovial cyst is a small fluid-filled sac or pouch that can develop over a tendon or joint creating a mass under the skin Synovial cyst is rare in ankle joint A synovial cyst may or may not be painful depending on their size and location
Ganglion cyst in the foot with bony erosion between navicular and cuneiform bones
Tarsal synovial cyst
Anechoic ganglion situated in the sinus tarsi fat between the talus and calcaneous
Plantar fasciitis (PF) refers to inflammation of the
plantar fascia of the foot It is considered the most common cause of heel pain
Clinical presentation Pain on the undersurface of the heel on weight bearing is the principal complaint It can be worse when weight is borne after a period of rest (eg in the morning) and eases with walking Passive dorsiflexion of the toes may exacerbates discomfort
UltrasoundOften the initial imaging modality of choice Ultrasound typically shows increased thickness of the fascia and a hypoechoic fascia
Thickened hypoechoic origin of the plantar fascia which has a convex superior margin
Complete avulsion of the plantar fascia from the calcaneal tubercle
Plantar fasciitis
bull LOCATING FOREIGN BODIES AND FRACTURES
As in any other location the ankle
area is also subsidiary host foreign
whose classification location and
existence can be defined perfectly by
ultrasound Being a focused study to
the area of interest and with great
resolution for surface structures can
be considered more resolute
examination to screen these cases
Osseous diseases and fractures | Sonography discovered Medial Malleolus Fracture
Ultrasound examination of left ankle A Longitudinal sonogram left ankle demonstrates a wooden foreign body B Transverse view left ankle Note the hypervascularity in the inflamed area C Corresponding X-ray of left ankle Note the swelling on the lateral aspect No foreign body is visible
Thank You
Tumor next to the peroneal tendons that proved to be a benign fibrous mass
MEDIAL COMPARTMENT
ANOMALIES POSTERIOR TIBIAL TENDON (TP)
It is the most frequently injured in this compartment with ruptures
in asymptomatic middle-aged obese women as a result of
widespread disease (RA seronegative Spondyloarthropathy) or
associated with bone fractures It causes a gradual collapse of the
medial longitudinal arch with hindfoot valgus deformity and
excessive forefoot pronation
The presence of small vessels in inflammatory diseases
intratendinosis can simulate a fissuration tendon confusion can be ignored using colour Doppler Another possible diagnostic difficulty is when the undamaged tendon flexor digitorum longus (FLD) moves back and simulates the TP unbroken but it is smaller and in this case we only see in the groove retromalleolar 1 only tendon
Ultrasound has also proven to be an effective resource for identifying alterations associated tendon tenosynovitis serosa and hypertrophicSubluxation and dislocation anteriorly and medial TP relative to internal
malleolus is rare and valued sonographically placing the foot in dorsiflexion with forced supination
Thickening moderate amount of fluid surrounding calcifications and
hyperemia affecting the sheath and the posterior tibial tendon related
to chronic tenosynovitis in patient affects rheumatoid arthritis
Thickening moderate amount of surrounding fluid and calcifications (arrow) affecting the
posterior tibial tendon related to chronic tenosynovitis in patient affects rheumatoid arthritis
Tenosynovitis of the posterior tibial tendon caused by a bony ridge at the insertion of the retinaculum The retinaculum is thickened and the tendon subluxates
Psoriatic arthritis Ankle Grayscale examination Posterior tibial tendon on longitudinal (a) and transverse (b) scan Marked tendon sheath widening with homogeneous anechoic aspect (asterisks) of the content indicating an exudative tenosynovitis Note as the normal fibrillar echotexture is conserved Hand Flexor tendons of second finger The volar longitudinal (c) and transverse scan (d) shows a tendon sheath widening with signs of synovial proliferation presence of intense power Doppler signal surrounding the tendon and micro interruption of the margin (arrow) e Wrist Extensor carpi ulnaris tendon (sixth compartment of the extensor tendons ecu) on lateral longitudinal (e) and transverse (f) scan Chronic tenosynovitis with clear areas of low of echogenicity and loss of the continuity of tendon fibrils indicative of partial tendon tear (arrows) Moreover note the presence of power Doppler signal within the interruption indicating still activity of the inflammatory process g Dactylitis Volar longitudinal scan using the ldquoextended viewrdquo technique showing proliferative tenosynovitis of the finger flexor tendon (circle) exudative synovitis of both proximal and distal interphalangeal joint (white asterisks) and edema of the peritendinous tissue (black asterisks) TP posterior tibial tendon mm medial malleolus DP distal phalanx mp middle phalanx cu cubital bone ft flexor tendons
Tenosynovitis of the posterior tibial (1) and flexor digitorum longus tendon (2)
Tibialis Posterior Tendon rupture
Tenosynovitis of the posterior tibial tendon the flexor digitorum tendon and flexor hallucis longus tendon
Tenosynovitis of the tendons on the medial side in the left ankle
bullLIGAMENT INJURIESThe ligament partial tear ligament shows a hypoechoic
areas swollen with internal focal or diffuse In the complete
ruptures within the substance of the divided ligament rift is
observed corresponding to the hematoma hypoechoic and
the free ends of the divided ligament can be and retracted
appreciated corrugated in contrast with normal
appearance straight
Grade I Mild stretching of the ligament without breakage
or instability
Grade II Partial tearing of the ligament
Grade III Complete tearing
Degrees depending on the severity of the injury and the
place of employment
LATERAL COMPARTMENTThese injuries occur secondary to inversion sprains with internal rotation of
the foot combined with ankle plantar flexion
The anterior talar fibular ligament tears (ATFL) usually occur as isolated
involvement (70) or associated with calcaneal fibular ligament (CFL) (20-40)
but the posterior talar fibular ligament (PTFL) affects only major trauma
involving ankle dislocation
ATFL breaks is associated with breakage of the joint capsule and synovial fluid
extravasation into the anterolateral soft ankle whereas the complete tearing of
CFL can communicate the ankle joint and synovial sheath peroneal tendons
Rupture of CFL is rarely associated with superior peroneal retinaculum tear
The CFL is tensioned during dorsiflexion pulling on peroneal tendons laterally
so that absence of its displacement is sign of a complete tear
Within a damaged ligament can also observe calcifications that often
correspond to fragments of avulsion bone
During the ultrasound can be performed forced maneuvers to detect to joint
laxity and ligament injuries The anterior drawer test is performed with the feet
hanging over the edge of the examination table while the forefoot is pulled
anteriorly when the foot is in plantar flexion and inversion This maneuver
helps differentiate partial tears (grade II) of the ATFL to complete (grade III)
where the anterior displacement of the talus on the tibia open a crack in the
substance becoming more visible the ligament injury
The sindesmosys sprains are up to 10 of ankle
injuries happening in eversion and pronation
movements (like the deltoid ligament injury) and
primarily affect the anterior tibiofibular ligament (ATFL)
the failure is frequently associated with fracture of the
fibula
According to the place of employment are 4 degrees
useful for prognostic evaluation and therapeutic strategy
choice
Grade I stretch or partial tear of the ATFL
Grade II complete tearing but only the ATFL
Grade III complete tear of the ATFL and partial CFL
Grade IV complete tear of the ATFL and CFL
The grade I and II injuries usually scarred without any
significant instability whereas grade III and IV injuries
can cause chronic pain and require surgical treatment
Thickened but continued ATFL right in relation to the partial rupture
Grade 111 sprain of right ATFL
Thickened anterior talofibular ligament with calcifications and a partial rupture
Thickened tibiofibular ligament after trauma
Anterior Talofibular Ligament Partial Tear and Elastography
Tibio fibular ligament rupture with bony avulsion
Complete rupture of right ATFL
Bony avulsion with radiographic evidence as visible calcification in a grade III sprain ATFL
Moderately thickened and hypoechoic ATFL
Discontinuity of the ATFL with fluid surrounding the torn ends (arrow)
Thickening and hypoechogenicity of the fibular end of the ligament seen here passing over the subtalar joint which contains a small of fluid
Complete disruption to the tibiofibular ligament with bony irregularity of particularly the tibial margin and fluid in the gap
MEDIAL COMPARTMENTBecause of the low incidence of eversion ankle
sprains and the thickness of the deltoid ligament
is rarely injured in isolation and when the injury
does not usually full thickness Usually
accompanied by lesions of the medial malleolus
and lateral displacement of the talus with
consequent widening of the ankle mortise
Ultrasound is useful for differentiating ligament
injury of the posterior tibial tendon injury
(TP) adjacent they have similar symptoms
The inability to visualize the deltoid ligament may
indicate tear but this is not considered a reliable
sign as its full ultrasound is not always possible
Partial medial ligament rupture
Thickened heterogeneous abnormal deltoid demonstrating hyperemia
Ultrasonogram showing a disrupted deltoid ligament with the probe in the coronal plane The white arrow indicates the medial malleolus the blue arrow indicates the talus and the red arrows indicate the disrupted deltoid ligament (A) Radiograph showing the same injury (B)
bullJOINT AND BONE DISORDERSUltrasound reliably detect spills mild (gt 2 ml) inside
of the ankle joint by exploring the front and rear
recess as well as areas of synovial proliferation and
may even display using the colour Doppler
hyperemic areas in arthritis patients
The intraarticular joints are displayed surrounded
fluid in one of the recesses of the ankle or subtalar
joint Sonographically diagnosed when changing position to perform flexion and extension Fracture of the lateral process of the talus is overlooked up to 50 of cases with plain radiography Ultrasound may suspect the presence of focal cortical disruption helping further to exclude concomitant ligament injury
Rheumatoid arthritis with synovial thickening (1) and erosion of the tibia (2)
Infectious arthritis with a pus filled anterior recess of the ankle
Arthritis and tenosynovitis of the ankle in a patient with rheumatoid arthritis
bullTUMOURSUltrasound can differentiate between a mass complex
and solid and a cystic in addition to verifying the
existence of accessory muscles (peroneus fourth
accessory flexor digitorum longus and accessory
soleus) As in any other location can be found
neoformative soft tissue tumors inflammatory
infectious etc
Ganglions of this location are more often symptomatic
and larger with multiple partitions
branched and lobed edges Differential diagnosis must
be made with tenosynovitis abscesses seromas and
varicosities
Neurogenic tumours are described as pathognomonic
homogeneous hypoechoic oval mass in continuity with
a nerve of origin
Ganglion cysts are non-malignant cystic masses that occur in association with musculoskeletal structures They are sometimes also simply referred to as ganglia or a ganglion but should not be confused with the anatomical term ganglion UltrasoundThe vast majority are anechoic to hypoechoic on ultrasound and have well defined margins Many demonstrate internal septations as well as acoustic enhancement A synovial cyst is a small fluid-filled sac or pouch that can develop over a tendon or joint creating a mass under the skin Synovial cyst is rare in ankle joint A synovial cyst may or may not be painful depending on their size and location
Ganglion cyst in the foot with bony erosion between navicular and cuneiform bones
Tarsal synovial cyst
Anechoic ganglion situated in the sinus tarsi fat between the talus and calcaneous
Plantar fasciitis (PF) refers to inflammation of the
plantar fascia of the foot It is considered the most common cause of heel pain
Clinical presentation Pain on the undersurface of the heel on weight bearing is the principal complaint It can be worse when weight is borne after a period of rest (eg in the morning) and eases with walking Passive dorsiflexion of the toes may exacerbates discomfort
UltrasoundOften the initial imaging modality of choice Ultrasound typically shows increased thickness of the fascia and a hypoechoic fascia
Thickened hypoechoic origin of the plantar fascia which has a convex superior margin
Complete avulsion of the plantar fascia from the calcaneal tubercle
Plantar fasciitis
bull LOCATING FOREIGN BODIES AND FRACTURES
As in any other location the ankle
area is also subsidiary host foreign
whose classification location and
existence can be defined perfectly by
ultrasound Being a focused study to
the area of interest and with great
resolution for surface structures can
be considered more resolute
examination to screen these cases
Osseous diseases and fractures | Sonography discovered Medial Malleolus Fracture
Ultrasound examination of left ankle A Longitudinal sonogram left ankle demonstrates a wooden foreign body B Transverse view left ankle Note the hypervascularity in the inflamed area C Corresponding X-ray of left ankle Note the swelling on the lateral aspect No foreign body is visible
Thank You
MEDIAL COMPARTMENT
ANOMALIES POSTERIOR TIBIAL TENDON (TP)
It is the most frequently injured in this compartment with ruptures
in asymptomatic middle-aged obese women as a result of
widespread disease (RA seronegative Spondyloarthropathy) or
associated with bone fractures It causes a gradual collapse of the
medial longitudinal arch with hindfoot valgus deformity and
excessive forefoot pronation
The presence of small vessels in inflammatory diseases
intratendinosis can simulate a fissuration tendon confusion can be ignored using colour Doppler Another possible diagnostic difficulty is when the undamaged tendon flexor digitorum longus (FLD) moves back and simulates the TP unbroken but it is smaller and in this case we only see in the groove retromalleolar 1 only tendon
Ultrasound has also proven to be an effective resource for identifying alterations associated tendon tenosynovitis serosa and hypertrophicSubluxation and dislocation anteriorly and medial TP relative to internal
malleolus is rare and valued sonographically placing the foot in dorsiflexion with forced supination
Thickening moderate amount of fluid surrounding calcifications and
hyperemia affecting the sheath and the posterior tibial tendon related
to chronic tenosynovitis in patient affects rheumatoid arthritis
Thickening moderate amount of surrounding fluid and calcifications (arrow) affecting the
posterior tibial tendon related to chronic tenosynovitis in patient affects rheumatoid arthritis
Tenosynovitis of the posterior tibial tendon caused by a bony ridge at the insertion of the retinaculum The retinaculum is thickened and the tendon subluxates
Psoriatic arthritis Ankle Grayscale examination Posterior tibial tendon on longitudinal (a) and transverse (b) scan Marked tendon sheath widening with homogeneous anechoic aspect (asterisks) of the content indicating an exudative tenosynovitis Note as the normal fibrillar echotexture is conserved Hand Flexor tendons of second finger The volar longitudinal (c) and transverse scan (d) shows a tendon sheath widening with signs of synovial proliferation presence of intense power Doppler signal surrounding the tendon and micro interruption of the margin (arrow) e Wrist Extensor carpi ulnaris tendon (sixth compartment of the extensor tendons ecu) on lateral longitudinal (e) and transverse (f) scan Chronic tenosynovitis with clear areas of low of echogenicity and loss of the continuity of tendon fibrils indicative of partial tendon tear (arrows) Moreover note the presence of power Doppler signal within the interruption indicating still activity of the inflammatory process g Dactylitis Volar longitudinal scan using the ldquoextended viewrdquo technique showing proliferative tenosynovitis of the finger flexor tendon (circle) exudative synovitis of both proximal and distal interphalangeal joint (white asterisks) and edema of the peritendinous tissue (black asterisks) TP posterior tibial tendon mm medial malleolus DP distal phalanx mp middle phalanx cu cubital bone ft flexor tendons
Tenosynovitis of the posterior tibial (1) and flexor digitorum longus tendon (2)
Tibialis Posterior Tendon rupture
Tenosynovitis of the posterior tibial tendon the flexor digitorum tendon and flexor hallucis longus tendon
Tenosynovitis of the tendons on the medial side in the left ankle
bullLIGAMENT INJURIESThe ligament partial tear ligament shows a hypoechoic
areas swollen with internal focal or diffuse In the complete
ruptures within the substance of the divided ligament rift is
observed corresponding to the hematoma hypoechoic and
the free ends of the divided ligament can be and retracted
appreciated corrugated in contrast with normal
appearance straight
Grade I Mild stretching of the ligament without breakage
or instability
Grade II Partial tearing of the ligament
Grade III Complete tearing
Degrees depending on the severity of the injury and the
place of employment
LATERAL COMPARTMENTThese injuries occur secondary to inversion sprains with internal rotation of
the foot combined with ankle plantar flexion
The anterior talar fibular ligament tears (ATFL) usually occur as isolated
involvement (70) or associated with calcaneal fibular ligament (CFL) (20-40)
but the posterior talar fibular ligament (PTFL) affects only major trauma
involving ankle dislocation
ATFL breaks is associated with breakage of the joint capsule and synovial fluid
extravasation into the anterolateral soft ankle whereas the complete tearing of
CFL can communicate the ankle joint and synovial sheath peroneal tendons
Rupture of CFL is rarely associated with superior peroneal retinaculum tear
The CFL is tensioned during dorsiflexion pulling on peroneal tendons laterally
so that absence of its displacement is sign of a complete tear
Within a damaged ligament can also observe calcifications that often
correspond to fragments of avulsion bone
During the ultrasound can be performed forced maneuvers to detect to joint
laxity and ligament injuries The anterior drawer test is performed with the feet
hanging over the edge of the examination table while the forefoot is pulled
anteriorly when the foot is in plantar flexion and inversion This maneuver
helps differentiate partial tears (grade II) of the ATFL to complete (grade III)
where the anterior displacement of the talus on the tibia open a crack in the
substance becoming more visible the ligament injury
The sindesmosys sprains are up to 10 of ankle
injuries happening in eversion and pronation
movements (like the deltoid ligament injury) and
primarily affect the anterior tibiofibular ligament (ATFL)
the failure is frequently associated with fracture of the
fibula
According to the place of employment are 4 degrees
useful for prognostic evaluation and therapeutic strategy
choice
Grade I stretch or partial tear of the ATFL
Grade II complete tearing but only the ATFL
Grade III complete tear of the ATFL and partial CFL
Grade IV complete tear of the ATFL and CFL
The grade I and II injuries usually scarred without any
significant instability whereas grade III and IV injuries
can cause chronic pain and require surgical treatment
Thickened but continued ATFL right in relation to the partial rupture
Grade 111 sprain of right ATFL
Thickened anterior talofibular ligament with calcifications and a partial rupture
Thickened tibiofibular ligament after trauma
Anterior Talofibular Ligament Partial Tear and Elastography
Tibio fibular ligament rupture with bony avulsion
Complete rupture of right ATFL
Bony avulsion with radiographic evidence as visible calcification in a grade III sprain ATFL
Moderately thickened and hypoechoic ATFL
Discontinuity of the ATFL with fluid surrounding the torn ends (arrow)
Thickening and hypoechogenicity of the fibular end of the ligament seen here passing over the subtalar joint which contains a small of fluid
Complete disruption to the tibiofibular ligament with bony irregularity of particularly the tibial margin and fluid in the gap
MEDIAL COMPARTMENTBecause of the low incidence of eversion ankle
sprains and the thickness of the deltoid ligament
is rarely injured in isolation and when the injury
does not usually full thickness Usually
accompanied by lesions of the medial malleolus
and lateral displacement of the talus with
consequent widening of the ankle mortise
Ultrasound is useful for differentiating ligament
injury of the posterior tibial tendon injury
(TP) adjacent they have similar symptoms
The inability to visualize the deltoid ligament may
indicate tear but this is not considered a reliable
sign as its full ultrasound is not always possible
Partial medial ligament rupture
Thickened heterogeneous abnormal deltoid demonstrating hyperemia
Ultrasonogram showing a disrupted deltoid ligament with the probe in the coronal plane The white arrow indicates the medial malleolus the blue arrow indicates the talus and the red arrows indicate the disrupted deltoid ligament (A) Radiograph showing the same injury (B)
bullJOINT AND BONE DISORDERSUltrasound reliably detect spills mild (gt 2 ml) inside
of the ankle joint by exploring the front and rear
recess as well as areas of synovial proliferation and
may even display using the colour Doppler
hyperemic areas in arthritis patients
The intraarticular joints are displayed surrounded
fluid in one of the recesses of the ankle or subtalar
joint Sonographically diagnosed when changing position to perform flexion and extension Fracture of the lateral process of the talus is overlooked up to 50 of cases with plain radiography Ultrasound may suspect the presence of focal cortical disruption helping further to exclude concomitant ligament injury
Rheumatoid arthritis with synovial thickening (1) and erosion of the tibia (2)
Infectious arthritis with a pus filled anterior recess of the ankle
Arthritis and tenosynovitis of the ankle in a patient with rheumatoid arthritis
bullTUMOURSUltrasound can differentiate between a mass complex
and solid and a cystic in addition to verifying the
existence of accessory muscles (peroneus fourth
accessory flexor digitorum longus and accessory
soleus) As in any other location can be found
neoformative soft tissue tumors inflammatory
infectious etc
Ganglions of this location are more often symptomatic
and larger with multiple partitions
branched and lobed edges Differential diagnosis must
be made with tenosynovitis abscesses seromas and
varicosities
Neurogenic tumours are described as pathognomonic
homogeneous hypoechoic oval mass in continuity with
a nerve of origin
Ganglion cysts are non-malignant cystic masses that occur in association with musculoskeletal structures They are sometimes also simply referred to as ganglia or a ganglion but should not be confused with the anatomical term ganglion UltrasoundThe vast majority are anechoic to hypoechoic on ultrasound and have well defined margins Many demonstrate internal septations as well as acoustic enhancement A synovial cyst is a small fluid-filled sac or pouch that can develop over a tendon or joint creating a mass under the skin Synovial cyst is rare in ankle joint A synovial cyst may or may not be painful depending on their size and location
Ganglion cyst in the foot with bony erosion between navicular and cuneiform bones
Tarsal synovial cyst
Anechoic ganglion situated in the sinus tarsi fat between the talus and calcaneous
Plantar fasciitis (PF) refers to inflammation of the
plantar fascia of the foot It is considered the most common cause of heel pain
Clinical presentation Pain on the undersurface of the heel on weight bearing is the principal complaint It can be worse when weight is borne after a period of rest (eg in the morning) and eases with walking Passive dorsiflexion of the toes may exacerbates discomfort
UltrasoundOften the initial imaging modality of choice Ultrasound typically shows increased thickness of the fascia and a hypoechoic fascia
Thickened hypoechoic origin of the plantar fascia which has a convex superior margin
Complete avulsion of the plantar fascia from the calcaneal tubercle
Plantar fasciitis
bull LOCATING FOREIGN BODIES AND FRACTURES
As in any other location the ankle
area is also subsidiary host foreign
whose classification location and
existence can be defined perfectly by
ultrasound Being a focused study to
the area of interest and with great
resolution for surface structures can
be considered more resolute
examination to screen these cases
Osseous diseases and fractures | Sonography discovered Medial Malleolus Fracture
Ultrasound examination of left ankle A Longitudinal sonogram left ankle demonstrates a wooden foreign body B Transverse view left ankle Note the hypervascularity in the inflamed area C Corresponding X-ray of left ankle Note the swelling on the lateral aspect No foreign body is visible
Thank You
Thickening moderate amount of fluid surrounding calcifications and
hyperemia affecting the sheath and the posterior tibial tendon related
to chronic tenosynovitis in patient affects rheumatoid arthritis
Thickening moderate amount of surrounding fluid and calcifications (arrow) affecting the
posterior tibial tendon related to chronic tenosynovitis in patient affects rheumatoid arthritis
Tenosynovitis of the posterior tibial tendon caused by a bony ridge at the insertion of the retinaculum The retinaculum is thickened and the tendon subluxates
Psoriatic arthritis Ankle Grayscale examination Posterior tibial tendon on longitudinal (a) and transverse (b) scan Marked tendon sheath widening with homogeneous anechoic aspect (asterisks) of the content indicating an exudative tenosynovitis Note as the normal fibrillar echotexture is conserved Hand Flexor tendons of second finger The volar longitudinal (c) and transverse scan (d) shows a tendon sheath widening with signs of synovial proliferation presence of intense power Doppler signal surrounding the tendon and micro interruption of the margin (arrow) e Wrist Extensor carpi ulnaris tendon (sixth compartment of the extensor tendons ecu) on lateral longitudinal (e) and transverse (f) scan Chronic tenosynovitis with clear areas of low of echogenicity and loss of the continuity of tendon fibrils indicative of partial tendon tear (arrows) Moreover note the presence of power Doppler signal within the interruption indicating still activity of the inflammatory process g Dactylitis Volar longitudinal scan using the ldquoextended viewrdquo technique showing proliferative tenosynovitis of the finger flexor tendon (circle) exudative synovitis of both proximal and distal interphalangeal joint (white asterisks) and edema of the peritendinous tissue (black asterisks) TP posterior tibial tendon mm medial malleolus DP distal phalanx mp middle phalanx cu cubital bone ft flexor tendons
Tenosynovitis of the posterior tibial (1) and flexor digitorum longus tendon (2)
Tibialis Posterior Tendon rupture
Tenosynovitis of the posterior tibial tendon the flexor digitorum tendon and flexor hallucis longus tendon
Tenosynovitis of the tendons on the medial side in the left ankle
bullLIGAMENT INJURIESThe ligament partial tear ligament shows a hypoechoic
areas swollen with internal focal or diffuse In the complete
ruptures within the substance of the divided ligament rift is
observed corresponding to the hematoma hypoechoic and
the free ends of the divided ligament can be and retracted
appreciated corrugated in contrast with normal
appearance straight
Grade I Mild stretching of the ligament without breakage
or instability
Grade II Partial tearing of the ligament
Grade III Complete tearing
Degrees depending on the severity of the injury and the
place of employment
LATERAL COMPARTMENTThese injuries occur secondary to inversion sprains with internal rotation of
the foot combined with ankle plantar flexion
The anterior talar fibular ligament tears (ATFL) usually occur as isolated
involvement (70) or associated with calcaneal fibular ligament (CFL) (20-40)
but the posterior talar fibular ligament (PTFL) affects only major trauma
involving ankle dislocation
ATFL breaks is associated with breakage of the joint capsule and synovial fluid
extravasation into the anterolateral soft ankle whereas the complete tearing of
CFL can communicate the ankle joint and synovial sheath peroneal tendons
Rupture of CFL is rarely associated with superior peroneal retinaculum tear
The CFL is tensioned during dorsiflexion pulling on peroneal tendons laterally
so that absence of its displacement is sign of a complete tear
Within a damaged ligament can also observe calcifications that often
correspond to fragments of avulsion bone
During the ultrasound can be performed forced maneuvers to detect to joint
laxity and ligament injuries The anterior drawer test is performed with the feet
hanging over the edge of the examination table while the forefoot is pulled
anteriorly when the foot is in plantar flexion and inversion This maneuver
helps differentiate partial tears (grade II) of the ATFL to complete (grade III)
where the anterior displacement of the talus on the tibia open a crack in the
substance becoming more visible the ligament injury
The sindesmosys sprains are up to 10 of ankle
injuries happening in eversion and pronation
movements (like the deltoid ligament injury) and
primarily affect the anterior tibiofibular ligament (ATFL)
the failure is frequently associated with fracture of the
fibula
According to the place of employment are 4 degrees
useful for prognostic evaluation and therapeutic strategy
choice
Grade I stretch or partial tear of the ATFL
Grade II complete tearing but only the ATFL
Grade III complete tear of the ATFL and partial CFL
Grade IV complete tear of the ATFL and CFL
The grade I and II injuries usually scarred without any
significant instability whereas grade III and IV injuries
can cause chronic pain and require surgical treatment
Thickened but continued ATFL right in relation to the partial rupture
Grade 111 sprain of right ATFL
Thickened anterior talofibular ligament with calcifications and a partial rupture
Thickened tibiofibular ligament after trauma
Anterior Talofibular Ligament Partial Tear and Elastography
Tibio fibular ligament rupture with bony avulsion
Complete rupture of right ATFL
Bony avulsion with radiographic evidence as visible calcification in a grade III sprain ATFL
Moderately thickened and hypoechoic ATFL
Discontinuity of the ATFL with fluid surrounding the torn ends (arrow)
Thickening and hypoechogenicity of the fibular end of the ligament seen here passing over the subtalar joint which contains a small of fluid
Complete disruption to the tibiofibular ligament with bony irregularity of particularly the tibial margin and fluid in the gap
MEDIAL COMPARTMENTBecause of the low incidence of eversion ankle
sprains and the thickness of the deltoid ligament
is rarely injured in isolation and when the injury
does not usually full thickness Usually
accompanied by lesions of the medial malleolus
and lateral displacement of the talus with
consequent widening of the ankle mortise
Ultrasound is useful for differentiating ligament
injury of the posterior tibial tendon injury
(TP) adjacent they have similar symptoms
The inability to visualize the deltoid ligament may
indicate tear but this is not considered a reliable
sign as its full ultrasound is not always possible
Partial medial ligament rupture
Thickened heterogeneous abnormal deltoid demonstrating hyperemia
Ultrasonogram showing a disrupted deltoid ligament with the probe in the coronal plane The white arrow indicates the medial malleolus the blue arrow indicates the talus and the red arrows indicate the disrupted deltoid ligament (A) Radiograph showing the same injury (B)
bullJOINT AND BONE DISORDERSUltrasound reliably detect spills mild (gt 2 ml) inside
of the ankle joint by exploring the front and rear
recess as well as areas of synovial proliferation and
may even display using the colour Doppler
hyperemic areas in arthritis patients
The intraarticular joints are displayed surrounded
fluid in one of the recesses of the ankle or subtalar
joint Sonographically diagnosed when changing position to perform flexion and extension Fracture of the lateral process of the talus is overlooked up to 50 of cases with plain radiography Ultrasound may suspect the presence of focal cortical disruption helping further to exclude concomitant ligament injury
Rheumatoid arthritis with synovial thickening (1) and erosion of the tibia (2)
Infectious arthritis with a pus filled anterior recess of the ankle
Arthritis and tenosynovitis of the ankle in a patient with rheumatoid arthritis
bullTUMOURSUltrasound can differentiate between a mass complex
and solid and a cystic in addition to verifying the
existence of accessory muscles (peroneus fourth
accessory flexor digitorum longus and accessory
soleus) As in any other location can be found
neoformative soft tissue tumors inflammatory
infectious etc
Ganglions of this location are more often symptomatic
and larger with multiple partitions
branched and lobed edges Differential diagnosis must
be made with tenosynovitis abscesses seromas and
varicosities
Neurogenic tumours are described as pathognomonic
homogeneous hypoechoic oval mass in continuity with
a nerve of origin
Ganglion cysts are non-malignant cystic masses that occur in association with musculoskeletal structures They are sometimes also simply referred to as ganglia or a ganglion but should not be confused with the anatomical term ganglion UltrasoundThe vast majority are anechoic to hypoechoic on ultrasound and have well defined margins Many demonstrate internal septations as well as acoustic enhancement A synovial cyst is a small fluid-filled sac or pouch that can develop over a tendon or joint creating a mass under the skin Synovial cyst is rare in ankle joint A synovial cyst may or may not be painful depending on their size and location
Ganglion cyst in the foot with bony erosion between navicular and cuneiform bones
Tarsal synovial cyst
Anechoic ganglion situated in the sinus tarsi fat between the talus and calcaneous
Plantar fasciitis (PF) refers to inflammation of the
plantar fascia of the foot It is considered the most common cause of heel pain
Clinical presentation Pain on the undersurface of the heel on weight bearing is the principal complaint It can be worse when weight is borne after a period of rest (eg in the morning) and eases with walking Passive dorsiflexion of the toes may exacerbates discomfort
UltrasoundOften the initial imaging modality of choice Ultrasound typically shows increased thickness of the fascia and a hypoechoic fascia
Thickened hypoechoic origin of the plantar fascia which has a convex superior margin
Complete avulsion of the plantar fascia from the calcaneal tubercle
Plantar fasciitis
bull LOCATING FOREIGN BODIES AND FRACTURES
As in any other location the ankle
area is also subsidiary host foreign
whose classification location and
existence can be defined perfectly by
ultrasound Being a focused study to
the area of interest and with great
resolution for surface structures can
be considered more resolute
examination to screen these cases
Osseous diseases and fractures | Sonography discovered Medial Malleolus Fracture
Ultrasound examination of left ankle A Longitudinal sonogram left ankle demonstrates a wooden foreign body B Transverse view left ankle Note the hypervascularity in the inflamed area C Corresponding X-ray of left ankle Note the swelling on the lateral aspect No foreign body is visible
Thank You
Thickening moderate amount of surrounding fluid and calcifications (arrow) affecting the
posterior tibial tendon related to chronic tenosynovitis in patient affects rheumatoid arthritis
Tenosynovitis of the posterior tibial tendon caused by a bony ridge at the insertion of the retinaculum The retinaculum is thickened and the tendon subluxates
Psoriatic arthritis Ankle Grayscale examination Posterior tibial tendon on longitudinal (a) and transverse (b) scan Marked tendon sheath widening with homogeneous anechoic aspect (asterisks) of the content indicating an exudative tenosynovitis Note as the normal fibrillar echotexture is conserved Hand Flexor tendons of second finger The volar longitudinal (c) and transverse scan (d) shows a tendon sheath widening with signs of synovial proliferation presence of intense power Doppler signal surrounding the tendon and micro interruption of the margin (arrow) e Wrist Extensor carpi ulnaris tendon (sixth compartment of the extensor tendons ecu) on lateral longitudinal (e) and transverse (f) scan Chronic tenosynovitis with clear areas of low of echogenicity and loss of the continuity of tendon fibrils indicative of partial tendon tear (arrows) Moreover note the presence of power Doppler signal within the interruption indicating still activity of the inflammatory process g Dactylitis Volar longitudinal scan using the ldquoextended viewrdquo technique showing proliferative tenosynovitis of the finger flexor tendon (circle) exudative synovitis of both proximal and distal interphalangeal joint (white asterisks) and edema of the peritendinous tissue (black asterisks) TP posterior tibial tendon mm medial malleolus DP distal phalanx mp middle phalanx cu cubital bone ft flexor tendons
Tenosynovitis of the posterior tibial (1) and flexor digitorum longus tendon (2)
Tibialis Posterior Tendon rupture
Tenosynovitis of the posterior tibial tendon the flexor digitorum tendon and flexor hallucis longus tendon
Tenosynovitis of the tendons on the medial side in the left ankle
bullLIGAMENT INJURIESThe ligament partial tear ligament shows a hypoechoic
areas swollen with internal focal or diffuse In the complete
ruptures within the substance of the divided ligament rift is
observed corresponding to the hematoma hypoechoic and
the free ends of the divided ligament can be and retracted
appreciated corrugated in contrast with normal
appearance straight
Grade I Mild stretching of the ligament without breakage
or instability
Grade II Partial tearing of the ligament
Grade III Complete tearing
Degrees depending on the severity of the injury and the
place of employment
LATERAL COMPARTMENTThese injuries occur secondary to inversion sprains with internal rotation of
the foot combined with ankle plantar flexion
The anterior talar fibular ligament tears (ATFL) usually occur as isolated
involvement (70) or associated with calcaneal fibular ligament (CFL) (20-40)
but the posterior talar fibular ligament (PTFL) affects only major trauma
involving ankle dislocation
ATFL breaks is associated with breakage of the joint capsule and synovial fluid
extravasation into the anterolateral soft ankle whereas the complete tearing of
CFL can communicate the ankle joint and synovial sheath peroneal tendons
Rupture of CFL is rarely associated with superior peroneal retinaculum tear
The CFL is tensioned during dorsiflexion pulling on peroneal tendons laterally
so that absence of its displacement is sign of a complete tear
Within a damaged ligament can also observe calcifications that often
correspond to fragments of avulsion bone
During the ultrasound can be performed forced maneuvers to detect to joint
laxity and ligament injuries The anterior drawer test is performed with the feet
hanging over the edge of the examination table while the forefoot is pulled
anteriorly when the foot is in plantar flexion and inversion This maneuver
helps differentiate partial tears (grade II) of the ATFL to complete (grade III)
where the anterior displacement of the talus on the tibia open a crack in the
substance becoming more visible the ligament injury
The sindesmosys sprains are up to 10 of ankle
injuries happening in eversion and pronation
movements (like the deltoid ligament injury) and
primarily affect the anterior tibiofibular ligament (ATFL)
the failure is frequently associated with fracture of the
fibula
According to the place of employment are 4 degrees
useful for prognostic evaluation and therapeutic strategy
choice
Grade I stretch or partial tear of the ATFL
Grade II complete tearing but only the ATFL
Grade III complete tear of the ATFL and partial CFL
Grade IV complete tear of the ATFL and CFL
The grade I and II injuries usually scarred without any
significant instability whereas grade III and IV injuries
can cause chronic pain and require surgical treatment
Thickened but continued ATFL right in relation to the partial rupture
Grade 111 sprain of right ATFL
Thickened anterior talofibular ligament with calcifications and a partial rupture
Thickened tibiofibular ligament after trauma
Anterior Talofibular Ligament Partial Tear and Elastography
Tibio fibular ligament rupture with bony avulsion
Complete rupture of right ATFL
Bony avulsion with radiographic evidence as visible calcification in a grade III sprain ATFL
Moderately thickened and hypoechoic ATFL
Discontinuity of the ATFL with fluid surrounding the torn ends (arrow)
Thickening and hypoechogenicity of the fibular end of the ligament seen here passing over the subtalar joint which contains a small of fluid
Complete disruption to the tibiofibular ligament with bony irregularity of particularly the tibial margin and fluid in the gap
MEDIAL COMPARTMENTBecause of the low incidence of eversion ankle
sprains and the thickness of the deltoid ligament
is rarely injured in isolation and when the injury
does not usually full thickness Usually
accompanied by lesions of the medial malleolus
and lateral displacement of the talus with
consequent widening of the ankle mortise
Ultrasound is useful for differentiating ligament
injury of the posterior tibial tendon injury
(TP) adjacent they have similar symptoms
The inability to visualize the deltoid ligament may
indicate tear but this is not considered a reliable
sign as its full ultrasound is not always possible
Partial medial ligament rupture
Thickened heterogeneous abnormal deltoid demonstrating hyperemia
Ultrasonogram showing a disrupted deltoid ligament with the probe in the coronal plane The white arrow indicates the medial malleolus the blue arrow indicates the talus and the red arrows indicate the disrupted deltoid ligament (A) Radiograph showing the same injury (B)
bullJOINT AND BONE DISORDERSUltrasound reliably detect spills mild (gt 2 ml) inside
of the ankle joint by exploring the front and rear
recess as well as areas of synovial proliferation and
may even display using the colour Doppler
hyperemic areas in arthritis patients
The intraarticular joints are displayed surrounded
fluid in one of the recesses of the ankle or subtalar
joint Sonographically diagnosed when changing position to perform flexion and extension Fracture of the lateral process of the talus is overlooked up to 50 of cases with plain radiography Ultrasound may suspect the presence of focal cortical disruption helping further to exclude concomitant ligament injury
Rheumatoid arthritis with synovial thickening (1) and erosion of the tibia (2)
Infectious arthritis with a pus filled anterior recess of the ankle
Arthritis and tenosynovitis of the ankle in a patient with rheumatoid arthritis
bullTUMOURSUltrasound can differentiate between a mass complex
and solid and a cystic in addition to verifying the
existence of accessory muscles (peroneus fourth
accessory flexor digitorum longus and accessory
soleus) As in any other location can be found
neoformative soft tissue tumors inflammatory
infectious etc
Ganglions of this location are more often symptomatic
and larger with multiple partitions
branched and lobed edges Differential diagnosis must
be made with tenosynovitis abscesses seromas and
varicosities
Neurogenic tumours are described as pathognomonic
homogeneous hypoechoic oval mass in continuity with
a nerve of origin
Ganglion cysts are non-malignant cystic masses that occur in association with musculoskeletal structures They are sometimes also simply referred to as ganglia or a ganglion but should not be confused with the anatomical term ganglion UltrasoundThe vast majority are anechoic to hypoechoic on ultrasound and have well defined margins Many demonstrate internal septations as well as acoustic enhancement A synovial cyst is a small fluid-filled sac or pouch that can develop over a tendon or joint creating a mass under the skin Synovial cyst is rare in ankle joint A synovial cyst may or may not be painful depending on their size and location
Ganglion cyst in the foot with bony erosion between navicular and cuneiform bones
Tarsal synovial cyst
Anechoic ganglion situated in the sinus tarsi fat between the talus and calcaneous
Plantar fasciitis (PF) refers to inflammation of the
plantar fascia of the foot It is considered the most common cause of heel pain
Clinical presentation Pain on the undersurface of the heel on weight bearing is the principal complaint It can be worse when weight is borne after a period of rest (eg in the morning) and eases with walking Passive dorsiflexion of the toes may exacerbates discomfort
UltrasoundOften the initial imaging modality of choice Ultrasound typically shows increased thickness of the fascia and a hypoechoic fascia
Thickened hypoechoic origin of the plantar fascia which has a convex superior margin
Complete avulsion of the plantar fascia from the calcaneal tubercle
Plantar fasciitis
bull LOCATING FOREIGN BODIES AND FRACTURES
As in any other location the ankle
area is also subsidiary host foreign
whose classification location and
existence can be defined perfectly by
ultrasound Being a focused study to
the area of interest and with great
resolution for surface structures can
be considered more resolute
examination to screen these cases
Osseous diseases and fractures | Sonography discovered Medial Malleolus Fracture
Ultrasound examination of left ankle A Longitudinal sonogram left ankle demonstrates a wooden foreign body B Transverse view left ankle Note the hypervascularity in the inflamed area C Corresponding X-ray of left ankle Note the swelling on the lateral aspect No foreign body is visible
Thank You
Tenosynovitis of the posterior tibial tendon caused by a bony ridge at the insertion of the retinaculum The retinaculum is thickened and the tendon subluxates
Psoriatic arthritis Ankle Grayscale examination Posterior tibial tendon on longitudinal (a) and transverse (b) scan Marked tendon sheath widening with homogeneous anechoic aspect (asterisks) of the content indicating an exudative tenosynovitis Note as the normal fibrillar echotexture is conserved Hand Flexor tendons of second finger The volar longitudinal (c) and transverse scan (d) shows a tendon sheath widening with signs of synovial proliferation presence of intense power Doppler signal surrounding the tendon and micro interruption of the margin (arrow) e Wrist Extensor carpi ulnaris tendon (sixth compartment of the extensor tendons ecu) on lateral longitudinal (e) and transverse (f) scan Chronic tenosynovitis with clear areas of low of echogenicity and loss of the continuity of tendon fibrils indicative of partial tendon tear (arrows) Moreover note the presence of power Doppler signal within the interruption indicating still activity of the inflammatory process g Dactylitis Volar longitudinal scan using the ldquoextended viewrdquo technique showing proliferative tenosynovitis of the finger flexor tendon (circle) exudative synovitis of both proximal and distal interphalangeal joint (white asterisks) and edema of the peritendinous tissue (black asterisks) TP posterior tibial tendon mm medial malleolus DP distal phalanx mp middle phalanx cu cubital bone ft flexor tendons
Tenosynovitis of the posterior tibial (1) and flexor digitorum longus tendon (2)
Tibialis Posterior Tendon rupture
Tenosynovitis of the posterior tibial tendon the flexor digitorum tendon and flexor hallucis longus tendon
Tenosynovitis of the tendons on the medial side in the left ankle
bullLIGAMENT INJURIESThe ligament partial tear ligament shows a hypoechoic
areas swollen with internal focal or diffuse In the complete
ruptures within the substance of the divided ligament rift is
observed corresponding to the hematoma hypoechoic and
the free ends of the divided ligament can be and retracted
appreciated corrugated in contrast with normal
appearance straight
Grade I Mild stretching of the ligament without breakage
or instability
Grade II Partial tearing of the ligament
Grade III Complete tearing
Degrees depending on the severity of the injury and the
place of employment
LATERAL COMPARTMENTThese injuries occur secondary to inversion sprains with internal rotation of
the foot combined with ankle plantar flexion
The anterior talar fibular ligament tears (ATFL) usually occur as isolated
involvement (70) or associated with calcaneal fibular ligament (CFL) (20-40)
but the posterior talar fibular ligament (PTFL) affects only major trauma
involving ankle dislocation
ATFL breaks is associated with breakage of the joint capsule and synovial fluid
extravasation into the anterolateral soft ankle whereas the complete tearing of
CFL can communicate the ankle joint and synovial sheath peroneal tendons
Rupture of CFL is rarely associated with superior peroneal retinaculum tear
The CFL is tensioned during dorsiflexion pulling on peroneal tendons laterally
so that absence of its displacement is sign of a complete tear
Within a damaged ligament can also observe calcifications that often
correspond to fragments of avulsion bone
During the ultrasound can be performed forced maneuvers to detect to joint
laxity and ligament injuries The anterior drawer test is performed with the feet
hanging over the edge of the examination table while the forefoot is pulled
anteriorly when the foot is in plantar flexion and inversion This maneuver
helps differentiate partial tears (grade II) of the ATFL to complete (grade III)
where the anterior displacement of the talus on the tibia open a crack in the
substance becoming more visible the ligament injury
The sindesmosys sprains are up to 10 of ankle
injuries happening in eversion and pronation
movements (like the deltoid ligament injury) and
primarily affect the anterior tibiofibular ligament (ATFL)
the failure is frequently associated with fracture of the
fibula
According to the place of employment are 4 degrees
useful for prognostic evaluation and therapeutic strategy
choice
Grade I stretch or partial tear of the ATFL
Grade II complete tearing but only the ATFL
Grade III complete tear of the ATFL and partial CFL
Grade IV complete tear of the ATFL and CFL
The grade I and II injuries usually scarred without any
significant instability whereas grade III and IV injuries
can cause chronic pain and require surgical treatment
Thickened but continued ATFL right in relation to the partial rupture
Grade 111 sprain of right ATFL
Thickened anterior talofibular ligament with calcifications and a partial rupture
Thickened tibiofibular ligament after trauma
Anterior Talofibular Ligament Partial Tear and Elastography
Tibio fibular ligament rupture with bony avulsion
Complete rupture of right ATFL
Bony avulsion with radiographic evidence as visible calcification in a grade III sprain ATFL
Moderately thickened and hypoechoic ATFL
Discontinuity of the ATFL with fluid surrounding the torn ends (arrow)
Thickening and hypoechogenicity of the fibular end of the ligament seen here passing over the subtalar joint which contains a small of fluid
Complete disruption to the tibiofibular ligament with bony irregularity of particularly the tibial margin and fluid in the gap
MEDIAL COMPARTMENTBecause of the low incidence of eversion ankle
sprains and the thickness of the deltoid ligament
is rarely injured in isolation and when the injury
does not usually full thickness Usually
accompanied by lesions of the medial malleolus
and lateral displacement of the talus with
consequent widening of the ankle mortise
Ultrasound is useful for differentiating ligament
injury of the posterior tibial tendon injury
(TP) adjacent they have similar symptoms
The inability to visualize the deltoid ligament may
indicate tear but this is not considered a reliable
sign as its full ultrasound is not always possible
Partial medial ligament rupture
Thickened heterogeneous abnormal deltoid demonstrating hyperemia
Ultrasonogram showing a disrupted deltoid ligament with the probe in the coronal plane The white arrow indicates the medial malleolus the blue arrow indicates the talus and the red arrows indicate the disrupted deltoid ligament (A) Radiograph showing the same injury (B)
bullJOINT AND BONE DISORDERSUltrasound reliably detect spills mild (gt 2 ml) inside
of the ankle joint by exploring the front and rear
recess as well as areas of synovial proliferation and
may even display using the colour Doppler
hyperemic areas in arthritis patients
The intraarticular joints are displayed surrounded
fluid in one of the recesses of the ankle or subtalar
joint Sonographically diagnosed when changing position to perform flexion and extension Fracture of the lateral process of the talus is overlooked up to 50 of cases with plain radiography Ultrasound may suspect the presence of focal cortical disruption helping further to exclude concomitant ligament injury
Rheumatoid arthritis with synovial thickening (1) and erosion of the tibia (2)
Infectious arthritis with a pus filled anterior recess of the ankle
Arthritis and tenosynovitis of the ankle in a patient with rheumatoid arthritis
bullTUMOURSUltrasound can differentiate between a mass complex
and solid and a cystic in addition to verifying the
existence of accessory muscles (peroneus fourth
accessory flexor digitorum longus and accessory
soleus) As in any other location can be found
neoformative soft tissue tumors inflammatory
infectious etc
Ganglions of this location are more often symptomatic
and larger with multiple partitions
branched and lobed edges Differential diagnosis must
be made with tenosynovitis abscesses seromas and
varicosities
Neurogenic tumours are described as pathognomonic
homogeneous hypoechoic oval mass in continuity with
a nerve of origin
Ganglion cysts are non-malignant cystic masses that occur in association with musculoskeletal structures They are sometimes also simply referred to as ganglia or a ganglion but should not be confused with the anatomical term ganglion UltrasoundThe vast majority are anechoic to hypoechoic on ultrasound and have well defined margins Many demonstrate internal septations as well as acoustic enhancement A synovial cyst is a small fluid-filled sac or pouch that can develop over a tendon or joint creating a mass under the skin Synovial cyst is rare in ankle joint A synovial cyst may or may not be painful depending on their size and location
Ganglion cyst in the foot with bony erosion between navicular and cuneiform bones
Tarsal synovial cyst
Anechoic ganglion situated in the sinus tarsi fat between the talus and calcaneous
Plantar fasciitis (PF) refers to inflammation of the
plantar fascia of the foot It is considered the most common cause of heel pain
Clinical presentation Pain on the undersurface of the heel on weight bearing is the principal complaint It can be worse when weight is borne after a period of rest (eg in the morning) and eases with walking Passive dorsiflexion of the toes may exacerbates discomfort
UltrasoundOften the initial imaging modality of choice Ultrasound typically shows increased thickness of the fascia and a hypoechoic fascia
Thickened hypoechoic origin of the plantar fascia which has a convex superior margin
Complete avulsion of the plantar fascia from the calcaneal tubercle
Plantar fasciitis
bull LOCATING FOREIGN BODIES AND FRACTURES
As in any other location the ankle
area is also subsidiary host foreign
whose classification location and
existence can be defined perfectly by
ultrasound Being a focused study to
the area of interest and with great
resolution for surface structures can
be considered more resolute
examination to screen these cases
Osseous diseases and fractures | Sonography discovered Medial Malleolus Fracture
Ultrasound examination of left ankle A Longitudinal sonogram left ankle demonstrates a wooden foreign body B Transverse view left ankle Note the hypervascularity in the inflamed area C Corresponding X-ray of left ankle Note the swelling on the lateral aspect No foreign body is visible
Thank You
Psoriatic arthritis Ankle Grayscale examination Posterior tibial tendon on longitudinal (a) and transverse (b) scan Marked tendon sheath widening with homogeneous anechoic aspect (asterisks) of the content indicating an exudative tenosynovitis Note as the normal fibrillar echotexture is conserved Hand Flexor tendons of second finger The volar longitudinal (c) and transverse scan (d) shows a tendon sheath widening with signs of synovial proliferation presence of intense power Doppler signal surrounding the tendon and micro interruption of the margin (arrow) e Wrist Extensor carpi ulnaris tendon (sixth compartment of the extensor tendons ecu) on lateral longitudinal (e) and transverse (f) scan Chronic tenosynovitis with clear areas of low of echogenicity and loss of the continuity of tendon fibrils indicative of partial tendon tear (arrows) Moreover note the presence of power Doppler signal within the interruption indicating still activity of the inflammatory process g Dactylitis Volar longitudinal scan using the ldquoextended viewrdquo technique showing proliferative tenosynovitis of the finger flexor tendon (circle) exudative synovitis of both proximal and distal interphalangeal joint (white asterisks) and edema of the peritendinous tissue (black asterisks) TP posterior tibial tendon mm medial malleolus DP distal phalanx mp middle phalanx cu cubital bone ft flexor tendons
Tenosynovitis of the posterior tibial (1) and flexor digitorum longus tendon (2)
Tibialis Posterior Tendon rupture
Tenosynovitis of the posterior tibial tendon the flexor digitorum tendon and flexor hallucis longus tendon
Tenosynovitis of the tendons on the medial side in the left ankle
bullLIGAMENT INJURIESThe ligament partial tear ligament shows a hypoechoic
areas swollen with internal focal or diffuse In the complete
ruptures within the substance of the divided ligament rift is
observed corresponding to the hematoma hypoechoic and
the free ends of the divided ligament can be and retracted
appreciated corrugated in contrast with normal
appearance straight
Grade I Mild stretching of the ligament without breakage
or instability
Grade II Partial tearing of the ligament
Grade III Complete tearing
Degrees depending on the severity of the injury and the
place of employment
LATERAL COMPARTMENTThese injuries occur secondary to inversion sprains with internal rotation of
the foot combined with ankle plantar flexion
The anterior talar fibular ligament tears (ATFL) usually occur as isolated
involvement (70) or associated with calcaneal fibular ligament (CFL) (20-40)
but the posterior talar fibular ligament (PTFL) affects only major trauma
involving ankle dislocation
ATFL breaks is associated with breakage of the joint capsule and synovial fluid
extravasation into the anterolateral soft ankle whereas the complete tearing of
CFL can communicate the ankle joint and synovial sheath peroneal tendons
Rupture of CFL is rarely associated with superior peroneal retinaculum tear
The CFL is tensioned during dorsiflexion pulling on peroneal tendons laterally
so that absence of its displacement is sign of a complete tear
Within a damaged ligament can also observe calcifications that often
correspond to fragments of avulsion bone
During the ultrasound can be performed forced maneuvers to detect to joint
laxity and ligament injuries The anterior drawer test is performed with the feet
hanging over the edge of the examination table while the forefoot is pulled
anteriorly when the foot is in plantar flexion and inversion This maneuver
helps differentiate partial tears (grade II) of the ATFL to complete (grade III)
where the anterior displacement of the talus on the tibia open a crack in the
substance becoming more visible the ligament injury
The sindesmosys sprains are up to 10 of ankle
injuries happening in eversion and pronation
movements (like the deltoid ligament injury) and
primarily affect the anterior tibiofibular ligament (ATFL)
the failure is frequently associated with fracture of the
fibula
According to the place of employment are 4 degrees
useful for prognostic evaluation and therapeutic strategy
choice
Grade I stretch or partial tear of the ATFL
Grade II complete tearing but only the ATFL
Grade III complete tear of the ATFL and partial CFL
Grade IV complete tear of the ATFL and CFL
The grade I and II injuries usually scarred without any
significant instability whereas grade III and IV injuries
can cause chronic pain and require surgical treatment
Thickened but continued ATFL right in relation to the partial rupture
Grade 111 sprain of right ATFL
Thickened anterior talofibular ligament with calcifications and a partial rupture
Thickened tibiofibular ligament after trauma
Anterior Talofibular Ligament Partial Tear and Elastography
Tibio fibular ligament rupture with bony avulsion
Complete rupture of right ATFL
Bony avulsion with radiographic evidence as visible calcification in a grade III sprain ATFL
Moderately thickened and hypoechoic ATFL
Discontinuity of the ATFL with fluid surrounding the torn ends (arrow)
Thickening and hypoechogenicity of the fibular end of the ligament seen here passing over the subtalar joint which contains a small of fluid
Complete disruption to the tibiofibular ligament with bony irregularity of particularly the tibial margin and fluid in the gap
MEDIAL COMPARTMENTBecause of the low incidence of eversion ankle
sprains and the thickness of the deltoid ligament
is rarely injured in isolation and when the injury
does not usually full thickness Usually
accompanied by lesions of the medial malleolus
and lateral displacement of the talus with
consequent widening of the ankle mortise
Ultrasound is useful for differentiating ligament
injury of the posterior tibial tendon injury
(TP) adjacent they have similar symptoms
The inability to visualize the deltoid ligament may
indicate tear but this is not considered a reliable
sign as its full ultrasound is not always possible
Partial medial ligament rupture
Thickened heterogeneous abnormal deltoid demonstrating hyperemia
Ultrasonogram showing a disrupted deltoid ligament with the probe in the coronal plane The white arrow indicates the medial malleolus the blue arrow indicates the talus and the red arrows indicate the disrupted deltoid ligament (A) Radiograph showing the same injury (B)
bullJOINT AND BONE DISORDERSUltrasound reliably detect spills mild (gt 2 ml) inside
of the ankle joint by exploring the front and rear
recess as well as areas of synovial proliferation and
may even display using the colour Doppler
hyperemic areas in arthritis patients
The intraarticular joints are displayed surrounded
fluid in one of the recesses of the ankle or subtalar
joint Sonographically diagnosed when changing position to perform flexion and extension Fracture of the lateral process of the talus is overlooked up to 50 of cases with plain radiography Ultrasound may suspect the presence of focal cortical disruption helping further to exclude concomitant ligament injury
Rheumatoid arthritis with synovial thickening (1) and erosion of the tibia (2)
Infectious arthritis with a pus filled anterior recess of the ankle
Arthritis and tenosynovitis of the ankle in a patient with rheumatoid arthritis
bullTUMOURSUltrasound can differentiate between a mass complex
and solid and a cystic in addition to verifying the
existence of accessory muscles (peroneus fourth
accessory flexor digitorum longus and accessory
soleus) As in any other location can be found
neoformative soft tissue tumors inflammatory
infectious etc
Ganglions of this location are more often symptomatic
and larger with multiple partitions
branched and lobed edges Differential diagnosis must
be made with tenosynovitis abscesses seromas and
varicosities
Neurogenic tumours are described as pathognomonic
homogeneous hypoechoic oval mass in continuity with
a nerve of origin
Ganglion cysts are non-malignant cystic masses that occur in association with musculoskeletal structures They are sometimes also simply referred to as ganglia or a ganglion but should not be confused with the anatomical term ganglion UltrasoundThe vast majority are anechoic to hypoechoic on ultrasound and have well defined margins Many demonstrate internal septations as well as acoustic enhancement A synovial cyst is a small fluid-filled sac or pouch that can develop over a tendon or joint creating a mass under the skin Synovial cyst is rare in ankle joint A synovial cyst may or may not be painful depending on their size and location
Ganglion cyst in the foot with bony erosion between navicular and cuneiform bones
Tarsal synovial cyst
Anechoic ganglion situated in the sinus tarsi fat between the talus and calcaneous
Plantar fasciitis (PF) refers to inflammation of the
plantar fascia of the foot It is considered the most common cause of heel pain
Clinical presentation Pain on the undersurface of the heel on weight bearing is the principal complaint It can be worse when weight is borne after a period of rest (eg in the morning) and eases with walking Passive dorsiflexion of the toes may exacerbates discomfort
UltrasoundOften the initial imaging modality of choice Ultrasound typically shows increased thickness of the fascia and a hypoechoic fascia
Thickened hypoechoic origin of the plantar fascia which has a convex superior margin
Complete avulsion of the plantar fascia from the calcaneal tubercle
Plantar fasciitis
bull LOCATING FOREIGN BODIES AND FRACTURES
As in any other location the ankle
area is also subsidiary host foreign
whose classification location and
existence can be defined perfectly by
ultrasound Being a focused study to
the area of interest and with great
resolution for surface structures can
be considered more resolute
examination to screen these cases
Osseous diseases and fractures | Sonography discovered Medial Malleolus Fracture
Ultrasound examination of left ankle A Longitudinal sonogram left ankle demonstrates a wooden foreign body B Transverse view left ankle Note the hypervascularity in the inflamed area C Corresponding X-ray of left ankle Note the swelling on the lateral aspect No foreign body is visible
Thank You
Tenosynovitis of the posterior tibial (1) and flexor digitorum longus tendon (2)
Tibialis Posterior Tendon rupture
Tenosynovitis of the posterior tibial tendon the flexor digitorum tendon and flexor hallucis longus tendon
Tenosynovitis of the tendons on the medial side in the left ankle
bullLIGAMENT INJURIESThe ligament partial tear ligament shows a hypoechoic
areas swollen with internal focal or diffuse In the complete
ruptures within the substance of the divided ligament rift is
observed corresponding to the hematoma hypoechoic and
the free ends of the divided ligament can be and retracted
appreciated corrugated in contrast with normal
appearance straight
Grade I Mild stretching of the ligament without breakage
or instability
Grade II Partial tearing of the ligament
Grade III Complete tearing
Degrees depending on the severity of the injury and the
place of employment
LATERAL COMPARTMENTThese injuries occur secondary to inversion sprains with internal rotation of
the foot combined with ankle plantar flexion
The anterior talar fibular ligament tears (ATFL) usually occur as isolated
involvement (70) or associated with calcaneal fibular ligament (CFL) (20-40)
but the posterior talar fibular ligament (PTFL) affects only major trauma
involving ankle dislocation
ATFL breaks is associated with breakage of the joint capsule and synovial fluid
extravasation into the anterolateral soft ankle whereas the complete tearing of
CFL can communicate the ankle joint and synovial sheath peroneal tendons
Rupture of CFL is rarely associated with superior peroneal retinaculum tear
The CFL is tensioned during dorsiflexion pulling on peroneal tendons laterally
so that absence of its displacement is sign of a complete tear
Within a damaged ligament can also observe calcifications that often
correspond to fragments of avulsion bone
During the ultrasound can be performed forced maneuvers to detect to joint
laxity and ligament injuries The anterior drawer test is performed with the feet
hanging over the edge of the examination table while the forefoot is pulled
anteriorly when the foot is in plantar flexion and inversion This maneuver
helps differentiate partial tears (grade II) of the ATFL to complete (grade III)
where the anterior displacement of the talus on the tibia open a crack in the
substance becoming more visible the ligament injury
The sindesmosys sprains are up to 10 of ankle
injuries happening in eversion and pronation
movements (like the deltoid ligament injury) and
primarily affect the anterior tibiofibular ligament (ATFL)
the failure is frequently associated with fracture of the
fibula
According to the place of employment are 4 degrees
useful for prognostic evaluation and therapeutic strategy
choice
Grade I stretch or partial tear of the ATFL
Grade II complete tearing but only the ATFL
Grade III complete tear of the ATFL and partial CFL
Grade IV complete tear of the ATFL and CFL
The grade I and II injuries usually scarred without any
significant instability whereas grade III and IV injuries
can cause chronic pain and require surgical treatment
Thickened but continued ATFL right in relation to the partial rupture
Grade 111 sprain of right ATFL
Thickened anterior talofibular ligament with calcifications and a partial rupture
Thickened tibiofibular ligament after trauma
Anterior Talofibular Ligament Partial Tear and Elastography
Tibio fibular ligament rupture with bony avulsion
Complete rupture of right ATFL
Bony avulsion with radiographic evidence as visible calcification in a grade III sprain ATFL
Moderately thickened and hypoechoic ATFL
Discontinuity of the ATFL with fluid surrounding the torn ends (arrow)
Thickening and hypoechogenicity of the fibular end of the ligament seen here passing over the subtalar joint which contains a small of fluid
Complete disruption to the tibiofibular ligament with bony irregularity of particularly the tibial margin and fluid in the gap
MEDIAL COMPARTMENTBecause of the low incidence of eversion ankle
sprains and the thickness of the deltoid ligament
is rarely injured in isolation and when the injury
does not usually full thickness Usually
accompanied by lesions of the medial malleolus
and lateral displacement of the talus with
consequent widening of the ankle mortise
Ultrasound is useful for differentiating ligament
injury of the posterior tibial tendon injury
(TP) adjacent they have similar symptoms
The inability to visualize the deltoid ligament may
indicate tear but this is not considered a reliable
sign as its full ultrasound is not always possible
Partial medial ligament rupture
Thickened heterogeneous abnormal deltoid demonstrating hyperemia
Ultrasonogram showing a disrupted deltoid ligament with the probe in the coronal plane The white arrow indicates the medial malleolus the blue arrow indicates the talus and the red arrows indicate the disrupted deltoid ligament (A) Radiograph showing the same injury (B)
bullJOINT AND BONE DISORDERSUltrasound reliably detect spills mild (gt 2 ml) inside
of the ankle joint by exploring the front and rear
recess as well as areas of synovial proliferation and
may even display using the colour Doppler
hyperemic areas in arthritis patients
The intraarticular joints are displayed surrounded
fluid in one of the recesses of the ankle or subtalar
joint Sonographically diagnosed when changing position to perform flexion and extension Fracture of the lateral process of the talus is overlooked up to 50 of cases with plain radiography Ultrasound may suspect the presence of focal cortical disruption helping further to exclude concomitant ligament injury
Rheumatoid arthritis with synovial thickening (1) and erosion of the tibia (2)
Infectious arthritis with a pus filled anterior recess of the ankle
Arthritis and tenosynovitis of the ankle in a patient with rheumatoid arthritis
bullTUMOURSUltrasound can differentiate between a mass complex
and solid and a cystic in addition to verifying the
existence of accessory muscles (peroneus fourth
accessory flexor digitorum longus and accessory
soleus) As in any other location can be found
neoformative soft tissue tumors inflammatory
infectious etc
Ganglions of this location are more often symptomatic
and larger with multiple partitions
branched and lobed edges Differential diagnosis must
be made with tenosynovitis abscesses seromas and
varicosities
Neurogenic tumours are described as pathognomonic
homogeneous hypoechoic oval mass in continuity with
a nerve of origin
Ganglion cysts are non-malignant cystic masses that occur in association with musculoskeletal structures They are sometimes also simply referred to as ganglia or a ganglion but should not be confused with the anatomical term ganglion UltrasoundThe vast majority are anechoic to hypoechoic on ultrasound and have well defined margins Many demonstrate internal septations as well as acoustic enhancement A synovial cyst is a small fluid-filled sac or pouch that can develop over a tendon or joint creating a mass under the skin Synovial cyst is rare in ankle joint A synovial cyst may or may not be painful depending on their size and location
Ganglion cyst in the foot with bony erosion between navicular and cuneiform bones
Tarsal synovial cyst
Anechoic ganglion situated in the sinus tarsi fat between the talus and calcaneous
Plantar fasciitis (PF) refers to inflammation of the
plantar fascia of the foot It is considered the most common cause of heel pain
Clinical presentation Pain on the undersurface of the heel on weight bearing is the principal complaint It can be worse when weight is borne after a period of rest (eg in the morning) and eases with walking Passive dorsiflexion of the toes may exacerbates discomfort
UltrasoundOften the initial imaging modality of choice Ultrasound typically shows increased thickness of the fascia and a hypoechoic fascia
Thickened hypoechoic origin of the plantar fascia which has a convex superior margin
Complete avulsion of the plantar fascia from the calcaneal tubercle
Plantar fasciitis
bull LOCATING FOREIGN BODIES AND FRACTURES
As in any other location the ankle
area is also subsidiary host foreign
whose classification location and
existence can be defined perfectly by
ultrasound Being a focused study to
the area of interest and with great
resolution for surface structures can
be considered more resolute
examination to screen these cases
Osseous diseases and fractures | Sonography discovered Medial Malleolus Fracture
Ultrasound examination of left ankle A Longitudinal sonogram left ankle demonstrates a wooden foreign body B Transverse view left ankle Note the hypervascularity in the inflamed area C Corresponding X-ray of left ankle Note the swelling on the lateral aspect No foreign body is visible
Thank You
Tibialis Posterior Tendon rupture
Tenosynovitis of the posterior tibial tendon the flexor digitorum tendon and flexor hallucis longus tendon
Tenosynovitis of the tendons on the medial side in the left ankle
bullLIGAMENT INJURIESThe ligament partial tear ligament shows a hypoechoic
areas swollen with internal focal or diffuse In the complete
ruptures within the substance of the divided ligament rift is
observed corresponding to the hematoma hypoechoic and
the free ends of the divided ligament can be and retracted
appreciated corrugated in contrast with normal
appearance straight
Grade I Mild stretching of the ligament without breakage
or instability
Grade II Partial tearing of the ligament
Grade III Complete tearing
Degrees depending on the severity of the injury and the
place of employment
LATERAL COMPARTMENTThese injuries occur secondary to inversion sprains with internal rotation of
the foot combined with ankle plantar flexion
The anterior talar fibular ligament tears (ATFL) usually occur as isolated
involvement (70) or associated with calcaneal fibular ligament (CFL) (20-40)
but the posterior talar fibular ligament (PTFL) affects only major trauma
involving ankle dislocation
ATFL breaks is associated with breakage of the joint capsule and synovial fluid
extravasation into the anterolateral soft ankle whereas the complete tearing of
CFL can communicate the ankle joint and synovial sheath peroneal tendons
Rupture of CFL is rarely associated with superior peroneal retinaculum tear
The CFL is tensioned during dorsiflexion pulling on peroneal tendons laterally
so that absence of its displacement is sign of a complete tear
Within a damaged ligament can also observe calcifications that often
correspond to fragments of avulsion bone
During the ultrasound can be performed forced maneuvers to detect to joint
laxity and ligament injuries The anterior drawer test is performed with the feet
hanging over the edge of the examination table while the forefoot is pulled
anteriorly when the foot is in plantar flexion and inversion This maneuver
helps differentiate partial tears (grade II) of the ATFL to complete (grade III)
where the anterior displacement of the talus on the tibia open a crack in the
substance becoming more visible the ligament injury
The sindesmosys sprains are up to 10 of ankle
injuries happening in eversion and pronation
movements (like the deltoid ligament injury) and
primarily affect the anterior tibiofibular ligament (ATFL)
the failure is frequently associated with fracture of the
fibula
According to the place of employment are 4 degrees
useful for prognostic evaluation and therapeutic strategy
choice
Grade I stretch or partial tear of the ATFL
Grade II complete tearing but only the ATFL
Grade III complete tear of the ATFL and partial CFL
Grade IV complete tear of the ATFL and CFL
The grade I and II injuries usually scarred without any
significant instability whereas grade III and IV injuries
can cause chronic pain and require surgical treatment
Thickened but continued ATFL right in relation to the partial rupture
Grade 111 sprain of right ATFL
Thickened anterior talofibular ligament with calcifications and a partial rupture
Thickened tibiofibular ligament after trauma
Anterior Talofibular Ligament Partial Tear and Elastography
Tibio fibular ligament rupture with bony avulsion
Complete rupture of right ATFL
Bony avulsion with radiographic evidence as visible calcification in a grade III sprain ATFL
Moderately thickened and hypoechoic ATFL
Discontinuity of the ATFL with fluid surrounding the torn ends (arrow)
Thickening and hypoechogenicity of the fibular end of the ligament seen here passing over the subtalar joint which contains a small of fluid
Complete disruption to the tibiofibular ligament with bony irregularity of particularly the tibial margin and fluid in the gap
MEDIAL COMPARTMENTBecause of the low incidence of eversion ankle
sprains and the thickness of the deltoid ligament
is rarely injured in isolation and when the injury
does not usually full thickness Usually
accompanied by lesions of the medial malleolus
and lateral displacement of the talus with
consequent widening of the ankle mortise
Ultrasound is useful for differentiating ligament
injury of the posterior tibial tendon injury
(TP) adjacent they have similar symptoms
The inability to visualize the deltoid ligament may
indicate tear but this is not considered a reliable
sign as its full ultrasound is not always possible
Partial medial ligament rupture
Thickened heterogeneous abnormal deltoid demonstrating hyperemia
Ultrasonogram showing a disrupted deltoid ligament with the probe in the coronal plane The white arrow indicates the medial malleolus the blue arrow indicates the talus and the red arrows indicate the disrupted deltoid ligament (A) Radiograph showing the same injury (B)
bullJOINT AND BONE DISORDERSUltrasound reliably detect spills mild (gt 2 ml) inside
of the ankle joint by exploring the front and rear
recess as well as areas of synovial proliferation and
may even display using the colour Doppler
hyperemic areas in arthritis patients
The intraarticular joints are displayed surrounded
fluid in one of the recesses of the ankle or subtalar
joint Sonographically diagnosed when changing position to perform flexion and extension Fracture of the lateral process of the talus is overlooked up to 50 of cases with plain radiography Ultrasound may suspect the presence of focal cortical disruption helping further to exclude concomitant ligament injury
Rheumatoid arthritis with synovial thickening (1) and erosion of the tibia (2)
Infectious arthritis with a pus filled anterior recess of the ankle
Arthritis and tenosynovitis of the ankle in a patient with rheumatoid arthritis
bullTUMOURSUltrasound can differentiate between a mass complex
and solid and a cystic in addition to verifying the
existence of accessory muscles (peroneus fourth
accessory flexor digitorum longus and accessory
soleus) As in any other location can be found
neoformative soft tissue tumors inflammatory
infectious etc
Ganglions of this location are more often symptomatic
and larger with multiple partitions
branched and lobed edges Differential diagnosis must
be made with tenosynovitis abscesses seromas and
varicosities
Neurogenic tumours are described as pathognomonic
homogeneous hypoechoic oval mass in continuity with
a nerve of origin
Ganglion cysts are non-malignant cystic masses that occur in association with musculoskeletal structures They are sometimes also simply referred to as ganglia or a ganglion but should not be confused with the anatomical term ganglion UltrasoundThe vast majority are anechoic to hypoechoic on ultrasound and have well defined margins Many demonstrate internal septations as well as acoustic enhancement A synovial cyst is a small fluid-filled sac or pouch that can develop over a tendon or joint creating a mass under the skin Synovial cyst is rare in ankle joint A synovial cyst may or may not be painful depending on their size and location
Ganglion cyst in the foot with bony erosion between navicular and cuneiform bones
Tarsal synovial cyst
Anechoic ganglion situated in the sinus tarsi fat between the talus and calcaneous
Plantar fasciitis (PF) refers to inflammation of the
plantar fascia of the foot It is considered the most common cause of heel pain
Clinical presentation Pain on the undersurface of the heel on weight bearing is the principal complaint It can be worse when weight is borne after a period of rest (eg in the morning) and eases with walking Passive dorsiflexion of the toes may exacerbates discomfort
UltrasoundOften the initial imaging modality of choice Ultrasound typically shows increased thickness of the fascia and a hypoechoic fascia
Thickened hypoechoic origin of the plantar fascia which has a convex superior margin
Complete avulsion of the plantar fascia from the calcaneal tubercle
Plantar fasciitis
bull LOCATING FOREIGN BODIES AND FRACTURES
As in any other location the ankle
area is also subsidiary host foreign
whose classification location and
existence can be defined perfectly by
ultrasound Being a focused study to
the area of interest and with great
resolution for surface structures can
be considered more resolute
examination to screen these cases
Osseous diseases and fractures | Sonography discovered Medial Malleolus Fracture
Ultrasound examination of left ankle A Longitudinal sonogram left ankle demonstrates a wooden foreign body B Transverse view left ankle Note the hypervascularity in the inflamed area C Corresponding X-ray of left ankle Note the swelling on the lateral aspect No foreign body is visible
Thank You
Tenosynovitis of the posterior tibial tendon the flexor digitorum tendon and flexor hallucis longus tendon
Tenosynovitis of the tendons on the medial side in the left ankle
bullLIGAMENT INJURIESThe ligament partial tear ligament shows a hypoechoic
areas swollen with internal focal or diffuse In the complete
ruptures within the substance of the divided ligament rift is
observed corresponding to the hematoma hypoechoic and
the free ends of the divided ligament can be and retracted
appreciated corrugated in contrast with normal
appearance straight
Grade I Mild stretching of the ligament without breakage
or instability
Grade II Partial tearing of the ligament
Grade III Complete tearing
Degrees depending on the severity of the injury and the
place of employment
LATERAL COMPARTMENTThese injuries occur secondary to inversion sprains with internal rotation of
the foot combined with ankle plantar flexion
The anterior talar fibular ligament tears (ATFL) usually occur as isolated
involvement (70) or associated with calcaneal fibular ligament (CFL) (20-40)
but the posterior talar fibular ligament (PTFL) affects only major trauma
involving ankle dislocation
ATFL breaks is associated with breakage of the joint capsule and synovial fluid
extravasation into the anterolateral soft ankle whereas the complete tearing of
CFL can communicate the ankle joint and synovial sheath peroneal tendons
Rupture of CFL is rarely associated with superior peroneal retinaculum tear
The CFL is tensioned during dorsiflexion pulling on peroneal tendons laterally
so that absence of its displacement is sign of a complete tear
Within a damaged ligament can also observe calcifications that often
correspond to fragments of avulsion bone
During the ultrasound can be performed forced maneuvers to detect to joint
laxity and ligament injuries The anterior drawer test is performed with the feet
hanging over the edge of the examination table while the forefoot is pulled
anteriorly when the foot is in plantar flexion and inversion This maneuver
helps differentiate partial tears (grade II) of the ATFL to complete (grade III)
where the anterior displacement of the talus on the tibia open a crack in the
substance becoming more visible the ligament injury
The sindesmosys sprains are up to 10 of ankle
injuries happening in eversion and pronation
movements (like the deltoid ligament injury) and
primarily affect the anterior tibiofibular ligament (ATFL)
the failure is frequently associated with fracture of the
fibula
According to the place of employment are 4 degrees
useful for prognostic evaluation and therapeutic strategy
choice
Grade I stretch or partial tear of the ATFL
Grade II complete tearing but only the ATFL
Grade III complete tear of the ATFL and partial CFL
Grade IV complete tear of the ATFL and CFL
The grade I and II injuries usually scarred without any
significant instability whereas grade III and IV injuries
can cause chronic pain and require surgical treatment
Thickened but continued ATFL right in relation to the partial rupture
Grade 111 sprain of right ATFL
Thickened anterior talofibular ligament with calcifications and a partial rupture
Thickened tibiofibular ligament after trauma
Anterior Talofibular Ligament Partial Tear and Elastography
Tibio fibular ligament rupture with bony avulsion
Complete rupture of right ATFL
Bony avulsion with radiographic evidence as visible calcification in a grade III sprain ATFL
Moderately thickened and hypoechoic ATFL
Discontinuity of the ATFL with fluid surrounding the torn ends (arrow)
Thickening and hypoechogenicity of the fibular end of the ligament seen here passing over the subtalar joint which contains a small of fluid
Complete disruption to the tibiofibular ligament with bony irregularity of particularly the tibial margin and fluid in the gap
MEDIAL COMPARTMENTBecause of the low incidence of eversion ankle
sprains and the thickness of the deltoid ligament
is rarely injured in isolation and when the injury
does not usually full thickness Usually
accompanied by lesions of the medial malleolus
and lateral displacement of the talus with
consequent widening of the ankle mortise
Ultrasound is useful for differentiating ligament
injury of the posterior tibial tendon injury
(TP) adjacent they have similar symptoms
The inability to visualize the deltoid ligament may
indicate tear but this is not considered a reliable
sign as its full ultrasound is not always possible
Partial medial ligament rupture
Thickened heterogeneous abnormal deltoid demonstrating hyperemia
Ultrasonogram showing a disrupted deltoid ligament with the probe in the coronal plane The white arrow indicates the medial malleolus the blue arrow indicates the talus and the red arrows indicate the disrupted deltoid ligament (A) Radiograph showing the same injury (B)
bullJOINT AND BONE DISORDERSUltrasound reliably detect spills mild (gt 2 ml) inside
of the ankle joint by exploring the front and rear
recess as well as areas of synovial proliferation and
may even display using the colour Doppler
hyperemic areas in arthritis patients
The intraarticular joints are displayed surrounded
fluid in one of the recesses of the ankle or subtalar
joint Sonographically diagnosed when changing position to perform flexion and extension Fracture of the lateral process of the talus is overlooked up to 50 of cases with plain radiography Ultrasound may suspect the presence of focal cortical disruption helping further to exclude concomitant ligament injury
Rheumatoid arthritis with synovial thickening (1) and erosion of the tibia (2)
Infectious arthritis with a pus filled anterior recess of the ankle
Arthritis and tenosynovitis of the ankle in a patient with rheumatoid arthritis
bullTUMOURSUltrasound can differentiate between a mass complex
and solid and a cystic in addition to verifying the
existence of accessory muscles (peroneus fourth
accessory flexor digitorum longus and accessory
soleus) As in any other location can be found
neoformative soft tissue tumors inflammatory
infectious etc
Ganglions of this location are more often symptomatic
and larger with multiple partitions
branched and lobed edges Differential diagnosis must
be made with tenosynovitis abscesses seromas and
varicosities
Neurogenic tumours are described as pathognomonic
homogeneous hypoechoic oval mass in continuity with
a nerve of origin
Ganglion cysts are non-malignant cystic masses that occur in association with musculoskeletal structures They are sometimes also simply referred to as ganglia or a ganglion but should not be confused with the anatomical term ganglion UltrasoundThe vast majority are anechoic to hypoechoic on ultrasound and have well defined margins Many demonstrate internal septations as well as acoustic enhancement A synovial cyst is a small fluid-filled sac or pouch that can develop over a tendon or joint creating a mass under the skin Synovial cyst is rare in ankle joint A synovial cyst may or may not be painful depending on their size and location
Ganglion cyst in the foot with bony erosion between navicular and cuneiform bones
Tarsal synovial cyst
Anechoic ganglion situated in the sinus tarsi fat between the talus and calcaneous
Plantar fasciitis (PF) refers to inflammation of the
plantar fascia of the foot It is considered the most common cause of heel pain
Clinical presentation Pain on the undersurface of the heel on weight bearing is the principal complaint It can be worse when weight is borne after a period of rest (eg in the morning) and eases with walking Passive dorsiflexion of the toes may exacerbates discomfort
UltrasoundOften the initial imaging modality of choice Ultrasound typically shows increased thickness of the fascia and a hypoechoic fascia
Thickened hypoechoic origin of the plantar fascia which has a convex superior margin
Complete avulsion of the plantar fascia from the calcaneal tubercle
Plantar fasciitis
bull LOCATING FOREIGN BODIES AND FRACTURES
As in any other location the ankle
area is also subsidiary host foreign
whose classification location and
existence can be defined perfectly by
ultrasound Being a focused study to
the area of interest and with great
resolution for surface structures can
be considered more resolute
examination to screen these cases
Osseous diseases and fractures | Sonography discovered Medial Malleolus Fracture
Ultrasound examination of left ankle A Longitudinal sonogram left ankle demonstrates a wooden foreign body B Transverse view left ankle Note the hypervascularity in the inflamed area C Corresponding X-ray of left ankle Note the swelling on the lateral aspect No foreign body is visible
Thank You
Tenosynovitis of the tendons on the medial side in the left ankle
bullLIGAMENT INJURIESThe ligament partial tear ligament shows a hypoechoic
areas swollen with internal focal or diffuse In the complete
ruptures within the substance of the divided ligament rift is
observed corresponding to the hematoma hypoechoic and
the free ends of the divided ligament can be and retracted
appreciated corrugated in contrast with normal
appearance straight
Grade I Mild stretching of the ligament without breakage
or instability
Grade II Partial tearing of the ligament
Grade III Complete tearing
Degrees depending on the severity of the injury and the
place of employment
LATERAL COMPARTMENTThese injuries occur secondary to inversion sprains with internal rotation of
the foot combined with ankle plantar flexion
The anterior talar fibular ligament tears (ATFL) usually occur as isolated
involvement (70) or associated with calcaneal fibular ligament (CFL) (20-40)
but the posterior talar fibular ligament (PTFL) affects only major trauma
involving ankle dislocation
ATFL breaks is associated with breakage of the joint capsule and synovial fluid
extravasation into the anterolateral soft ankle whereas the complete tearing of
CFL can communicate the ankle joint and synovial sheath peroneal tendons
Rupture of CFL is rarely associated with superior peroneal retinaculum tear
The CFL is tensioned during dorsiflexion pulling on peroneal tendons laterally
so that absence of its displacement is sign of a complete tear
Within a damaged ligament can also observe calcifications that often
correspond to fragments of avulsion bone
During the ultrasound can be performed forced maneuvers to detect to joint
laxity and ligament injuries The anterior drawer test is performed with the feet
hanging over the edge of the examination table while the forefoot is pulled
anteriorly when the foot is in plantar flexion and inversion This maneuver
helps differentiate partial tears (grade II) of the ATFL to complete (grade III)
where the anterior displacement of the talus on the tibia open a crack in the
substance becoming more visible the ligament injury
The sindesmosys sprains are up to 10 of ankle
injuries happening in eversion and pronation
movements (like the deltoid ligament injury) and
primarily affect the anterior tibiofibular ligament (ATFL)
the failure is frequently associated with fracture of the
fibula
According to the place of employment are 4 degrees
useful for prognostic evaluation and therapeutic strategy
choice
Grade I stretch or partial tear of the ATFL
Grade II complete tearing but only the ATFL
Grade III complete tear of the ATFL and partial CFL
Grade IV complete tear of the ATFL and CFL
The grade I and II injuries usually scarred without any
significant instability whereas grade III and IV injuries
can cause chronic pain and require surgical treatment
Thickened but continued ATFL right in relation to the partial rupture
Grade 111 sprain of right ATFL
Thickened anterior talofibular ligament with calcifications and a partial rupture
Thickened tibiofibular ligament after trauma
Anterior Talofibular Ligament Partial Tear and Elastography
Tibio fibular ligament rupture with bony avulsion
Complete rupture of right ATFL
Bony avulsion with radiographic evidence as visible calcification in a grade III sprain ATFL
Moderately thickened and hypoechoic ATFL
Discontinuity of the ATFL with fluid surrounding the torn ends (arrow)
Thickening and hypoechogenicity of the fibular end of the ligament seen here passing over the subtalar joint which contains a small of fluid
Complete disruption to the tibiofibular ligament with bony irregularity of particularly the tibial margin and fluid in the gap
MEDIAL COMPARTMENTBecause of the low incidence of eversion ankle
sprains and the thickness of the deltoid ligament
is rarely injured in isolation and when the injury
does not usually full thickness Usually
accompanied by lesions of the medial malleolus
and lateral displacement of the talus with
consequent widening of the ankle mortise
Ultrasound is useful for differentiating ligament
injury of the posterior tibial tendon injury
(TP) adjacent they have similar symptoms
The inability to visualize the deltoid ligament may
indicate tear but this is not considered a reliable
sign as its full ultrasound is not always possible
Partial medial ligament rupture
Thickened heterogeneous abnormal deltoid demonstrating hyperemia
Ultrasonogram showing a disrupted deltoid ligament with the probe in the coronal plane The white arrow indicates the medial malleolus the blue arrow indicates the talus and the red arrows indicate the disrupted deltoid ligament (A) Radiograph showing the same injury (B)
bullJOINT AND BONE DISORDERSUltrasound reliably detect spills mild (gt 2 ml) inside
of the ankle joint by exploring the front and rear
recess as well as areas of synovial proliferation and
may even display using the colour Doppler
hyperemic areas in arthritis patients
The intraarticular joints are displayed surrounded
fluid in one of the recesses of the ankle or subtalar
joint Sonographically diagnosed when changing position to perform flexion and extension Fracture of the lateral process of the talus is overlooked up to 50 of cases with plain radiography Ultrasound may suspect the presence of focal cortical disruption helping further to exclude concomitant ligament injury
Rheumatoid arthritis with synovial thickening (1) and erosion of the tibia (2)
Infectious arthritis with a pus filled anterior recess of the ankle
Arthritis and tenosynovitis of the ankle in a patient with rheumatoid arthritis
bullTUMOURSUltrasound can differentiate between a mass complex
and solid and a cystic in addition to verifying the
existence of accessory muscles (peroneus fourth
accessory flexor digitorum longus and accessory
soleus) As in any other location can be found
neoformative soft tissue tumors inflammatory
infectious etc
Ganglions of this location are more often symptomatic
and larger with multiple partitions
branched and lobed edges Differential diagnosis must
be made with tenosynovitis abscesses seromas and
varicosities
Neurogenic tumours are described as pathognomonic
homogeneous hypoechoic oval mass in continuity with
a nerve of origin
Ganglion cysts are non-malignant cystic masses that occur in association with musculoskeletal structures They are sometimes also simply referred to as ganglia or a ganglion but should not be confused with the anatomical term ganglion UltrasoundThe vast majority are anechoic to hypoechoic on ultrasound and have well defined margins Many demonstrate internal septations as well as acoustic enhancement A synovial cyst is a small fluid-filled sac or pouch that can develop over a tendon or joint creating a mass under the skin Synovial cyst is rare in ankle joint A synovial cyst may or may not be painful depending on their size and location
Ganglion cyst in the foot with bony erosion between navicular and cuneiform bones
Tarsal synovial cyst
Anechoic ganglion situated in the sinus tarsi fat between the talus and calcaneous
Plantar fasciitis (PF) refers to inflammation of the
plantar fascia of the foot It is considered the most common cause of heel pain
Clinical presentation Pain on the undersurface of the heel on weight bearing is the principal complaint It can be worse when weight is borne after a period of rest (eg in the morning) and eases with walking Passive dorsiflexion of the toes may exacerbates discomfort
UltrasoundOften the initial imaging modality of choice Ultrasound typically shows increased thickness of the fascia and a hypoechoic fascia
Thickened hypoechoic origin of the plantar fascia which has a convex superior margin
Complete avulsion of the plantar fascia from the calcaneal tubercle
Plantar fasciitis
bull LOCATING FOREIGN BODIES AND FRACTURES
As in any other location the ankle
area is also subsidiary host foreign
whose classification location and
existence can be defined perfectly by
ultrasound Being a focused study to
the area of interest and with great
resolution for surface structures can
be considered more resolute
examination to screen these cases
Osseous diseases and fractures | Sonography discovered Medial Malleolus Fracture
Ultrasound examination of left ankle A Longitudinal sonogram left ankle demonstrates a wooden foreign body B Transverse view left ankle Note the hypervascularity in the inflamed area C Corresponding X-ray of left ankle Note the swelling on the lateral aspect No foreign body is visible
Thank You
bullLIGAMENT INJURIESThe ligament partial tear ligament shows a hypoechoic
areas swollen with internal focal or diffuse In the complete
ruptures within the substance of the divided ligament rift is
observed corresponding to the hematoma hypoechoic and
the free ends of the divided ligament can be and retracted
appreciated corrugated in contrast with normal
appearance straight
Grade I Mild stretching of the ligament without breakage
or instability
Grade II Partial tearing of the ligament
Grade III Complete tearing
Degrees depending on the severity of the injury and the
place of employment
LATERAL COMPARTMENTThese injuries occur secondary to inversion sprains with internal rotation of
the foot combined with ankle plantar flexion
The anterior talar fibular ligament tears (ATFL) usually occur as isolated
involvement (70) or associated with calcaneal fibular ligament (CFL) (20-40)
but the posterior talar fibular ligament (PTFL) affects only major trauma
involving ankle dislocation
ATFL breaks is associated with breakage of the joint capsule and synovial fluid
extravasation into the anterolateral soft ankle whereas the complete tearing of
CFL can communicate the ankle joint and synovial sheath peroneal tendons
Rupture of CFL is rarely associated with superior peroneal retinaculum tear
The CFL is tensioned during dorsiflexion pulling on peroneal tendons laterally
so that absence of its displacement is sign of a complete tear
Within a damaged ligament can also observe calcifications that often
correspond to fragments of avulsion bone
During the ultrasound can be performed forced maneuvers to detect to joint
laxity and ligament injuries The anterior drawer test is performed with the feet
hanging over the edge of the examination table while the forefoot is pulled
anteriorly when the foot is in plantar flexion and inversion This maneuver
helps differentiate partial tears (grade II) of the ATFL to complete (grade III)
where the anterior displacement of the talus on the tibia open a crack in the
substance becoming more visible the ligament injury
The sindesmosys sprains are up to 10 of ankle
injuries happening in eversion and pronation
movements (like the deltoid ligament injury) and
primarily affect the anterior tibiofibular ligament (ATFL)
the failure is frequently associated with fracture of the
fibula
According to the place of employment are 4 degrees
useful for prognostic evaluation and therapeutic strategy
choice
Grade I stretch or partial tear of the ATFL
Grade II complete tearing but only the ATFL
Grade III complete tear of the ATFL and partial CFL
Grade IV complete tear of the ATFL and CFL
The grade I and II injuries usually scarred without any
significant instability whereas grade III and IV injuries
can cause chronic pain and require surgical treatment
Thickened but continued ATFL right in relation to the partial rupture
Grade 111 sprain of right ATFL
Thickened anterior talofibular ligament with calcifications and a partial rupture
Thickened tibiofibular ligament after trauma
Anterior Talofibular Ligament Partial Tear and Elastography
Tibio fibular ligament rupture with bony avulsion
Complete rupture of right ATFL
Bony avulsion with radiographic evidence as visible calcification in a grade III sprain ATFL
Moderately thickened and hypoechoic ATFL
Discontinuity of the ATFL with fluid surrounding the torn ends (arrow)
Thickening and hypoechogenicity of the fibular end of the ligament seen here passing over the subtalar joint which contains a small of fluid
Complete disruption to the tibiofibular ligament with bony irregularity of particularly the tibial margin and fluid in the gap
MEDIAL COMPARTMENTBecause of the low incidence of eversion ankle
sprains and the thickness of the deltoid ligament
is rarely injured in isolation and when the injury
does not usually full thickness Usually
accompanied by lesions of the medial malleolus
and lateral displacement of the talus with
consequent widening of the ankle mortise
Ultrasound is useful for differentiating ligament
injury of the posterior tibial tendon injury
(TP) adjacent they have similar symptoms
The inability to visualize the deltoid ligament may
indicate tear but this is not considered a reliable
sign as its full ultrasound is not always possible
Partial medial ligament rupture
Thickened heterogeneous abnormal deltoid demonstrating hyperemia
Ultrasonogram showing a disrupted deltoid ligament with the probe in the coronal plane The white arrow indicates the medial malleolus the blue arrow indicates the talus and the red arrows indicate the disrupted deltoid ligament (A) Radiograph showing the same injury (B)
bullJOINT AND BONE DISORDERSUltrasound reliably detect spills mild (gt 2 ml) inside
of the ankle joint by exploring the front and rear
recess as well as areas of synovial proliferation and
may even display using the colour Doppler
hyperemic areas in arthritis patients
The intraarticular joints are displayed surrounded
fluid in one of the recesses of the ankle or subtalar
joint Sonographically diagnosed when changing position to perform flexion and extension Fracture of the lateral process of the talus is overlooked up to 50 of cases with plain radiography Ultrasound may suspect the presence of focal cortical disruption helping further to exclude concomitant ligament injury
Rheumatoid arthritis with synovial thickening (1) and erosion of the tibia (2)
Infectious arthritis with a pus filled anterior recess of the ankle
Arthritis and tenosynovitis of the ankle in a patient with rheumatoid arthritis
bullTUMOURSUltrasound can differentiate between a mass complex
and solid and a cystic in addition to verifying the
existence of accessory muscles (peroneus fourth
accessory flexor digitorum longus and accessory
soleus) As in any other location can be found
neoformative soft tissue tumors inflammatory
infectious etc
Ganglions of this location are more often symptomatic
and larger with multiple partitions
branched and lobed edges Differential diagnosis must
be made with tenosynovitis abscesses seromas and
varicosities
Neurogenic tumours are described as pathognomonic
homogeneous hypoechoic oval mass in continuity with
a nerve of origin
Ganglion cysts are non-malignant cystic masses that occur in association with musculoskeletal structures They are sometimes also simply referred to as ganglia or a ganglion but should not be confused with the anatomical term ganglion UltrasoundThe vast majority are anechoic to hypoechoic on ultrasound and have well defined margins Many demonstrate internal septations as well as acoustic enhancement A synovial cyst is a small fluid-filled sac or pouch that can develop over a tendon or joint creating a mass under the skin Synovial cyst is rare in ankle joint A synovial cyst may or may not be painful depending on their size and location
Ganglion cyst in the foot with bony erosion between navicular and cuneiform bones
Tarsal synovial cyst
Anechoic ganglion situated in the sinus tarsi fat between the talus and calcaneous
Plantar fasciitis (PF) refers to inflammation of the
plantar fascia of the foot It is considered the most common cause of heel pain
Clinical presentation Pain on the undersurface of the heel on weight bearing is the principal complaint It can be worse when weight is borne after a period of rest (eg in the morning) and eases with walking Passive dorsiflexion of the toes may exacerbates discomfort
UltrasoundOften the initial imaging modality of choice Ultrasound typically shows increased thickness of the fascia and a hypoechoic fascia
Thickened hypoechoic origin of the plantar fascia which has a convex superior margin
Complete avulsion of the plantar fascia from the calcaneal tubercle
Plantar fasciitis
bull LOCATING FOREIGN BODIES AND FRACTURES
As in any other location the ankle
area is also subsidiary host foreign
whose classification location and
existence can be defined perfectly by
ultrasound Being a focused study to
the area of interest and with great
resolution for surface structures can
be considered more resolute
examination to screen these cases
Osseous diseases and fractures | Sonography discovered Medial Malleolus Fracture
Ultrasound examination of left ankle A Longitudinal sonogram left ankle demonstrates a wooden foreign body B Transverse view left ankle Note the hypervascularity in the inflamed area C Corresponding X-ray of left ankle Note the swelling on the lateral aspect No foreign body is visible
Thank You
LATERAL COMPARTMENTThese injuries occur secondary to inversion sprains with internal rotation of
the foot combined with ankle plantar flexion
The anterior talar fibular ligament tears (ATFL) usually occur as isolated
involvement (70) or associated with calcaneal fibular ligament (CFL) (20-40)
but the posterior talar fibular ligament (PTFL) affects only major trauma
involving ankle dislocation
ATFL breaks is associated with breakage of the joint capsule and synovial fluid
extravasation into the anterolateral soft ankle whereas the complete tearing of
CFL can communicate the ankle joint and synovial sheath peroneal tendons
Rupture of CFL is rarely associated with superior peroneal retinaculum tear
The CFL is tensioned during dorsiflexion pulling on peroneal tendons laterally
so that absence of its displacement is sign of a complete tear
Within a damaged ligament can also observe calcifications that often
correspond to fragments of avulsion bone
During the ultrasound can be performed forced maneuvers to detect to joint
laxity and ligament injuries The anterior drawer test is performed with the feet
hanging over the edge of the examination table while the forefoot is pulled
anteriorly when the foot is in plantar flexion and inversion This maneuver
helps differentiate partial tears (grade II) of the ATFL to complete (grade III)
where the anterior displacement of the talus on the tibia open a crack in the
substance becoming more visible the ligament injury
The sindesmosys sprains are up to 10 of ankle
injuries happening in eversion and pronation
movements (like the deltoid ligament injury) and
primarily affect the anterior tibiofibular ligament (ATFL)
the failure is frequently associated with fracture of the
fibula
According to the place of employment are 4 degrees
useful for prognostic evaluation and therapeutic strategy
choice
Grade I stretch or partial tear of the ATFL
Grade II complete tearing but only the ATFL
Grade III complete tear of the ATFL and partial CFL
Grade IV complete tear of the ATFL and CFL
The grade I and II injuries usually scarred without any
significant instability whereas grade III and IV injuries
can cause chronic pain and require surgical treatment
Thickened but continued ATFL right in relation to the partial rupture
Grade 111 sprain of right ATFL
Thickened anterior talofibular ligament with calcifications and a partial rupture
Thickened tibiofibular ligament after trauma
Anterior Talofibular Ligament Partial Tear and Elastography
Tibio fibular ligament rupture with bony avulsion
Complete rupture of right ATFL
Bony avulsion with radiographic evidence as visible calcification in a grade III sprain ATFL
Moderately thickened and hypoechoic ATFL
Discontinuity of the ATFL with fluid surrounding the torn ends (arrow)
Thickening and hypoechogenicity of the fibular end of the ligament seen here passing over the subtalar joint which contains a small of fluid
Complete disruption to the tibiofibular ligament with bony irregularity of particularly the tibial margin and fluid in the gap
MEDIAL COMPARTMENTBecause of the low incidence of eversion ankle
sprains and the thickness of the deltoid ligament
is rarely injured in isolation and when the injury
does not usually full thickness Usually
accompanied by lesions of the medial malleolus
and lateral displacement of the talus with
consequent widening of the ankle mortise
Ultrasound is useful for differentiating ligament
injury of the posterior tibial tendon injury
(TP) adjacent they have similar symptoms
The inability to visualize the deltoid ligament may
indicate tear but this is not considered a reliable
sign as its full ultrasound is not always possible
Partial medial ligament rupture
Thickened heterogeneous abnormal deltoid demonstrating hyperemia
Ultrasonogram showing a disrupted deltoid ligament with the probe in the coronal plane The white arrow indicates the medial malleolus the blue arrow indicates the talus and the red arrows indicate the disrupted deltoid ligament (A) Radiograph showing the same injury (B)
bullJOINT AND BONE DISORDERSUltrasound reliably detect spills mild (gt 2 ml) inside
of the ankle joint by exploring the front and rear
recess as well as areas of synovial proliferation and
may even display using the colour Doppler
hyperemic areas in arthritis patients
The intraarticular joints are displayed surrounded
fluid in one of the recesses of the ankle or subtalar
joint Sonographically diagnosed when changing position to perform flexion and extension Fracture of the lateral process of the talus is overlooked up to 50 of cases with plain radiography Ultrasound may suspect the presence of focal cortical disruption helping further to exclude concomitant ligament injury
Rheumatoid arthritis with synovial thickening (1) and erosion of the tibia (2)
Infectious arthritis with a pus filled anterior recess of the ankle
Arthritis and tenosynovitis of the ankle in a patient with rheumatoid arthritis
bullTUMOURSUltrasound can differentiate between a mass complex
and solid and a cystic in addition to verifying the
existence of accessory muscles (peroneus fourth
accessory flexor digitorum longus and accessory
soleus) As in any other location can be found
neoformative soft tissue tumors inflammatory
infectious etc
Ganglions of this location are more often symptomatic
and larger with multiple partitions
branched and lobed edges Differential diagnosis must
be made with tenosynovitis abscesses seromas and
varicosities
Neurogenic tumours are described as pathognomonic
homogeneous hypoechoic oval mass in continuity with
a nerve of origin
Ganglion cysts are non-malignant cystic masses that occur in association with musculoskeletal structures They are sometimes also simply referred to as ganglia or a ganglion but should not be confused with the anatomical term ganglion UltrasoundThe vast majority are anechoic to hypoechoic on ultrasound and have well defined margins Many demonstrate internal septations as well as acoustic enhancement A synovial cyst is a small fluid-filled sac or pouch that can develop over a tendon or joint creating a mass under the skin Synovial cyst is rare in ankle joint A synovial cyst may or may not be painful depending on their size and location
Ganglion cyst in the foot with bony erosion between navicular and cuneiform bones
Tarsal synovial cyst
Anechoic ganglion situated in the sinus tarsi fat between the talus and calcaneous
Plantar fasciitis (PF) refers to inflammation of the
plantar fascia of the foot It is considered the most common cause of heel pain
Clinical presentation Pain on the undersurface of the heel on weight bearing is the principal complaint It can be worse when weight is borne after a period of rest (eg in the morning) and eases with walking Passive dorsiflexion of the toes may exacerbates discomfort
UltrasoundOften the initial imaging modality of choice Ultrasound typically shows increased thickness of the fascia and a hypoechoic fascia
Thickened hypoechoic origin of the plantar fascia which has a convex superior margin
Complete avulsion of the plantar fascia from the calcaneal tubercle
Plantar fasciitis
bull LOCATING FOREIGN BODIES AND FRACTURES
As in any other location the ankle
area is also subsidiary host foreign
whose classification location and
existence can be defined perfectly by
ultrasound Being a focused study to
the area of interest and with great
resolution for surface structures can
be considered more resolute
examination to screen these cases
Osseous diseases and fractures | Sonography discovered Medial Malleolus Fracture
Ultrasound examination of left ankle A Longitudinal sonogram left ankle demonstrates a wooden foreign body B Transverse view left ankle Note the hypervascularity in the inflamed area C Corresponding X-ray of left ankle Note the swelling on the lateral aspect No foreign body is visible
Thank You
The sindesmosys sprains are up to 10 of ankle
injuries happening in eversion and pronation
movements (like the deltoid ligament injury) and
primarily affect the anterior tibiofibular ligament (ATFL)
the failure is frequently associated with fracture of the
fibula
According to the place of employment are 4 degrees
useful for prognostic evaluation and therapeutic strategy
choice
Grade I stretch or partial tear of the ATFL
Grade II complete tearing but only the ATFL
Grade III complete tear of the ATFL and partial CFL
Grade IV complete tear of the ATFL and CFL
The grade I and II injuries usually scarred without any
significant instability whereas grade III and IV injuries
can cause chronic pain and require surgical treatment
Thickened but continued ATFL right in relation to the partial rupture
Grade 111 sprain of right ATFL
Thickened anterior talofibular ligament with calcifications and a partial rupture
Thickened tibiofibular ligament after trauma
Anterior Talofibular Ligament Partial Tear and Elastography
Tibio fibular ligament rupture with bony avulsion
Complete rupture of right ATFL
Bony avulsion with radiographic evidence as visible calcification in a grade III sprain ATFL
Moderately thickened and hypoechoic ATFL
Discontinuity of the ATFL with fluid surrounding the torn ends (arrow)
Thickening and hypoechogenicity of the fibular end of the ligament seen here passing over the subtalar joint which contains a small of fluid
Complete disruption to the tibiofibular ligament with bony irregularity of particularly the tibial margin and fluid in the gap
MEDIAL COMPARTMENTBecause of the low incidence of eversion ankle
sprains and the thickness of the deltoid ligament
is rarely injured in isolation and when the injury
does not usually full thickness Usually
accompanied by lesions of the medial malleolus
and lateral displacement of the talus with
consequent widening of the ankle mortise
Ultrasound is useful for differentiating ligament
injury of the posterior tibial tendon injury
(TP) adjacent they have similar symptoms
The inability to visualize the deltoid ligament may
indicate tear but this is not considered a reliable
sign as its full ultrasound is not always possible
Partial medial ligament rupture
Thickened heterogeneous abnormal deltoid demonstrating hyperemia
Ultrasonogram showing a disrupted deltoid ligament with the probe in the coronal plane The white arrow indicates the medial malleolus the blue arrow indicates the talus and the red arrows indicate the disrupted deltoid ligament (A) Radiograph showing the same injury (B)
bullJOINT AND BONE DISORDERSUltrasound reliably detect spills mild (gt 2 ml) inside
of the ankle joint by exploring the front and rear
recess as well as areas of synovial proliferation and
may even display using the colour Doppler
hyperemic areas in arthritis patients
The intraarticular joints are displayed surrounded
fluid in one of the recesses of the ankle or subtalar
joint Sonographically diagnosed when changing position to perform flexion and extension Fracture of the lateral process of the talus is overlooked up to 50 of cases with plain radiography Ultrasound may suspect the presence of focal cortical disruption helping further to exclude concomitant ligament injury
Rheumatoid arthritis with synovial thickening (1) and erosion of the tibia (2)
Infectious arthritis with a pus filled anterior recess of the ankle
Arthritis and tenosynovitis of the ankle in a patient with rheumatoid arthritis
bullTUMOURSUltrasound can differentiate between a mass complex
and solid and a cystic in addition to verifying the
existence of accessory muscles (peroneus fourth
accessory flexor digitorum longus and accessory
soleus) As in any other location can be found
neoformative soft tissue tumors inflammatory
infectious etc
Ganglions of this location are more often symptomatic
and larger with multiple partitions
branched and lobed edges Differential diagnosis must
be made with tenosynovitis abscesses seromas and
varicosities
Neurogenic tumours are described as pathognomonic
homogeneous hypoechoic oval mass in continuity with
a nerve of origin
Ganglion cysts are non-malignant cystic masses that occur in association with musculoskeletal structures They are sometimes also simply referred to as ganglia or a ganglion but should not be confused with the anatomical term ganglion UltrasoundThe vast majority are anechoic to hypoechoic on ultrasound and have well defined margins Many demonstrate internal septations as well as acoustic enhancement A synovial cyst is a small fluid-filled sac or pouch that can develop over a tendon or joint creating a mass under the skin Synovial cyst is rare in ankle joint A synovial cyst may or may not be painful depending on their size and location
Ganglion cyst in the foot with bony erosion between navicular and cuneiform bones
Tarsal synovial cyst
Anechoic ganglion situated in the sinus tarsi fat between the talus and calcaneous
Plantar fasciitis (PF) refers to inflammation of the
plantar fascia of the foot It is considered the most common cause of heel pain
Clinical presentation Pain on the undersurface of the heel on weight bearing is the principal complaint It can be worse when weight is borne after a period of rest (eg in the morning) and eases with walking Passive dorsiflexion of the toes may exacerbates discomfort
UltrasoundOften the initial imaging modality of choice Ultrasound typically shows increased thickness of the fascia and a hypoechoic fascia
Thickened hypoechoic origin of the plantar fascia which has a convex superior margin
Complete avulsion of the plantar fascia from the calcaneal tubercle
Plantar fasciitis
bull LOCATING FOREIGN BODIES AND FRACTURES
As in any other location the ankle
area is also subsidiary host foreign
whose classification location and
existence can be defined perfectly by
ultrasound Being a focused study to
the area of interest and with great
resolution for surface structures can
be considered more resolute
examination to screen these cases
Osseous diseases and fractures | Sonography discovered Medial Malleolus Fracture
Ultrasound examination of left ankle A Longitudinal sonogram left ankle demonstrates a wooden foreign body B Transverse view left ankle Note the hypervascularity in the inflamed area C Corresponding X-ray of left ankle Note the swelling on the lateral aspect No foreign body is visible
Thank You
Thickened but continued ATFL right in relation to the partial rupture
Grade 111 sprain of right ATFL
Thickened anterior talofibular ligament with calcifications and a partial rupture
Thickened tibiofibular ligament after trauma
Anterior Talofibular Ligament Partial Tear and Elastography
Tibio fibular ligament rupture with bony avulsion
Complete rupture of right ATFL
Bony avulsion with radiographic evidence as visible calcification in a grade III sprain ATFL
Moderately thickened and hypoechoic ATFL
Discontinuity of the ATFL with fluid surrounding the torn ends (arrow)
Thickening and hypoechogenicity of the fibular end of the ligament seen here passing over the subtalar joint which contains a small of fluid
Complete disruption to the tibiofibular ligament with bony irregularity of particularly the tibial margin and fluid in the gap
MEDIAL COMPARTMENTBecause of the low incidence of eversion ankle
sprains and the thickness of the deltoid ligament
is rarely injured in isolation and when the injury
does not usually full thickness Usually
accompanied by lesions of the medial malleolus
and lateral displacement of the talus with
consequent widening of the ankle mortise
Ultrasound is useful for differentiating ligament
injury of the posterior tibial tendon injury
(TP) adjacent they have similar symptoms
The inability to visualize the deltoid ligament may
indicate tear but this is not considered a reliable
sign as its full ultrasound is not always possible
Partial medial ligament rupture
Thickened heterogeneous abnormal deltoid demonstrating hyperemia
Ultrasonogram showing a disrupted deltoid ligament with the probe in the coronal plane The white arrow indicates the medial malleolus the blue arrow indicates the talus and the red arrows indicate the disrupted deltoid ligament (A) Radiograph showing the same injury (B)
bullJOINT AND BONE DISORDERSUltrasound reliably detect spills mild (gt 2 ml) inside
of the ankle joint by exploring the front and rear
recess as well as areas of synovial proliferation and
may even display using the colour Doppler
hyperemic areas in arthritis patients
The intraarticular joints are displayed surrounded
fluid in one of the recesses of the ankle or subtalar
joint Sonographically diagnosed when changing position to perform flexion and extension Fracture of the lateral process of the talus is overlooked up to 50 of cases with plain radiography Ultrasound may suspect the presence of focal cortical disruption helping further to exclude concomitant ligament injury
Rheumatoid arthritis with synovial thickening (1) and erosion of the tibia (2)
Infectious arthritis with a pus filled anterior recess of the ankle
Arthritis and tenosynovitis of the ankle in a patient with rheumatoid arthritis
bullTUMOURSUltrasound can differentiate between a mass complex
and solid and a cystic in addition to verifying the
existence of accessory muscles (peroneus fourth
accessory flexor digitorum longus and accessory
soleus) As in any other location can be found
neoformative soft tissue tumors inflammatory
infectious etc
Ganglions of this location are more often symptomatic
and larger with multiple partitions
branched and lobed edges Differential diagnosis must
be made with tenosynovitis abscesses seromas and
varicosities
Neurogenic tumours are described as pathognomonic
homogeneous hypoechoic oval mass in continuity with
a nerve of origin
Ganglion cysts are non-malignant cystic masses that occur in association with musculoskeletal structures They are sometimes also simply referred to as ganglia or a ganglion but should not be confused with the anatomical term ganglion UltrasoundThe vast majority are anechoic to hypoechoic on ultrasound and have well defined margins Many demonstrate internal septations as well as acoustic enhancement A synovial cyst is a small fluid-filled sac or pouch that can develop over a tendon or joint creating a mass under the skin Synovial cyst is rare in ankle joint A synovial cyst may or may not be painful depending on their size and location
Ganglion cyst in the foot with bony erosion between navicular and cuneiform bones
Tarsal synovial cyst
Anechoic ganglion situated in the sinus tarsi fat between the talus and calcaneous
Plantar fasciitis (PF) refers to inflammation of the
plantar fascia of the foot It is considered the most common cause of heel pain
Clinical presentation Pain on the undersurface of the heel on weight bearing is the principal complaint It can be worse when weight is borne after a period of rest (eg in the morning) and eases with walking Passive dorsiflexion of the toes may exacerbates discomfort
UltrasoundOften the initial imaging modality of choice Ultrasound typically shows increased thickness of the fascia and a hypoechoic fascia
Thickened hypoechoic origin of the plantar fascia which has a convex superior margin
Complete avulsion of the plantar fascia from the calcaneal tubercle
Plantar fasciitis
bull LOCATING FOREIGN BODIES AND FRACTURES
As in any other location the ankle
area is also subsidiary host foreign
whose classification location and
existence can be defined perfectly by
ultrasound Being a focused study to
the area of interest and with great
resolution for surface structures can
be considered more resolute
examination to screen these cases
Osseous diseases and fractures | Sonography discovered Medial Malleolus Fracture
Ultrasound examination of left ankle A Longitudinal sonogram left ankle demonstrates a wooden foreign body B Transverse view left ankle Note the hypervascularity in the inflamed area C Corresponding X-ray of left ankle Note the swelling on the lateral aspect No foreign body is visible
Thank You
Grade 111 sprain of right ATFL
Thickened anterior talofibular ligament with calcifications and a partial rupture
Thickened tibiofibular ligament after trauma
Anterior Talofibular Ligament Partial Tear and Elastography
Tibio fibular ligament rupture with bony avulsion
Complete rupture of right ATFL
Bony avulsion with radiographic evidence as visible calcification in a grade III sprain ATFL
Moderately thickened and hypoechoic ATFL
Discontinuity of the ATFL with fluid surrounding the torn ends (arrow)
Thickening and hypoechogenicity of the fibular end of the ligament seen here passing over the subtalar joint which contains a small of fluid
Complete disruption to the tibiofibular ligament with bony irregularity of particularly the tibial margin and fluid in the gap
MEDIAL COMPARTMENTBecause of the low incidence of eversion ankle
sprains and the thickness of the deltoid ligament
is rarely injured in isolation and when the injury
does not usually full thickness Usually
accompanied by lesions of the medial malleolus
and lateral displacement of the talus with
consequent widening of the ankle mortise
Ultrasound is useful for differentiating ligament
injury of the posterior tibial tendon injury
(TP) adjacent they have similar symptoms
The inability to visualize the deltoid ligament may
indicate tear but this is not considered a reliable
sign as its full ultrasound is not always possible
Partial medial ligament rupture
Thickened heterogeneous abnormal deltoid demonstrating hyperemia
Ultrasonogram showing a disrupted deltoid ligament with the probe in the coronal plane The white arrow indicates the medial malleolus the blue arrow indicates the talus and the red arrows indicate the disrupted deltoid ligament (A) Radiograph showing the same injury (B)
bullJOINT AND BONE DISORDERSUltrasound reliably detect spills mild (gt 2 ml) inside
of the ankle joint by exploring the front and rear
recess as well as areas of synovial proliferation and
may even display using the colour Doppler
hyperemic areas in arthritis patients
The intraarticular joints are displayed surrounded
fluid in one of the recesses of the ankle or subtalar
joint Sonographically diagnosed when changing position to perform flexion and extension Fracture of the lateral process of the talus is overlooked up to 50 of cases with plain radiography Ultrasound may suspect the presence of focal cortical disruption helping further to exclude concomitant ligament injury
Rheumatoid arthritis with synovial thickening (1) and erosion of the tibia (2)
Infectious arthritis with a pus filled anterior recess of the ankle
Arthritis and tenosynovitis of the ankle in a patient with rheumatoid arthritis
bullTUMOURSUltrasound can differentiate between a mass complex
and solid and a cystic in addition to verifying the
existence of accessory muscles (peroneus fourth
accessory flexor digitorum longus and accessory
soleus) As in any other location can be found
neoformative soft tissue tumors inflammatory
infectious etc
Ganglions of this location are more often symptomatic
and larger with multiple partitions
branched and lobed edges Differential diagnosis must
be made with tenosynovitis abscesses seromas and
varicosities
Neurogenic tumours are described as pathognomonic
homogeneous hypoechoic oval mass in continuity with
a nerve of origin
Ganglion cysts are non-malignant cystic masses that occur in association with musculoskeletal structures They are sometimes also simply referred to as ganglia or a ganglion but should not be confused with the anatomical term ganglion UltrasoundThe vast majority are anechoic to hypoechoic on ultrasound and have well defined margins Many demonstrate internal septations as well as acoustic enhancement A synovial cyst is a small fluid-filled sac or pouch that can develop over a tendon or joint creating a mass under the skin Synovial cyst is rare in ankle joint A synovial cyst may or may not be painful depending on their size and location
Ganglion cyst in the foot with bony erosion between navicular and cuneiform bones
Tarsal synovial cyst
Anechoic ganglion situated in the sinus tarsi fat between the talus and calcaneous
Plantar fasciitis (PF) refers to inflammation of the
plantar fascia of the foot It is considered the most common cause of heel pain
Clinical presentation Pain on the undersurface of the heel on weight bearing is the principal complaint It can be worse when weight is borne after a period of rest (eg in the morning) and eases with walking Passive dorsiflexion of the toes may exacerbates discomfort
UltrasoundOften the initial imaging modality of choice Ultrasound typically shows increased thickness of the fascia and a hypoechoic fascia
Thickened hypoechoic origin of the plantar fascia which has a convex superior margin
Complete avulsion of the plantar fascia from the calcaneal tubercle
Plantar fasciitis
bull LOCATING FOREIGN BODIES AND FRACTURES
As in any other location the ankle
area is also subsidiary host foreign
whose classification location and
existence can be defined perfectly by
ultrasound Being a focused study to
the area of interest and with great
resolution for surface structures can
be considered more resolute
examination to screen these cases
Osseous diseases and fractures | Sonography discovered Medial Malleolus Fracture
Ultrasound examination of left ankle A Longitudinal sonogram left ankle demonstrates a wooden foreign body B Transverse view left ankle Note the hypervascularity in the inflamed area C Corresponding X-ray of left ankle Note the swelling on the lateral aspect No foreign body is visible
Thank You
Thickened anterior talofibular ligament with calcifications and a partial rupture
Thickened tibiofibular ligament after trauma
Anterior Talofibular Ligament Partial Tear and Elastography
Tibio fibular ligament rupture with bony avulsion
Complete rupture of right ATFL
Bony avulsion with radiographic evidence as visible calcification in a grade III sprain ATFL
Moderately thickened and hypoechoic ATFL
Discontinuity of the ATFL with fluid surrounding the torn ends (arrow)
Thickening and hypoechogenicity of the fibular end of the ligament seen here passing over the subtalar joint which contains a small of fluid
Complete disruption to the tibiofibular ligament with bony irregularity of particularly the tibial margin and fluid in the gap
MEDIAL COMPARTMENTBecause of the low incidence of eversion ankle
sprains and the thickness of the deltoid ligament
is rarely injured in isolation and when the injury
does not usually full thickness Usually
accompanied by lesions of the medial malleolus
and lateral displacement of the talus with
consequent widening of the ankle mortise
Ultrasound is useful for differentiating ligament
injury of the posterior tibial tendon injury
(TP) adjacent they have similar symptoms
The inability to visualize the deltoid ligament may
indicate tear but this is not considered a reliable
sign as its full ultrasound is not always possible
Partial medial ligament rupture
Thickened heterogeneous abnormal deltoid demonstrating hyperemia
Ultrasonogram showing a disrupted deltoid ligament with the probe in the coronal plane The white arrow indicates the medial malleolus the blue arrow indicates the talus and the red arrows indicate the disrupted deltoid ligament (A) Radiograph showing the same injury (B)
bullJOINT AND BONE DISORDERSUltrasound reliably detect spills mild (gt 2 ml) inside
of the ankle joint by exploring the front and rear
recess as well as areas of synovial proliferation and
may even display using the colour Doppler
hyperemic areas in arthritis patients
The intraarticular joints are displayed surrounded
fluid in one of the recesses of the ankle or subtalar
joint Sonographically diagnosed when changing position to perform flexion and extension Fracture of the lateral process of the talus is overlooked up to 50 of cases with plain radiography Ultrasound may suspect the presence of focal cortical disruption helping further to exclude concomitant ligament injury
Rheumatoid arthritis with synovial thickening (1) and erosion of the tibia (2)
Infectious arthritis with a pus filled anterior recess of the ankle
Arthritis and tenosynovitis of the ankle in a patient with rheumatoid arthritis
bullTUMOURSUltrasound can differentiate between a mass complex
and solid and a cystic in addition to verifying the
existence of accessory muscles (peroneus fourth
accessory flexor digitorum longus and accessory
soleus) As in any other location can be found
neoformative soft tissue tumors inflammatory
infectious etc
Ganglions of this location are more often symptomatic
and larger with multiple partitions
branched and lobed edges Differential diagnosis must
be made with tenosynovitis abscesses seromas and
varicosities
Neurogenic tumours are described as pathognomonic
homogeneous hypoechoic oval mass in continuity with
a nerve of origin
Ganglion cysts are non-malignant cystic masses that occur in association with musculoskeletal structures They are sometimes also simply referred to as ganglia or a ganglion but should not be confused with the anatomical term ganglion UltrasoundThe vast majority are anechoic to hypoechoic on ultrasound and have well defined margins Many demonstrate internal septations as well as acoustic enhancement A synovial cyst is a small fluid-filled sac or pouch that can develop over a tendon or joint creating a mass under the skin Synovial cyst is rare in ankle joint A synovial cyst may or may not be painful depending on their size and location
Ganglion cyst in the foot with bony erosion between navicular and cuneiform bones
Tarsal synovial cyst
Anechoic ganglion situated in the sinus tarsi fat between the talus and calcaneous
Plantar fasciitis (PF) refers to inflammation of the
plantar fascia of the foot It is considered the most common cause of heel pain
Clinical presentation Pain on the undersurface of the heel on weight bearing is the principal complaint It can be worse when weight is borne after a period of rest (eg in the morning) and eases with walking Passive dorsiflexion of the toes may exacerbates discomfort
UltrasoundOften the initial imaging modality of choice Ultrasound typically shows increased thickness of the fascia and a hypoechoic fascia
Thickened hypoechoic origin of the plantar fascia which has a convex superior margin
Complete avulsion of the plantar fascia from the calcaneal tubercle
Plantar fasciitis
bull LOCATING FOREIGN BODIES AND FRACTURES
As in any other location the ankle
area is also subsidiary host foreign
whose classification location and
existence can be defined perfectly by
ultrasound Being a focused study to
the area of interest and with great
resolution for surface structures can
be considered more resolute
examination to screen these cases
Osseous diseases and fractures | Sonography discovered Medial Malleolus Fracture
Ultrasound examination of left ankle A Longitudinal sonogram left ankle demonstrates a wooden foreign body B Transverse view left ankle Note the hypervascularity in the inflamed area C Corresponding X-ray of left ankle Note the swelling on the lateral aspect No foreign body is visible
Thank You
Thickened tibiofibular ligament after trauma
Anterior Talofibular Ligament Partial Tear and Elastography
Tibio fibular ligament rupture with bony avulsion
Complete rupture of right ATFL
Bony avulsion with radiographic evidence as visible calcification in a grade III sprain ATFL
Moderately thickened and hypoechoic ATFL
Discontinuity of the ATFL with fluid surrounding the torn ends (arrow)
Thickening and hypoechogenicity of the fibular end of the ligament seen here passing over the subtalar joint which contains a small of fluid
Complete disruption to the tibiofibular ligament with bony irregularity of particularly the tibial margin and fluid in the gap
MEDIAL COMPARTMENTBecause of the low incidence of eversion ankle
sprains and the thickness of the deltoid ligament
is rarely injured in isolation and when the injury
does not usually full thickness Usually
accompanied by lesions of the medial malleolus
and lateral displacement of the talus with
consequent widening of the ankle mortise
Ultrasound is useful for differentiating ligament
injury of the posterior tibial tendon injury
(TP) adjacent they have similar symptoms
The inability to visualize the deltoid ligament may
indicate tear but this is not considered a reliable
sign as its full ultrasound is not always possible
Partial medial ligament rupture
Thickened heterogeneous abnormal deltoid demonstrating hyperemia
Ultrasonogram showing a disrupted deltoid ligament with the probe in the coronal plane The white arrow indicates the medial malleolus the blue arrow indicates the talus and the red arrows indicate the disrupted deltoid ligament (A) Radiograph showing the same injury (B)
bullJOINT AND BONE DISORDERSUltrasound reliably detect spills mild (gt 2 ml) inside
of the ankle joint by exploring the front and rear
recess as well as areas of synovial proliferation and
may even display using the colour Doppler
hyperemic areas in arthritis patients
The intraarticular joints are displayed surrounded
fluid in one of the recesses of the ankle or subtalar
joint Sonographically diagnosed when changing position to perform flexion and extension Fracture of the lateral process of the talus is overlooked up to 50 of cases with plain radiography Ultrasound may suspect the presence of focal cortical disruption helping further to exclude concomitant ligament injury
Rheumatoid arthritis with synovial thickening (1) and erosion of the tibia (2)
Infectious arthritis with a pus filled anterior recess of the ankle
Arthritis and tenosynovitis of the ankle in a patient with rheumatoid arthritis
bullTUMOURSUltrasound can differentiate between a mass complex
and solid and a cystic in addition to verifying the
existence of accessory muscles (peroneus fourth
accessory flexor digitorum longus and accessory
soleus) As in any other location can be found
neoformative soft tissue tumors inflammatory
infectious etc
Ganglions of this location are more often symptomatic
and larger with multiple partitions
branched and lobed edges Differential diagnosis must
be made with tenosynovitis abscesses seromas and
varicosities
Neurogenic tumours are described as pathognomonic
homogeneous hypoechoic oval mass in continuity with
a nerve of origin
Ganglion cysts are non-malignant cystic masses that occur in association with musculoskeletal structures They are sometimes also simply referred to as ganglia or a ganglion but should not be confused with the anatomical term ganglion UltrasoundThe vast majority are anechoic to hypoechoic on ultrasound and have well defined margins Many demonstrate internal septations as well as acoustic enhancement A synovial cyst is a small fluid-filled sac or pouch that can develop over a tendon or joint creating a mass under the skin Synovial cyst is rare in ankle joint A synovial cyst may or may not be painful depending on their size and location
Ganglion cyst in the foot with bony erosion between navicular and cuneiform bones
Tarsal synovial cyst
Anechoic ganglion situated in the sinus tarsi fat between the talus and calcaneous
Plantar fasciitis (PF) refers to inflammation of the
plantar fascia of the foot It is considered the most common cause of heel pain
Clinical presentation Pain on the undersurface of the heel on weight bearing is the principal complaint It can be worse when weight is borne after a period of rest (eg in the morning) and eases with walking Passive dorsiflexion of the toes may exacerbates discomfort
UltrasoundOften the initial imaging modality of choice Ultrasound typically shows increased thickness of the fascia and a hypoechoic fascia
Thickened hypoechoic origin of the plantar fascia which has a convex superior margin
Complete avulsion of the plantar fascia from the calcaneal tubercle
Plantar fasciitis
bull LOCATING FOREIGN BODIES AND FRACTURES
As in any other location the ankle
area is also subsidiary host foreign
whose classification location and
existence can be defined perfectly by
ultrasound Being a focused study to
the area of interest and with great
resolution for surface structures can
be considered more resolute
examination to screen these cases
Osseous diseases and fractures | Sonography discovered Medial Malleolus Fracture
Ultrasound examination of left ankle A Longitudinal sonogram left ankle demonstrates a wooden foreign body B Transverse view left ankle Note the hypervascularity in the inflamed area C Corresponding X-ray of left ankle Note the swelling on the lateral aspect No foreign body is visible
Thank You
Anterior Talofibular Ligament Partial Tear and Elastography
Tibio fibular ligament rupture with bony avulsion
Complete rupture of right ATFL
Bony avulsion with radiographic evidence as visible calcification in a grade III sprain ATFL
Moderately thickened and hypoechoic ATFL
Discontinuity of the ATFL with fluid surrounding the torn ends (arrow)
Thickening and hypoechogenicity of the fibular end of the ligament seen here passing over the subtalar joint which contains a small of fluid
Complete disruption to the tibiofibular ligament with bony irregularity of particularly the tibial margin and fluid in the gap
MEDIAL COMPARTMENTBecause of the low incidence of eversion ankle
sprains and the thickness of the deltoid ligament
is rarely injured in isolation and when the injury
does not usually full thickness Usually
accompanied by lesions of the medial malleolus
and lateral displacement of the talus with
consequent widening of the ankle mortise
Ultrasound is useful for differentiating ligament
injury of the posterior tibial tendon injury
(TP) adjacent they have similar symptoms
The inability to visualize the deltoid ligament may
indicate tear but this is not considered a reliable
sign as its full ultrasound is not always possible
Partial medial ligament rupture
Thickened heterogeneous abnormal deltoid demonstrating hyperemia
Ultrasonogram showing a disrupted deltoid ligament with the probe in the coronal plane The white arrow indicates the medial malleolus the blue arrow indicates the talus and the red arrows indicate the disrupted deltoid ligament (A) Radiograph showing the same injury (B)
bullJOINT AND BONE DISORDERSUltrasound reliably detect spills mild (gt 2 ml) inside
of the ankle joint by exploring the front and rear
recess as well as areas of synovial proliferation and
may even display using the colour Doppler
hyperemic areas in arthritis patients
The intraarticular joints are displayed surrounded
fluid in one of the recesses of the ankle or subtalar
joint Sonographically diagnosed when changing position to perform flexion and extension Fracture of the lateral process of the talus is overlooked up to 50 of cases with plain radiography Ultrasound may suspect the presence of focal cortical disruption helping further to exclude concomitant ligament injury
Rheumatoid arthritis with synovial thickening (1) and erosion of the tibia (2)
Infectious arthritis with a pus filled anterior recess of the ankle
Arthritis and tenosynovitis of the ankle in a patient with rheumatoid arthritis
bullTUMOURSUltrasound can differentiate between a mass complex
and solid and a cystic in addition to verifying the
existence of accessory muscles (peroneus fourth
accessory flexor digitorum longus and accessory
soleus) As in any other location can be found
neoformative soft tissue tumors inflammatory
infectious etc
Ganglions of this location are more often symptomatic
and larger with multiple partitions
branched and lobed edges Differential diagnosis must
be made with tenosynovitis abscesses seromas and
varicosities
Neurogenic tumours are described as pathognomonic
homogeneous hypoechoic oval mass in continuity with
a nerve of origin
Ganglion cysts are non-malignant cystic masses that occur in association with musculoskeletal structures They are sometimes also simply referred to as ganglia or a ganglion but should not be confused with the anatomical term ganglion UltrasoundThe vast majority are anechoic to hypoechoic on ultrasound and have well defined margins Many demonstrate internal septations as well as acoustic enhancement A synovial cyst is a small fluid-filled sac or pouch that can develop over a tendon or joint creating a mass under the skin Synovial cyst is rare in ankle joint A synovial cyst may or may not be painful depending on their size and location
Ganglion cyst in the foot with bony erosion between navicular and cuneiform bones
Tarsal synovial cyst
Anechoic ganglion situated in the sinus tarsi fat between the talus and calcaneous
Plantar fasciitis (PF) refers to inflammation of the
plantar fascia of the foot It is considered the most common cause of heel pain
Clinical presentation Pain on the undersurface of the heel on weight bearing is the principal complaint It can be worse when weight is borne after a period of rest (eg in the morning) and eases with walking Passive dorsiflexion of the toes may exacerbates discomfort
UltrasoundOften the initial imaging modality of choice Ultrasound typically shows increased thickness of the fascia and a hypoechoic fascia
Thickened hypoechoic origin of the plantar fascia which has a convex superior margin
Complete avulsion of the plantar fascia from the calcaneal tubercle
Plantar fasciitis
bull LOCATING FOREIGN BODIES AND FRACTURES
As in any other location the ankle
area is also subsidiary host foreign
whose classification location and
existence can be defined perfectly by
ultrasound Being a focused study to
the area of interest and with great
resolution for surface structures can
be considered more resolute
examination to screen these cases
Osseous diseases and fractures | Sonography discovered Medial Malleolus Fracture
Ultrasound examination of left ankle A Longitudinal sonogram left ankle demonstrates a wooden foreign body B Transverse view left ankle Note the hypervascularity in the inflamed area C Corresponding X-ray of left ankle Note the swelling on the lateral aspect No foreign body is visible
Thank You
Tibio fibular ligament rupture with bony avulsion
Complete rupture of right ATFL
Bony avulsion with radiographic evidence as visible calcification in a grade III sprain ATFL
Moderately thickened and hypoechoic ATFL
Discontinuity of the ATFL with fluid surrounding the torn ends (arrow)
Thickening and hypoechogenicity of the fibular end of the ligament seen here passing over the subtalar joint which contains a small of fluid
Complete disruption to the tibiofibular ligament with bony irregularity of particularly the tibial margin and fluid in the gap
MEDIAL COMPARTMENTBecause of the low incidence of eversion ankle
sprains and the thickness of the deltoid ligament
is rarely injured in isolation and when the injury
does not usually full thickness Usually
accompanied by lesions of the medial malleolus
and lateral displacement of the talus with
consequent widening of the ankle mortise
Ultrasound is useful for differentiating ligament
injury of the posterior tibial tendon injury
(TP) adjacent they have similar symptoms
The inability to visualize the deltoid ligament may
indicate tear but this is not considered a reliable
sign as its full ultrasound is not always possible
Partial medial ligament rupture
Thickened heterogeneous abnormal deltoid demonstrating hyperemia
Ultrasonogram showing a disrupted deltoid ligament with the probe in the coronal plane The white arrow indicates the medial malleolus the blue arrow indicates the talus and the red arrows indicate the disrupted deltoid ligament (A) Radiograph showing the same injury (B)
bullJOINT AND BONE DISORDERSUltrasound reliably detect spills mild (gt 2 ml) inside
of the ankle joint by exploring the front and rear
recess as well as areas of synovial proliferation and
may even display using the colour Doppler
hyperemic areas in arthritis patients
The intraarticular joints are displayed surrounded
fluid in one of the recesses of the ankle or subtalar
joint Sonographically diagnosed when changing position to perform flexion and extension Fracture of the lateral process of the talus is overlooked up to 50 of cases with plain radiography Ultrasound may suspect the presence of focal cortical disruption helping further to exclude concomitant ligament injury
Rheumatoid arthritis with synovial thickening (1) and erosion of the tibia (2)
Infectious arthritis with a pus filled anterior recess of the ankle
Arthritis and tenosynovitis of the ankle in a patient with rheumatoid arthritis
bullTUMOURSUltrasound can differentiate between a mass complex
and solid and a cystic in addition to verifying the
existence of accessory muscles (peroneus fourth
accessory flexor digitorum longus and accessory
soleus) As in any other location can be found
neoformative soft tissue tumors inflammatory
infectious etc
Ganglions of this location are more often symptomatic
and larger with multiple partitions
branched and lobed edges Differential diagnosis must
be made with tenosynovitis abscesses seromas and
varicosities
Neurogenic tumours are described as pathognomonic
homogeneous hypoechoic oval mass in continuity with
a nerve of origin
Ganglion cysts are non-malignant cystic masses that occur in association with musculoskeletal structures They are sometimes also simply referred to as ganglia or a ganglion but should not be confused with the anatomical term ganglion UltrasoundThe vast majority are anechoic to hypoechoic on ultrasound and have well defined margins Many demonstrate internal septations as well as acoustic enhancement A synovial cyst is a small fluid-filled sac or pouch that can develop over a tendon or joint creating a mass under the skin Synovial cyst is rare in ankle joint A synovial cyst may or may not be painful depending on their size and location
Ganglion cyst in the foot with bony erosion between navicular and cuneiform bones
Tarsal synovial cyst
Anechoic ganglion situated in the sinus tarsi fat between the talus and calcaneous
Plantar fasciitis (PF) refers to inflammation of the
plantar fascia of the foot It is considered the most common cause of heel pain
Clinical presentation Pain on the undersurface of the heel on weight bearing is the principal complaint It can be worse when weight is borne after a period of rest (eg in the morning) and eases with walking Passive dorsiflexion of the toes may exacerbates discomfort
UltrasoundOften the initial imaging modality of choice Ultrasound typically shows increased thickness of the fascia and a hypoechoic fascia
Thickened hypoechoic origin of the plantar fascia which has a convex superior margin
Complete avulsion of the plantar fascia from the calcaneal tubercle
Plantar fasciitis
bull LOCATING FOREIGN BODIES AND FRACTURES
As in any other location the ankle
area is also subsidiary host foreign
whose classification location and
existence can be defined perfectly by
ultrasound Being a focused study to
the area of interest and with great
resolution for surface structures can
be considered more resolute
examination to screen these cases
Osseous diseases and fractures | Sonography discovered Medial Malleolus Fracture
Ultrasound examination of left ankle A Longitudinal sonogram left ankle demonstrates a wooden foreign body B Transverse view left ankle Note the hypervascularity in the inflamed area C Corresponding X-ray of left ankle Note the swelling on the lateral aspect No foreign body is visible
Thank You
Complete rupture of right ATFL
Bony avulsion with radiographic evidence as visible calcification in a grade III sprain ATFL
Moderately thickened and hypoechoic ATFL
Discontinuity of the ATFL with fluid surrounding the torn ends (arrow)
Thickening and hypoechogenicity of the fibular end of the ligament seen here passing over the subtalar joint which contains a small of fluid
Complete disruption to the tibiofibular ligament with bony irregularity of particularly the tibial margin and fluid in the gap
MEDIAL COMPARTMENTBecause of the low incidence of eversion ankle
sprains and the thickness of the deltoid ligament
is rarely injured in isolation and when the injury
does not usually full thickness Usually
accompanied by lesions of the medial malleolus
and lateral displacement of the talus with
consequent widening of the ankle mortise
Ultrasound is useful for differentiating ligament
injury of the posterior tibial tendon injury
(TP) adjacent they have similar symptoms
The inability to visualize the deltoid ligament may
indicate tear but this is not considered a reliable
sign as its full ultrasound is not always possible
Partial medial ligament rupture
Thickened heterogeneous abnormal deltoid demonstrating hyperemia
Ultrasonogram showing a disrupted deltoid ligament with the probe in the coronal plane The white arrow indicates the medial malleolus the blue arrow indicates the talus and the red arrows indicate the disrupted deltoid ligament (A) Radiograph showing the same injury (B)
bullJOINT AND BONE DISORDERSUltrasound reliably detect spills mild (gt 2 ml) inside
of the ankle joint by exploring the front and rear
recess as well as areas of synovial proliferation and
may even display using the colour Doppler
hyperemic areas in arthritis patients
The intraarticular joints are displayed surrounded
fluid in one of the recesses of the ankle or subtalar
joint Sonographically diagnosed when changing position to perform flexion and extension Fracture of the lateral process of the talus is overlooked up to 50 of cases with plain radiography Ultrasound may suspect the presence of focal cortical disruption helping further to exclude concomitant ligament injury
Rheumatoid arthritis with synovial thickening (1) and erosion of the tibia (2)
Infectious arthritis with a pus filled anterior recess of the ankle
Arthritis and tenosynovitis of the ankle in a patient with rheumatoid arthritis
bullTUMOURSUltrasound can differentiate between a mass complex
and solid and a cystic in addition to verifying the
existence of accessory muscles (peroneus fourth
accessory flexor digitorum longus and accessory
soleus) As in any other location can be found
neoformative soft tissue tumors inflammatory
infectious etc
Ganglions of this location are more often symptomatic
and larger with multiple partitions
branched and lobed edges Differential diagnosis must
be made with tenosynovitis abscesses seromas and
varicosities
Neurogenic tumours are described as pathognomonic
homogeneous hypoechoic oval mass in continuity with
a nerve of origin
Ganglion cysts are non-malignant cystic masses that occur in association with musculoskeletal structures They are sometimes also simply referred to as ganglia or a ganglion but should not be confused with the anatomical term ganglion UltrasoundThe vast majority are anechoic to hypoechoic on ultrasound and have well defined margins Many demonstrate internal septations as well as acoustic enhancement A synovial cyst is a small fluid-filled sac or pouch that can develop over a tendon or joint creating a mass under the skin Synovial cyst is rare in ankle joint A synovial cyst may or may not be painful depending on their size and location
Ganglion cyst in the foot with bony erosion between navicular and cuneiform bones
Tarsal synovial cyst
Anechoic ganglion situated in the sinus tarsi fat between the talus and calcaneous
Plantar fasciitis (PF) refers to inflammation of the
plantar fascia of the foot It is considered the most common cause of heel pain
Clinical presentation Pain on the undersurface of the heel on weight bearing is the principal complaint It can be worse when weight is borne after a period of rest (eg in the morning) and eases with walking Passive dorsiflexion of the toes may exacerbates discomfort
UltrasoundOften the initial imaging modality of choice Ultrasound typically shows increased thickness of the fascia and a hypoechoic fascia
Thickened hypoechoic origin of the plantar fascia which has a convex superior margin
Complete avulsion of the plantar fascia from the calcaneal tubercle
Plantar fasciitis
bull LOCATING FOREIGN BODIES AND FRACTURES
As in any other location the ankle
area is also subsidiary host foreign
whose classification location and
existence can be defined perfectly by
ultrasound Being a focused study to
the area of interest and with great
resolution for surface structures can
be considered more resolute
examination to screen these cases
Osseous diseases and fractures | Sonography discovered Medial Malleolus Fracture
Ultrasound examination of left ankle A Longitudinal sonogram left ankle demonstrates a wooden foreign body B Transverse view left ankle Note the hypervascularity in the inflamed area C Corresponding X-ray of left ankle Note the swelling on the lateral aspect No foreign body is visible
Thank You
Bony avulsion with radiographic evidence as visible calcification in a grade III sprain ATFL
Moderately thickened and hypoechoic ATFL
Discontinuity of the ATFL with fluid surrounding the torn ends (arrow)
Thickening and hypoechogenicity of the fibular end of the ligament seen here passing over the subtalar joint which contains a small of fluid
Complete disruption to the tibiofibular ligament with bony irregularity of particularly the tibial margin and fluid in the gap
MEDIAL COMPARTMENTBecause of the low incidence of eversion ankle
sprains and the thickness of the deltoid ligament
is rarely injured in isolation and when the injury
does not usually full thickness Usually
accompanied by lesions of the medial malleolus
and lateral displacement of the talus with
consequent widening of the ankle mortise
Ultrasound is useful for differentiating ligament
injury of the posterior tibial tendon injury
(TP) adjacent they have similar symptoms
The inability to visualize the deltoid ligament may
indicate tear but this is not considered a reliable
sign as its full ultrasound is not always possible
Partial medial ligament rupture
Thickened heterogeneous abnormal deltoid demonstrating hyperemia
Ultrasonogram showing a disrupted deltoid ligament with the probe in the coronal plane The white arrow indicates the medial malleolus the blue arrow indicates the talus and the red arrows indicate the disrupted deltoid ligament (A) Radiograph showing the same injury (B)
bullJOINT AND BONE DISORDERSUltrasound reliably detect spills mild (gt 2 ml) inside
of the ankle joint by exploring the front and rear
recess as well as areas of synovial proliferation and
may even display using the colour Doppler
hyperemic areas in arthritis patients
The intraarticular joints are displayed surrounded
fluid in one of the recesses of the ankle or subtalar
joint Sonographically diagnosed when changing position to perform flexion and extension Fracture of the lateral process of the talus is overlooked up to 50 of cases with plain radiography Ultrasound may suspect the presence of focal cortical disruption helping further to exclude concomitant ligament injury
Rheumatoid arthritis with synovial thickening (1) and erosion of the tibia (2)
Infectious arthritis with a pus filled anterior recess of the ankle
Arthritis and tenosynovitis of the ankle in a patient with rheumatoid arthritis
bullTUMOURSUltrasound can differentiate between a mass complex
and solid and a cystic in addition to verifying the
existence of accessory muscles (peroneus fourth
accessory flexor digitorum longus and accessory
soleus) As in any other location can be found
neoformative soft tissue tumors inflammatory
infectious etc
Ganglions of this location are more often symptomatic
and larger with multiple partitions
branched and lobed edges Differential diagnosis must
be made with tenosynovitis abscesses seromas and
varicosities
Neurogenic tumours are described as pathognomonic
homogeneous hypoechoic oval mass in continuity with
a nerve of origin
Ganglion cysts are non-malignant cystic masses that occur in association with musculoskeletal structures They are sometimes also simply referred to as ganglia or a ganglion but should not be confused with the anatomical term ganglion UltrasoundThe vast majority are anechoic to hypoechoic on ultrasound and have well defined margins Many demonstrate internal septations as well as acoustic enhancement A synovial cyst is a small fluid-filled sac or pouch that can develop over a tendon or joint creating a mass under the skin Synovial cyst is rare in ankle joint A synovial cyst may or may not be painful depending on their size and location
Ganglion cyst in the foot with bony erosion between navicular and cuneiform bones
Tarsal synovial cyst
Anechoic ganglion situated in the sinus tarsi fat between the talus and calcaneous
Plantar fasciitis (PF) refers to inflammation of the
plantar fascia of the foot It is considered the most common cause of heel pain
Clinical presentation Pain on the undersurface of the heel on weight bearing is the principal complaint It can be worse when weight is borne after a period of rest (eg in the morning) and eases with walking Passive dorsiflexion of the toes may exacerbates discomfort
UltrasoundOften the initial imaging modality of choice Ultrasound typically shows increased thickness of the fascia and a hypoechoic fascia
Thickened hypoechoic origin of the plantar fascia which has a convex superior margin
Complete avulsion of the plantar fascia from the calcaneal tubercle
Plantar fasciitis
bull LOCATING FOREIGN BODIES AND FRACTURES
As in any other location the ankle
area is also subsidiary host foreign
whose classification location and
existence can be defined perfectly by
ultrasound Being a focused study to
the area of interest and with great
resolution for surface structures can
be considered more resolute
examination to screen these cases
Osseous diseases and fractures | Sonography discovered Medial Malleolus Fracture
Ultrasound examination of left ankle A Longitudinal sonogram left ankle demonstrates a wooden foreign body B Transverse view left ankle Note the hypervascularity in the inflamed area C Corresponding X-ray of left ankle Note the swelling on the lateral aspect No foreign body is visible
Thank You
Moderately thickened and hypoechoic ATFL
Discontinuity of the ATFL with fluid surrounding the torn ends (arrow)
Thickening and hypoechogenicity of the fibular end of the ligament seen here passing over the subtalar joint which contains a small of fluid
Complete disruption to the tibiofibular ligament with bony irregularity of particularly the tibial margin and fluid in the gap
MEDIAL COMPARTMENTBecause of the low incidence of eversion ankle
sprains and the thickness of the deltoid ligament
is rarely injured in isolation and when the injury
does not usually full thickness Usually
accompanied by lesions of the medial malleolus
and lateral displacement of the talus with
consequent widening of the ankle mortise
Ultrasound is useful for differentiating ligament
injury of the posterior tibial tendon injury
(TP) adjacent they have similar symptoms
The inability to visualize the deltoid ligament may
indicate tear but this is not considered a reliable
sign as its full ultrasound is not always possible
Partial medial ligament rupture
Thickened heterogeneous abnormal deltoid demonstrating hyperemia
Ultrasonogram showing a disrupted deltoid ligament with the probe in the coronal plane The white arrow indicates the medial malleolus the blue arrow indicates the talus and the red arrows indicate the disrupted deltoid ligament (A) Radiograph showing the same injury (B)
bullJOINT AND BONE DISORDERSUltrasound reliably detect spills mild (gt 2 ml) inside
of the ankle joint by exploring the front and rear
recess as well as areas of synovial proliferation and
may even display using the colour Doppler
hyperemic areas in arthritis patients
The intraarticular joints are displayed surrounded
fluid in one of the recesses of the ankle or subtalar
joint Sonographically diagnosed when changing position to perform flexion and extension Fracture of the lateral process of the talus is overlooked up to 50 of cases with plain radiography Ultrasound may suspect the presence of focal cortical disruption helping further to exclude concomitant ligament injury
Rheumatoid arthritis with synovial thickening (1) and erosion of the tibia (2)
Infectious arthritis with a pus filled anterior recess of the ankle
Arthritis and tenosynovitis of the ankle in a patient with rheumatoid arthritis
bullTUMOURSUltrasound can differentiate between a mass complex
and solid and a cystic in addition to verifying the
existence of accessory muscles (peroneus fourth
accessory flexor digitorum longus and accessory
soleus) As in any other location can be found
neoformative soft tissue tumors inflammatory
infectious etc
Ganglions of this location are more often symptomatic
and larger with multiple partitions
branched and lobed edges Differential diagnosis must
be made with tenosynovitis abscesses seromas and
varicosities
Neurogenic tumours are described as pathognomonic
homogeneous hypoechoic oval mass in continuity with
a nerve of origin
Ganglion cysts are non-malignant cystic masses that occur in association with musculoskeletal structures They are sometimes also simply referred to as ganglia or a ganglion but should not be confused with the anatomical term ganglion UltrasoundThe vast majority are anechoic to hypoechoic on ultrasound and have well defined margins Many demonstrate internal septations as well as acoustic enhancement A synovial cyst is a small fluid-filled sac or pouch that can develop over a tendon or joint creating a mass under the skin Synovial cyst is rare in ankle joint A synovial cyst may or may not be painful depending on their size and location
Ganglion cyst in the foot with bony erosion between navicular and cuneiform bones
Tarsal synovial cyst
Anechoic ganglion situated in the sinus tarsi fat between the talus and calcaneous
Plantar fasciitis (PF) refers to inflammation of the
plantar fascia of the foot It is considered the most common cause of heel pain
Clinical presentation Pain on the undersurface of the heel on weight bearing is the principal complaint It can be worse when weight is borne after a period of rest (eg in the morning) and eases with walking Passive dorsiflexion of the toes may exacerbates discomfort
UltrasoundOften the initial imaging modality of choice Ultrasound typically shows increased thickness of the fascia and a hypoechoic fascia
Thickened hypoechoic origin of the plantar fascia which has a convex superior margin
Complete avulsion of the plantar fascia from the calcaneal tubercle
Plantar fasciitis
bull LOCATING FOREIGN BODIES AND FRACTURES
As in any other location the ankle
area is also subsidiary host foreign
whose classification location and
existence can be defined perfectly by
ultrasound Being a focused study to
the area of interest and with great
resolution for surface structures can
be considered more resolute
examination to screen these cases
Osseous diseases and fractures | Sonography discovered Medial Malleolus Fracture
Ultrasound examination of left ankle A Longitudinal sonogram left ankle demonstrates a wooden foreign body B Transverse view left ankle Note the hypervascularity in the inflamed area C Corresponding X-ray of left ankle Note the swelling on the lateral aspect No foreign body is visible
Thank You
Discontinuity of the ATFL with fluid surrounding the torn ends (arrow)
Thickening and hypoechogenicity of the fibular end of the ligament seen here passing over the subtalar joint which contains a small of fluid
Complete disruption to the tibiofibular ligament with bony irregularity of particularly the tibial margin and fluid in the gap
MEDIAL COMPARTMENTBecause of the low incidence of eversion ankle
sprains and the thickness of the deltoid ligament
is rarely injured in isolation and when the injury
does not usually full thickness Usually
accompanied by lesions of the medial malleolus
and lateral displacement of the talus with
consequent widening of the ankle mortise
Ultrasound is useful for differentiating ligament
injury of the posterior tibial tendon injury
(TP) adjacent they have similar symptoms
The inability to visualize the deltoid ligament may
indicate tear but this is not considered a reliable
sign as its full ultrasound is not always possible
Partial medial ligament rupture
Thickened heterogeneous abnormal deltoid demonstrating hyperemia
Ultrasonogram showing a disrupted deltoid ligament with the probe in the coronal plane The white arrow indicates the medial malleolus the blue arrow indicates the talus and the red arrows indicate the disrupted deltoid ligament (A) Radiograph showing the same injury (B)
bullJOINT AND BONE DISORDERSUltrasound reliably detect spills mild (gt 2 ml) inside
of the ankle joint by exploring the front and rear
recess as well as areas of synovial proliferation and
may even display using the colour Doppler
hyperemic areas in arthritis patients
The intraarticular joints are displayed surrounded
fluid in one of the recesses of the ankle or subtalar
joint Sonographically diagnosed when changing position to perform flexion and extension Fracture of the lateral process of the talus is overlooked up to 50 of cases with plain radiography Ultrasound may suspect the presence of focal cortical disruption helping further to exclude concomitant ligament injury
Rheumatoid arthritis with synovial thickening (1) and erosion of the tibia (2)
Infectious arthritis with a pus filled anterior recess of the ankle
Arthritis and tenosynovitis of the ankle in a patient with rheumatoid arthritis
bullTUMOURSUltrasound can differentiate between a mass complex
and solid and a cystic in addition to verifying the
existence of accessory muscles (peroneus fourth
accessory flexor digitorum longus and accessory
soleus) As in any other location can be found
neoformative soft tissue tumors inflammatory
infectious etc
Ganglions of this location are more often symptomatic
and larger with multiple partitions
branched and lobed edges Differential diagnosis must
be made with tenosynovitis abscesses seromas and
varicosities
Neurogenic tumours are described as pathognomonic
homogeneous hypoechoic oval mass in continuity with
a nerve of origin
Ganglion cysts are non-malignant cystic masses that occur in association with musculoskeletal structures They are sometimes also simply referred to as ganglia or a ganglion but should not be confused with the anatomical term ganglion UltrasoundThe vast majority are anechoic to hypoechoic on ultrasound and have well defined margins Many demonstrate internal septations as well as acoustic enhancement A synovial cyst is a small fluid-filled sac or pouch that can develop over a tendon or joint creating a mass under the skin Synovial cyst is rare in ankle joint A synovial cyst may or may not be painful depending on their size and location
Ganglion cyst in the foot with bony erosion between navicular and cuneiform bones
Tarsal synovial cyst
Anechoic ganglion situated in the sinus tarsi fat between the talus and calcaneous
Plantar fasciitis (PF) refers to inflammation of the
plantar fascia of the foot It is considered the most common cause of heel pain
Clinical presentation Pain on the undersurface of the heel on weight bearing is the principal complaint It can be worse when weight is borne after a period of rest (eg in the morning) and eases with walking Passive dorsiflexion of the toes may exacerbates discomfort
UltrasoundOften the initial imaging modality of choice Ultrasound typically shows increased thickness of the fascia and a hypoechoic fascia
Thickened hypoechoic origin of the plantar fascia which has a convex superior margin
Complete avulsion of the plantar fascia from the calcaneal tubercle
Plantar fasciitis
bull LOCATING FOREIGN BODIES AND FRACTURES
As in any other location the ankle
area is also subsidiary host foreign
whose classification location and
existence can be defined perfectly by
ultrasound Being a focused study to
the area of interest and with great
resolution for surface structures can
be considered more resolute
examination to screen these cases
Osseous diseases and fractures | Sonography discovered Medial Malleolus Fracture
Ultrasound examination of left ankle A Longitudinal sonogram left ankle demonstrates a wooden foreign body B Transverse view left ankle Note the hypervascularity in the inflamed area C Corresponding X-ray of left ankle Note the swelling on the lateral aspect No foreign body is visible
Thank You
Thickening and hypoechogenicity of the fibular end of the ligament seen here passing over the subtalar joint which contains a small of fluid
Complete disruption to the tibiofibular ligament with bony irregularity of particularly the tibial margin and fluid in the gap
MEDIAL COMPARTMENTBecause of the low incidence of eversion ankle
sprains and the thickness of the deltoid ligament
is rarely injured in isolation and when the injury
does not usually full thickness Usually
accompanied by lesions of the medial malleolus
and lateral displacement of the talus with
consequent widening of the ankle mortise
Ultrasound is useful for differentiating ligament
injury of the posterior tibial tendon injury
(TP) adjacent they have similar symptoms
The inability to visualize the deltoid ligament may
indicate tear but this is not considered a reliable
sign as its full ultrasound is not always possible
Partial medial ligament rupture
Thickened heterogeneous abnormal deltoid demonstrating hyperemia
Ultrasonogram showing a disrupted deltoid ligament with the probe in the coronal plane The white arrow indicates the medial malleolus the blue arrow indicates the talus and the red arrows indicate the disrupted deltoid ligament (A) Radiograph showing the same injury (B)
bullJOINT AND BONE DISORDERSUltrasound reliably detect spills mild (gt 2 ml) inside
of the ankle joint by exploring the front and rear
recess as well as areas of synovial proliferation and
may even display using the colour Doppler
hyperemic areas in arthritis patients
The intraarticular joints are displayed surrounded
fluid in one of the recesses of the ankle or subtalar
joint Sonographically diagnosed when changing position to perform flexion and extension Fracture of the lateral process of the talus is overlooked up to 50 of cases with plain radiography Ultrasound may suspect the presence of focal cortical disruption helping further to exclude concomitant ligament injury
Rheumatoid arthritis with synovial thickening (1) and erosion of the tibia (2)
Infectious arthritis with a pus filled anterior recess of the ankle
Arthritis and tenosynovitis of the ankle in a patient with rheumatoid arthritis
bullTUMOURSUltrasound can differentiate between a mass complex
and solid and a cystic in addition to verifying the
existence of accessory muscles (peroneus fourth
accessory flexor digitorum longus and accessory
soleus) As in any other location can be found
neoformative soft tissue tumors inflammatory
infectious etc
Ganglions of this location are more often symptomatic
and larger with multiple partitions
branched and lobed edges Differential diagnosis must
be made with tenosynovitis abscesses seromas and
varicosities
Neurogenic tumours are described as pathognomonic
homogeneous hypoechoic oval mass in continuity with
a nerve of origin
Ganglion cysts are non-malignant cystic masses that occur in association with musculoskeletal structures They are sometimes also simply referred to as ganglia or a ganglion but should not be confused with the anatomical term ganglion UltrasoundThe vast majority are anechoic to hypoechoic on ultrasound and have well defined margins Many demonstrate internal septations as well as acoustic enhancement A synovial cyst is a small fluid-filled sac or pouch that can develop over a tendon or joint creating a mass under the skin Synovial cyst is rare in ankle joint A synovial cyst may or may not be painful depending on their size and location
Ganglion cyst in the foot with bony erosion between navicular and cuneiform bones
Tarsal synovial cyst
Anechoic ganglion situated in the sinus tarsi fat between the talus and calcaneous
Plantar fasciitis (PF) refers to inflammation of the
plantar fascia of the foot It is considered the most common cause of heel pain
Clinical presentation Pain on the undersurface of the heel on weight bearing is the principal complaint It can be worse when weight is borne after a period of rest (eg in the morning) and eases with walking Passive dorsiflexion of the toes may exacerbates discomfort
UltrasoundOften the initial imaging modality of choice Ultrasound typically shows increased thickness of the fascia and a hypoechoic fascia
Thickened hypoechoic origin of the plantar fascia which has a convex superior margin
Complete avulsion of the plantar fascia from the calcaneal tubercle
Plantar fasciitis
bull LOCATING FOREIGN BODIES AND FRACTURES
As in any other location the ankle
area is also subsidiary host foreign
whose classification location and
existence can be defined perfectly by
ultrasound Being a focused study to
the area of interest and with great
resolution for surface structures can
be considered more resolute
examination to screen these cases
Osseous diseases and fractures | Sonography discovered Medial Malleolus Fracture
Ultrasound examination of left ankle A Longitudinal sonogram left ankle demonstrates a wooden foreign body B Transverse view left ankle Note the hypervascularity in the inflamed area C Corresponding X-ray of left ankle Note the swelling on the lateral aspect No foreign body is visible
Thank You
Complete disruption to the tibiofibular ligament with bony irregularity of particularly the tibial margin and fluid in the gap
MEDIAL COMPARTMENTBecause of the low incidence of eversion ankle
sprains and the thickness of the deltoid ligament
is rarely injured in isolation and when the injury
does not usually full thickness Usually
accompanied by lesions of the medial malleolus
and lateral displacement of the talus with
consequent widening of the ankle mortise
Ultrasound is useful for differentiating ligament
injury of the posterior tibial tendon injury
(TP) adjacent they have similar symptoms
The inability to visualize the deltoid ligament may
indicate tear but this is not considered a reliable
sign as its full ultrasound is not always possible
Partial medial ligament rupture
Thickened heterogeneous abnormal deltoid demonstrating hyperemia
Ultrasonogram showing a disrupted deltoid ligament with the probe in the coronal plane The white arrow indicates the medial malleolus the blue arrow indicates the talus and the red arrows indicate the disrupted deltoid ligament (A) Radiograph showing the same injury (B)
bullJOINT AND BONE DISORDERSUltrasound reliably detect spills mild (gt 2 ml) inside
of the ankle joint by exploring the front and rear
recess as well as areas of synovial proliferation and
may even display using the colour Doppler
hyperemic areas in arthritis patients
The intraarticular joints are displayed surrounded
fluid in one of the recesses of the ankle or subtalar
joint Sonographically diagnosed when changing position to perform flexion and extension Fracture of the lateral process of the talus is overlooked up to 50 of cases with plain radiography Ultrasound may suspect the presence of focal cortical disruption helping further to exclude concomitant ligament injury
Rheumatoid arthritis with synovial thickening (1) and erosion of the tibia (2)
Infectious arthritis with a pus filled anterior recess of the ankle
Arthritis and tenosynovitis of the ankle in a patient with rheumatoid arthritis
bullTUMOURSUltrasound can differentiate between a mass complex
and solid and a cystic in addition to verifying the
existence of accessory muscles (peroneus fourth
accessory flexor digitorum longus and accessory
soleus) As in any other location can be found
neoformative soft tissue tumors inflammatory
infectious etc
Ganglions of this location are more often symptomatic
and larger with multiple partitions
branched and lobed edges Differential diagnosis must
be made with tenosynovitis abscesses seromas and
varicosities
Neurogenic tumours are described as pathognomonic
homogeneous hypoechoic oval mass in continuity with
a nerve of origin
Ganglion cysts are non-malignant cystic masses that occur in association with musculoskeletal structures They are sometimes also simply referred to as ganglia or a ganglion but should not be confused with the anatomical term ganglion UltrasoundThe vast majority are anechoic to hypoechoic on ultrasound and have well defined margins Many demonstrate internal septations as well as acoustic enhancement A synovial cyst is a small fluid-filled sac or pouch that can develop over a tendon or joint creating a mass under the skin Synovial cyst is rare in ankle joint A synovial cyst may or may not be painful depending on their size and location
Ganglion cyst in the foot with bony erosion between navicular and cuneiform bones
Tarsal synovial cyst
Anechoic ganglion situated in the sinus tarsi fat between the talus and calcaneous
Plantar fasciitis (PF) refers to inflammation of the
plantar fascia of the foot It is considered the most common cause of heel pain
Clinical presentation Pain on the undersurface of the heel on weight bearing is the principal complaint It can be worse when weight is borne after a period of rest (eg in the morning) and eases with walking Passive dorsiflexion of the toes may exacerbates discomfort
UltrasoundOften the initial imaging modality of choice Ultrasound typically shows increased thickness of the fascia and a hypoechoic fascia
Thickened hypoechoic origin of the plantar fascia which has a convex superior margin
Complete avulsion of the plantar fascia from the calcaneal tubercle
Plantar fasciitis
bull LOCATING FOREIGN BODIES AND FRACTURES
As in any other location the ankle
area is also subsidiary host foreign
whose classification location and
existence can be defined perfectly by
ultrasound Being a focused study to
the area of interest and with great
resolution for surface structures can
be considered more resolute
examination to screen these cases
Osseous diseases and fractures | Sonography discovered Medial Malleolus Fracture
Ultrasound examination of left ankle A Longitudinal sonogram left ankle demonstrates a wooden foreign body B Transverse view left ankle Note the hypervascularity in the inflamed area C Corresponding X-ray of left ankle Note the swelling on the lateral aspect No foreign body is visible
Thank You
MEDIAL COMPARTMENTBecause of the low incidence of eversion ankle
sprains and the thickness of the deltoid ligament
is rarely injured in isolation and when the injury
does not usually full thickness Usually
accompanied by lesions of the medial malleolus
and lateral displacement of the talus with
consequent widening of the ankle mortise
Ultrasound is useful for differentiating ligament
injury of the posterior tibial tendon injury
(TP) adjacent they have similar symptoms
The inability to visualize the deltoid ligament may
indicate tear but this is not considered a reliable
sign as its full ultrasound is not always possible
Partial medial ligament rupture
Thickened heterogeneous abnormal deltoid demonstrating hyperemia
Ultrasonogram showing a disrupted deltoid ligament with the probe in the coronal plane The white arrow indicates the medial malleolus the blue arrow indicates the talus and the red arrows indicate the disrupted deltoid ligament (A) Radiograph showing the same injury (B)
bullJOINT AND BONE DISORDERSUltrasound reliably detect spills mild (gt 2 ml) inside
of the ankle joint by exploring the front and rear
recess as well as areas of synovial proliferation and
may even display using the colour Doppler
hyperemic areas in arthritis patients
The intraarticular joints are displayed surrounded
fluid in one of the recesses of the ankle or subtalar
joint Sonographically diagnosed when changing position to perform flexion and extension Fracture of the lateral process of the talus is overlooked up to 50 of cases with plain radiography Ultrasound may suspect the presence of focal cortical disruption helping further to exclude concomitant ligament injury
Rheumatoid arthritis with synovial thickening (1) and erosion of the tibia (2)
Infectious arthritis with a pus filled anterior recess of the ankle
Arthritis and tenosynovitis of the ankle in a patient with rheumatoid arthritis
bullTUMOURSUltrasound can differentiate between a mass complex
and solid and a cystic in addition to verifying the
existence of accessory muscles (peroneus fourth
accessory flexor digitorum longus and accessory
soleus) As in any other location can be found
neoformative soft tissue tumors inflammatory
infectious etc
Ganglions of this location are more often symptomatic
and larger with multiple partitions
branched and lobed edges Differential diagnosis must
be made with tenosynovitis abscesses seromas and
varicosities
Neurogenic tumours are described as pathognomonic
homogeneous hypoechoic oval mass in continuity with
a nerve of origin
Ganglion cysts are non-malignant cystic masses that occur in association with musculoskeletal structures They are sometimes also simply referred to as ganglia or a ganglion but should not be confused with the anatomical term ganglion UltrasoundThe vast majority are anechoic to hypoechoic on ultrasound and have well defined margins Many demonstrate internal septations as well as acoustic enhancement A synovial cyst is a small fluid-filled sac or pouch that can develop over a tendon or joint creating a mass under the skin Synovial cyst is rare in ankle joint A synovial cyst may or may not be painful depending on their size and location
Ganglion cyst in the foot with bony erosion between navicular and cuneiform bones
Tarsal synovial cyst
Anechoic ganglion situated in the sinus tarsi fat between the talus and calcaneous
Plantar fasciitis (PF) refers to inflammation of the
plantar fascia of the foot It is considered the most common cause of heel pain
Clinical presentation Pain on the undersurface of the heel on weight bearing is the principal complaint It can be worse when weight is borne after a period of rest (eg in the morning) and eases with walking Passive dorsiflexion of the toes may exacerbates discomfort
UltrasoundOften the initial imaging modality of choice Ultrasound typically shows increased thickness of the fascia and a hypoechoic fascia
Thickened hypoechoic origin of the plantar fascia which has a convex superior margin
Complete avulsion of the plantar fascia from the calcaneal tubercle
Plantar fasciitis
bull LOCATING FOREIGN BODIES AND FRACTURES
As in any other location the ankle
area is also subsidiary host foreign
whose classification location and
existence can be defined perfectly by
ultrasound Being a focused study to
the area of interest and with great
resolution for surface structures can
be considered more resolute
examination to screen these cases
Osseous diseases and fractures | Sonography discovered Medial Malleolus Fracture
Ultrasound examination of left ankle A Longitudinal sonogram left ankle demonstrates a wooden foreign body B Transverse view left ankle Note the hypervascularity in the inflamed area C Corresponding X-ray of left ankle Note the swelling on the lateral aspect No foreign body is visible
Thank You
Partial medial ligament rupture
Thickened heterogeneous abnormal deltoid demonstrating hyperemia
Ultrasonogram showing a disrupted deltoid ligament with the probe in the coronal plane The white arrow indicates the medial malleolus the blue arrow indicates the talus and the red arrows indicate the disrupted deltoid ligament (A) Radiograph showing the same injury (B)
bullJOINT AND BONE DISORDERSUltrasound reliably detect spills mild (gt 2 ml) inside
of the ankle joint by exploring the front and rear
recess as well as areas of synovial proliferation and
may even display using the colour Doppler
hyperemic areas in arthritis patients
The intraarticular joints are displayed surrounded
fluid in one of the recesses of the ankle or subtalar
joint Sonographically diagnosed when changing position to perform flexion and extension Fracture of the lateral process of the talus is overlooked up to 50 of cases with plain radiography Ultrasound may suspect the presence of focal cortical disruption helping further to exclude concomitant ligament injury
Rheumatoid arthritis with synovial thickening (1) and erosion of the tibia (2)
Infectious arthritis with a pus filled anterior recess of the ankle
Arthritis and tenosynovitis of the ankle in a patient with rheumatoid arthritis
bullTUMOURSUltrasound can differentiate between a mass complex
and solid and a cystic in addition to verifying the
existence of accessory muscles (peroneus fourth
accessory flexor digitorum longus and accessory
soleus) As in any other location can be found
neoformative soft tissue tumors inflammatory
infectious etc
Ganglions of this location are more often symptomatic
and larger with multiple partitions
branched and lobed edges Differential diagnosis must
be made with tenosynovitis abscesses seromas and
varicosities
Neurogenic tumours are described as pathognomonic
homogeneous hypoechoic oval mass in continuity with
a nerve of origin
Ganglion cysts are non-malignant cystic masses that occur in association with musculoskeletal structures They are sometimes also simply referred to as ganglia or a ganglion but should not be confused with the anatomical term ganglion UltrasoundThe vast majority are anechoic to hypoechoic on ultrasound and have well defined margins Many demonstrate internal septations as well as acoustic enhancement A synovial cyst is a small fluid-filled sac or pouch that can develop over a tendon or joint creating a mass under the skin Synovial cyst is rare in ankle joint A synovial cyst may or may not be painful depending on their size and location
Ganglion cyst in the foot with bony erosion between navicular and cuneiform bones
Tarsal synovial cyst
Anechoic ganglion situated in the sinus tarsi fat between the talus and calcaneous
Plantar fasciitis (PF) refers to inflammation of the
plantar fascia of the foot It is considered the most common cause of heel pain
Clinical presentation Pain on the undersurface of the heel on weight bearing is the principal complaint It can be worse when weight is borne after a period of rest (eg in the morning) and eases with walking Passive dorsiflexion of the toes may exacerbates discomfort
UltrasoundOften the initial imaging modality of choice Ultrasound typically shows increased thickness of the fascia and a hypoechoic fascia
Thickened hypoechoic origin of the plantar fascia which has a convex superior margin
Complete avulsion of the plantar fascia from the calcaneal tubercle
Plantar fasciitis
bull LOCATING FOREIGN BODIES AND FRACTURES
As in any other location the ankle
area is also subsidiary host foreign
whose classification location and
existence can be defined perfectly by
ultrasound Being a focused study to
the area of interest and with great
resolution for surface structures can
be considered more resolute
examination to screen these cases
Osseous diseases and fractures | Sonography discovered Medial Malleolus Fracture
Ultrasound examination of left ankle A Longitudinal sonogram left ankle demonstrates a wooden foreign body B Transverse view left ankle Note the hypervascularity in the inflamed area C Corresponding X-ray of left ankle Note the swelling on the lateral aspect No foreign body is visible
Thank You
Thickened heterogeneous abnormal deltoid demonstrating hyperemia
Ultrasonogram showing a disrupted deltoid ligament with the probe in the coronal plane The white arrow indicates the medial malleolus the blue arrow indicates the talus and the red arrows indicate the disrupted deltoid ligament (A) Radiograph showing the same injury (B)
bullJOINT AND BONE DISORDERSUltrasound reliably detect spills mild (gt 2 ml) inside
of the ankle joint by exploring the front and rear
recess as well as areas of synovial proliferation and
may even display using the colour Doppler
hyperemic areas in arthritis patients
The intraarticular joints are displayed surrounded
fluid in one of the recesses of the ankle or subtalar
joint Sonographically diagnosed when changing position to perform flexion and extension Fracture of the lateral process of the talus is overlooked up to 50 of cases with plain radiography Ultrasound may suspect the presence of focal cortical disruption helping further to exclude concomitant ligament injury
Rheumatoid arthritis with synovial thickening (1) and erosion of the tibia (2)
Infectious arthritis with a pus filled anterior recess of the ankle
Arthritis and tenosynovitis of the ankle in a patient with rheumatoid arthritis
bullTUMOURSUltrasound can differentiate between a mass complex
and solid and a cystic in addition to verifying the
existence of accessory muscles (peroneus fourth
accessory flexor digitorum longus and accessory
soleus) As in any other location can be found
neoformative soft tissue tumors inflammatory
infectious etc
Ganglions of this location are more often symptomatic
and larger with multiple partitions
branched and lobed edges Differential diagnosis must
be made with tenosynovitis abscesses seromas and
varicosities
Neurogenic tumours are described as pathognomonic
homogeneous hypoechoic oval mass in continuity with
a nerve of origin
Ganglion cysts are non-malignant cystic masses that occur in association with musculoskeletal structures They are sometimes also simply referred to as ganglia or a ganglion but should not be confused with the anatomical term ganglion UltrasoundThe vast majority are anechoic to hypoechoic on ultrasound and have well defined margins Many demonstrate internal septations as well as acoustic enhancement A synovial cyst is a small fluid-filled sac or pouch that can develop over a tendon or joint creating a mass under the skin Synovial cyst is rare in ankle joint A synovial cyst may or may not be painful depending on their size and location
Ganglion cyst in the foot with bony erosion between navicular and cuneiform bones
Tarsal synovial cyst
Anechoic ganglion situated in the sinus tarsi fat between the talus and calcaneous
Plantar fasciitis (PF) refers to inflammation of the
plantar fascia of the foot It is considered the most common cause of heel pain
Clinical presentation Pain on the undersurface of the heel on weight bearing is the principal complaint It can be worse when weight is borne after a period of rest (eg in the morning) and eases with walking Passive dorsiflexion of the toes may exacerbates discomfort
UltrasoundOften the initial imaging modality of choice Ultrasound typically shows increased thickness of the fascia and a hypoechoic fascia
Thickened hypoechoic origin of the plantar fascia which has a convex superior margin
Complete avulsion of the plantar fascia from the calcaneal tubercle
Plantar fasciitis
bull LOCATING FOREIGN BODIES AND FRACTURES
As in any other location the ankle
area is also subsidiary host foreign
whose classification location and
existence can be defined perfectly by
ultrasound Being a focused study to
the area of interest and with great
resolution for surface structures can
be considered more resolute
examination to screen these cases
Osseous diseases and fractures | Sonography discovered Medial Malleolus Fracture
Ultrasound examination of left ankle A Longitudinal sonogram left ankle demonstrates a wooden foreign body B Transverse view left ankle Note the hypervascularity in the inflamed area C Corresponding X-ray of left ankle Note the swelling on the lateral aspect No foreign body is visible
Thank You
Ultrasonogram showing a disrupted deltoid ligament with the probe in the coronal plane The white arrow indicates the medial malleolus the blue arrow indicates the talus and the red arrows indicate the disrupted deltoid ligament (A) Radiograph showing the same injury (B)
bullJOINT AND BONE DISORDERSUltrasound reliably detect spills mild (gt 2 ml) inside
of the ankle joint by exploring the front and rear
recess as well as areas of synovial proliferation and
may even display using the colour Doppler
hyperemic areas in arthritis patients
The intraarticular joints are displayed surrounded
fluid in one of the recesses of the ankle or subtalar
joint Sonographically diagnosed when changing position to perform flexion and extension Fracture of the lateral process of the talus is overlooked up to 50 of cases with plain radiography Ultrasound may suspect the presence of focal cortical disruption helping further to exclude concomitant ligament injury
Rheumatoid arthritis with synovial thickening (1) and erosion of the tibia (2)
Infectious arthritis with a pus filled anterior recess of the ankle
Arthritis and tenosynovitis of the ankle in a patient with rheumatoid arthritis
bullTUMOURSUltrasound can differentiate between a mass complex
and solid and a cystic in addition to verifying the
existence of accessory muscles (peroneus fourth
accessory flexor digitorum longus and accessory
soleus) As in any other location can be found
neoformative soft tissue tumors inflammatory
infectious etc
Ganglions of this location are more often symptomatic
and larger with multiple partitions
branched and lobed edges Differential diagnosis must
be made with tenosynovitis abscesses seromas and
varicosities
Neurogenic tumours are described as pathognomonic
homogeneous hypoechoic oval mass in continuity with
a nerve of origin
Ganglion cysts are non-malignant cystic masses that occur in association with musculoskeletal structures They are sometimes also simply referred to as ganglia or a ganglion but should not be confused with the anatomical term ganglion UltrasoundThe vast majority are anechoic to hypoechoic on ultrasound and have well defined margins Many demonstrate internal septations as well as acoustic enhancement A synovial cyst is a small fluid-filled sac or pouch that can develop over a tendon or joint creating a mass under the skin Synovial cyst is rare in ankle joint A synovial cyst may or may not be painful depending on their size and location
Ganglion cyst in the foot with bony erosion between navicular and cuneiform bones
Tarsal synovial cyst
Anechoic ganglion situated in the sinus tarsi fat between the talus and calcaneous
Plantar fasciitis (PF) refers to inflammation of the
plantar fascia of the foot It is considered the most common cause of heel pain
Clinical presentation Pain on the undersurface of the heel on weight bearing is the principal complaint It can be worse when weight is borne after a period of rest (eg in the morning) and eases with walking Passive dorsiflexion of the toes may exacerbates discomfort
UltrasoundOften the initial imaging modality of choice Ultrasound typically shows increased thickness of the fascia and a hypoechoic fascia
Thickened hypoechoic origin of the plantar fascia which has a convex superior margin
Complete avulsion of the plantar fascia from the calcaneal tubercle
Plantar fasciitis
bull LOCATING FOREIGN BODIES AND FRACTURES
As in any other location the ankle
area is also subsidiary host foreign
whose classification location and
existence can be defined perfectly by
ultrasound Being a focused study to
the area of interest and with great
resolution for surface structures can
be considered more resolute
examination to screen these cases
Osseous diseases and fractures | Sonography discovered Medial Malleolus Fracture
Ultrasound examination of left ankle A Longitudinal sonogram left ankle demonstrates a wooden foreign body B Transverse view left ankle Note the hypervascularity in the inflamed area C Corresponding X-ray of left ankle Note the swelling on the lateral aspect No foreign body is visible
Thank You
bullJOINT AND BONE DISORDERSUltrasound reliably detect spills mild (gt 2 ml) inside
of the ankle joint by exploring the front and rear
recess as well as areas of synovial proliferation and
may even display using the colour Doppler
hyperemic areas in arthritis patients
The intraarticular joints are displayed surrounded
fluid in one of the recesses of the ankle or subtalar
joint Sonographically diagnosed when changing position to perform flexion and extension Fracture of the lateral process of the talus is overlooked up to 50 of cases with plain radiography Ultrasound may suspect the presence of focal cortical disruption helping further to exclude concomitant ligament injury
Rheumatoid arthritis with synovial thickening (1) and erosion of the tibia (2)
Infectious arthritis with a pus filled anterior recess of the ankle
Arthritis and tenosynovitis of the ankle in a patient with rheumatoid arthritis
bullTUMOURSUltrasound can differentiate between a mass complex
and solid and a cystic in addition to verifying the
existence of accessory muscles (peroneus fourth
accessory flexor digitorum longus and accessory
soleus) As in any other location can be found
neoformative soft tissue tumors inflammatory
infectious etc
Ganglions of this location are more often symptomatic
and larger with multiple partitions
branched and lobed edges Differential diagnosis must
be made with tenosynovitis abscesses seromas and
varicosities
Neurogenic tumours are described as pathognomonic
homogeneous hypoechoic oval mass in continuity with
a nerve of origin
Ganglion cysts are non-malignant cystic masses that occur in association with musculoskeletal structures They are sometimes also simply referred to as ganglia or a ganglion but should not be confused with the anatomical term ganglion UltrasoundThe vast majority are anechoic to hypoechoic on ultrasound and have well defined margins Many demonstrate internal septations as well as acoustic enhancement A synovial cyst is a small fluid-filled sac or pouch that can develop over a tendon or joint creating a mass under the skin Synovial cyst is rare in ankle joint A synovial cyst may or may not be painful depending on their size and location
Ganglion cyst in the foot with bony erosion between navicular and cuneiform bones
Tarsal synovial cyst
Anechoic ganglion situated in the sinus tarsi fat between the talus and calcaneous
Plantar fasciitis (PF) refers to inflammation of the
plantar fascia of the foot It is considered the most common cause of heel pain
Clinical presentation Pain on the undersurface of the heel on weight bearing is the principal complaint It can be worse when weight is borne after a period of rest (eg in the morning) and eases with walking Passive dorsiflexion of the toes may exacerbates discomfort
UltrasoundOften the initial imaging modality of choice Ultrasound typically shows increased thickness of the fascia and a hypoechoic fascia
Thickened hypoechoic origin of the plantar fascia which has a convex superior margin
Complete avulsion of the plantar fascia from the calcaneal tubercle
Plantar fasciitis
bull LOCATING FOREIGN BODIES AND FRACTURES
As in any other location the ankle
area is also subsidiary host foreign
whose classification location and
existence can be defined perfectly by
ultrasound Being a focused study to
the area of interest and with great
resolution for surface structures can
be considered more resolute
examination to screen these cases
Osseous diseases and fractures | Sonography discovered Medial Malleolus Fracture
Ultrasound examination of left ankle A Longitudinal sonogram left ankle demonstrates a wooden foreign body B Transverse view left ankle Note the hypervascularity in the inflamed area C Corresponding X-ray of left ankle Note the swelling on the lateral aspect No foreign body is visible
Thank You
Rheumatoid arthritis with synovial thickening (1) and erosion of the tibia (2)
Infectious arthritis with a pus filled anterior recess of the ankle
Arthritis and tenosynovitis of the ankle in a patient with rheumatoid arthritis
bullTUMOURSUltrasound can differentiate between a mass complex
and solid and a cystic in addition to verifying the
existence of accessory muscles (peroneus fourth
accessory flexor digitorum longus and accessory
soleus) As in any other location can be found
neoformative soft tissue tumors inflammatory
infectious etc
Ganglions of this location are more often symptomatic
and larger with multiple partitions
branched and lobed edges Differential diagnosis must
be made with tenosynovitis abscesses seromas and
varicosities
Neurogenic tumours are described as pathognomonic
homogeneous hypoechoic oval mass in continuity with
a nerve of origin
Ganglion cysts are non-malignant cystic masses that occur in association with musculoskeletal structures They are sometimes also simply referred to as ganglia or a ganglion but should not be confused with the anatomical term ganglion UltrasoundThe vast majority are anechoic to hypoechoic on ultrasound and have well defined margins Many demonstrate internal septations as well as acoustic enhancement A synovial cyst is a small fluid-filled sac or pouch that can develop over a tendon or joint creating a mass under the skin Synovial cyst is rare in ankle joint A synovial cyst may or may not be painful depending on their size and location
Ganglion cyst in the foot with bony erosion between navicular and cuneiform bones
Tarsal synovial cyst
Anechoic ganglion situated in the sinus tarsi fat between the talus and calcaneous
Plantar fasciitis (PF) refers to inflammation of the
plantar fascia of the foot It is considered the most common cause of heel pain
Clinical presentation Pain on the undersurface of the heel on weight bearing is the principal complaint It can be worse when weight is borne after a period of rest (eg in the morning) and eases with walking Passive dorsiflexion of the toes may exacerbates discomfort
UltrasoundOften the initial imaging modality of choice Ultrasound typically shows increased thickness of the fascia and a hypoechoic fascia
Thickened hypoechoic origin of the plantar fascia which has a convex superior margin
Complete avulsion of the plantar fascia from the calcaneal tubercle
Plantar fasciitis
bull LOCATING FOREIGN BODIES AND FRACTURES
As in any other location the ankle
area is also subsidiary host foreign
whose classification location and
existence can be defined perfectly by
ultrasound Being a focused study to
the area of interest and with great
resolution for surface structures can
be considered more resolute
examination to screen these cases
Osseous diseases and fractures | Sonography discovered Medial Malleolus Fracture
Ultrasound examination of left ankle A Longitudinal sonogram left ankle demonstrates a wooden foreign body B Transverse view left ankle Note the hypervascularity in the inflamed area C Corresponding X-ray of left ankle Note the swelling on the lateral aspect No foreign body is visible
Thank You
Infectious arthritis with a pus filled anterior recess of the ankle
Arthritis and tenosynovitis of the ankle in a patient with rheumatoid arthritis
bullTUMOURSUltrasound can differentiate between a mass complex
and solid and a cystic in addition to verifying the
existence of accessory muscles (peroneus fourth
accessory flexor digitorum longus and accessory
soleus) As in any other location can be found
neoformative soft tissue tumors inflammatory
infectious etc
Ganglions of this location are more often symptomatic
and larger with multiple partitions
branched and lobed edges Differential diagnosis must
be made with tenosynovitis abscesses seromas and
varicosities
Neurogenic tumours are described as pathognomonic
homogeneous hypoechoic oval mass in continuity with
a nerve of origin
Ganglion cysts are non-malignant cystic masses that occur in association with musculoskeletal structures They are sometimes also simply referred to as ganglia or a ganglion but should not be confused with the anatomical term ganglion UltrasoundThe vast majority are anechoic to hypoechoic on ultrasound and have well defined margins Many demonstrate internal septations as well as acoustic enhancement A synovial cyst is a small fluid-filled sac or pouch that can develop over a tendon or joint creating a mass under the skin Synovial cyst is rare in ankle joint A synovial cyst may or may not be painful depending on their size and location
Ganglion cyst in the foot with bony erosion between navicular and cuneiform bones
Tarsal synovial cyst
Anechoic ganglion situated in the sinus tarsi fat between the talus and calcaneous
Plantar fasciitis (PF) refers to inflammation of the
plantar fascia of the foot It is considered the most common cause of heel pain
Clinical presentation Pain on the undersurface of the heel on weight bearing is the principal complaint It can be worse when weight is borne after a period of rest (eg in the morning) and eases with walking Passive dorsiflexion of the toes may exacerbates discomfort
UltrasoundOften the initial imaging modality of choice Ultrasound typically shows increased thickness of the fascia and a hypoechoic fascia
Thickened hypoechoic origin of the plantar fascia which has a convex superior margin
Complete avulsion of the plantar fascia from the calcaneal tubercle
Plantar fasciitis
bull LOCATING FOREIGN BODIES AND FRACTURES
As in any other location the ankle
area is also subsidiary host foreign
whose classification location and
existence can be defined perfectly by
ultrasound Being a focused study to
the area of interest and with great
resolution for surface structures can
be considered more resolute
examination to screen these cases
Osseous diseases and fractures | Sonography discovered Medial Malleolus Fracture
Ultrasound examination of left ankle A Longitudinal sonogram left ankle demonstrates a wooden foreign body B Transverse view left ankle Note the hypervascularity in the inflamed area C Corresponding X-ray of left ankle Note the swelling on the lateral aspect No foreign body is visible
Thank You
Arthritis and tenosynovitis of the ankle in a patient with rheumatoid arthritis
bullTUMOURSUltrasound can differentiate between a mass complex
and solid and a cystic in addition to verifying the
existence of accessory muscles (peroneus fourth
accessory flexor digitorum longus and accessory
soleus) As in any other location can be found
neoformative soft tissue tumors inflammatory
infectious etc
Ganglions of this location are more often symptomatic
and larger with multiple partitions
branched and lobed edges Differential diagnosis must
be made with tenosynovitis abscesses seromas and
varicosities
Neurogenic tumours are described as pathognomonic
homogeneous hypoechoic oval mass in continuity with
a nerve of origin
Ganglion cysts are non-malignant cystic masses that occur in association with musculoskeletal structures They are sometimes also simply referred to as ganglia or a ganglion but should not be confused with the anatomical term ganglion UltrasoundThe vast majority are anechoic to hypoechoic on ultrasound and have well defined margins Many demonstrate internal septations as well as acoustic enhancement A synovial cyst is a small fluid-filled sac or pouch that can develop over a tendon or joint creating a mass under the skin Synovial cyst is rare in ankle joint A synovial cyst may or may not be painful depending on their size and location
Ganglion cyst in the foot with bony erosion between navicular and cuneiform bones
Tarsal synovial cyst
Anechoic ganglion situated in the sinus tarsi fat between the talus and calcaneous
Plantar fasciitis (PF) refers to inflammation of the
plantar fascia of the foot It is considered the most common cause of heel pain
Clinical presentation Pain on the undersurface of the heel on weight bearing is the principal complaint It can be worse when weight is borne after a period of rest (eg in the morning) and eases with walking Passive dorsiflexion of the toes may exacerbates discomfort
UltrasoundOften the initial imaging modality of choice Ultrasound typically shows increased thickness of the fascia and a hypoechoic fascia
Thickened hypoechoic origin of the plantar fascia which has a convex superior margin
Complete avulsion of the plantar fascia from the calcaneal tubercle
Plantar fasciitis
bull LOCATING FOREIGN BODIES AND FRACTURES
As in any other location the ankle
area is also subsidiary host foreign
whose classification location and
existence can be defined perfectly by
ultrasound Being a focused study to
the area of interest and with great
resolution for surface structures can
be considered more resolute
examination to screen these cases
Osseous diseases and fractures | Sonography discovered Medial Malleolus Fracture
Ultrasound examination of left ankle A Longitudinal sonogram left ankle demonstrates a wooden foreign body B Transverse view left ankle Note the hypervascularity in the inflamed area C Corresponding X-ray of left ankle Note the swelling on the lateral aspect No foreign body is visible
Thank You
bullTUMOURSUltrasound can differentiate between a mass complex
and solid and a cystic in addition to verifying the
existence of accessory muscles (peroneus fourth
accessory flexor digitorum longus and accessory
soleus) As in any other location can be found
neoformative soft tissue tumors inflammatory
infectious etc
Ganglions of this location are more often symptomatic
and larger with multiple partitions
branched and lobed edges Differential diagnosis must
be made with tenosynovitis abscesses seromas and
varicosities
Neurogenic tumours are described as pathognomonic
homogeneous hypoechoic oval mass in continuity with
a nerve of origin
Ganglion cysts are non-malignant cystic masses that occur in association with musculoskeletal structures They are sometimes also simply referred to as ganglia or a ganglion but should not be confused with the anatomical term ganglion UltrasoundThe vast majority are anechoic to hypoechoic on ultrasound and have well defined margins Many demonstrate internal septations as well as acoustic enhancement A synovial cyst is a small fluid-filled sac or pouch that can develop over a tendon or joint creating a mass under the skin Synovial cyst is rare in ankle joint A synovial cyst may or may not be painful depending on their size and location
Ganglion cyst in the foot with bony erosion between navicular and cuneiform bones
Tarsal synovial cyst
Anechoic ganglion situated in the sinus tarsi fat between the talus and calcaneous
Plantar fasciitis (PF) refers to inflammation of the
plantar fascia of the foot It is considered the most common cause of heel pain
Clinical presentation Pain on the undersurface of the heel on weight bearing is the principal complaint It can be worse when weight is borne after a period of rest (eg in the morning) and eases with walking Passive dorsiflexion of the toes may exacerbates discomfort
UltrasoundOften the initial imaging modality of choice Ultrasound typically shows increased thickness of the fascia and a hypoechoic fascia
Thickened hypoechoic origin of the plantar fascia which has a convex superior margin
Complete avulsion of the plantar fascia from the calcaneal tubercle
Plantar fasciitis
bull LOCATING FOREIGN BODIES AND FRACTURES
As in any other location the ankle
area is also subsidiary host foreign
whose classification location and
existence can be defined perfectly by
ultrasound Being a focused study to
the area of interest and with great
resolution for surface structures can
be considered more resolute
examination to screen these cases
Osseous diseases and fractures | Sonography discovered Medial Malleolus Fracture
Ultrasound examination of left ankle A Longitudinal sonogram left ankle demonstrates a wooden foreign body B Transverse view left ankle Note the hypervascularity in the inflamed area C Corresponding X-ray of left ankle Note the swelling on the lateral aspect No foreign body is visible
Thank You
Ganglion cysts are non-malignant cystic masses that occur in association with musculoskeletal structures They are sometimes also simply referred to as ganglia or a ganglion but should not be confused with the anatomical term ganglion UltrasoundThe vast majority are anechoic to hypoechoic on ultrasound and have well defined margins Many demonstrate internal septations as well as acoustic enhancement A synovial cyst is a small fluid-filled sac or pouch that can develop over a tendon or joint creating a mass under the skin Synovial cyst is rare in ankle joint A synovial cyst may or may not be painful depending on their size and location
Ganglion cyst in the foot with bony erosion between navicular and cuneiform bones
Tarsal synovial cyst
Anechoic ganglion situated in the sinus tarsi fat between the talus and calcaneous
Plantar fasciitis (PF) refers to inflammation of the
plantar fascia of the foot It is considered the most common cause of heel pain
Clinical presentation Pain on the undersurface of the heel on weight bearing is the principal complaint It can be worse when weight is borne after a period of rest (eg in the morning) and eases with walking Passive dorsiflexion of the toes may exacerbates discomfort
UltrasoundOften the initial imaging modality of choice Ultrasound typically shows increased thickness of the fascia and a hypoechoic fascia
Thickened hypoechoic origin of the plantar fascia which has a convex superior margin
Complete avulsion of the plantar fascia from the calcaneal tubercle
Plantar fasciitis
bull LOCATING FOREIGN BODIES AND FRACTURES
As in any other location the ankle
area is also subsidiary host foreign
whose classification location and
existence can be defined perfectly by
ultrasound Being a focused study to
the area of interest and with great
resolution for surface structures can
be considered more resolute
examination to screen these cases
Osseous diseases and fractures | Sonography discovered Medial Malleolus Fracture
Ultrasound examination of left ankle A Longitudinal sonogram left ankle demonstrates a wooden foreign body B Transverse view left ankle Note the hypervascularity in the inflamed area C Corresponding X-ray of left ankle Note the swelling on the lateral aspect No foreign body is visible
Thank You
Ganglion cyst in the foot with bony erosion between navicular and cuneiform bones
Tarsal synovial cyst
Anechoic ganglion situated in the sinus tarsi fat between the talus and calcaneous
Plantar fasciitis (PF) refers to inflammation of the
plantar fascia of the foot It is considered the most common cause of heel pain
Clinical presentation Pain on the undersurface of the heel on weight bearing is the principal complaint It can be worse when weight is borne after a period of rest (eg in the morning) and eases with walking Passive dorsiflexion of the toes may exacerbates discomfort
UltrasoundOften the initial imaging modality of choice Ultrasound typically shows increased thickness of the fascia and a hypoechoic fascia
Thickened hypoechoic origin of the plantar fascia which has a convex superior margin
Complete avulsion of the plantar fascia from the calcaneal tubercle
Plantar fasciitis
bull LOCATING FOREIGN BODIES AND FRACTURES
As in any other location the ankle
area is also subsidiary host foreign
whose classification location and
existence can be defined perfectly by
ultrasound Being a focused study to
the area of interest and with great
resolution for surface structures can
be considered more resolute
examination to screen these cases
Osseous diseases and fractures | Sonography discovered Medial Malleolus Fracture
Ultrasound examination of left ankle A Longitudinal sonogram left ankle demonstrates a wooden foreign body B Transverse view left ankle Note the hypervascularity in the inflamed area C Corresponding X-ray of left ankle Note the swelling on the lateral aspect No foreign body is visible
Thank You
Tarsal synovial cyst
Anechoic ganglion situated in the sinus tarsi fat between the talus and calcaneous
Plantar fasciitis (PF) refers to inflammation of the
plantar fascia of the foot It is considered the most common cause of heel pain
Clinical presentation Pain on the undersurface of the heel on weight bearing is the principal complaint It can be worse when weight is borne after a period of rest (eg in the morning) and eases with walking Passive dorsiflexion of the toes may exacerbates discomfort
UltrasoundOften the initial imaging modality of choice Ultrasound typically shows increased thickness of the fascia and a hypoechoic fascia
Thickened hypoechoic origin of the plantar fascia which has a convex superior margin
Complete avulsion of the plantar fascia from the calcaneal tubercle
Plantar fasciitis
bull LOCATING FOREIGN BODIES AND FRACTURES
As in any other location the ankle
area is also subsidiary host foreign
whose classification location and
existence can be defined perfectly by
ultrasound Being a focused study to
the area of interest and with great
resolution for surface structures can
be considered more resolute
examination to screen these cases
Osseous diseases and fractures | Sonography discovered Medial Malleolus Fracture
Ultrasound examination of left ankle A Longitudinal sonogram left ankle demonstrates a wooden foreign body B Transverse view left ankle Note the hypervascularity in the inflamed area C Corresponding X-ray of left ankle Note the swelling on the lateral aspect No foreign body is visible
Thank You
Anechoic ganglion situated in the sinus tarsi fat between the talus and calcaneous
Plantar fasciitis (PF) refers to inflammation of the
plantar fascia of the foot It is considered the most common cause of heel pain
Clinical presentation Pain on the undersurface of the heel on weight bearing is the principal complaint It can be worse when weight is borne after a period of rest (eg in the morning) and eases with walking Passive dorsiflexion of the toes may exacerbates discomfort
UltrasoundOften the initial imaging modality of choice Ultrasound typically shows increased thickness of the fascia and a hypoechoic fascia
Thickened hypoechoic origin of the plantar fascia which has a convex superior margin
Complete avulsion of the plantar fascia from the calcaneal tubercle
Plantar fasciitis
bull LOCATING FOREIGN BODIES AND FRACTURES
As in any other location the ankle
area is also subsidiary host foreign
whose classification location and
existence can be defined perfectly by
ultrasound Being a focused study to
the area of interest and with great
resolution for surface structures can
be considered more resolute
examination to screen these cases
Osseous diseases and fractures | Sonography discovered Medial Malleolus Fracture
Ultrasound examination of left ankle A Longitudinal sonogram left ankle demonstrates a wooden foreign body B Transverse view left ankle Note the hypervascularity in the inflamed area C Corresponding X-ray of left ankle Note the swelling on the lateral aspect No foreign body is visible
Thank You
Plantar fasciitis (PF) refers to inflammation of the
plantar fascia of the foot It is considered the most common cause of heel pain
Clinical presentation Pain on the undersurface of the heel on weight bearing is the principal complaint It can be worse when weight is borne after a period of rest (eg in the morning) and eases with walking Passive dorsiflexion of the toes may exacerbates discomfort
UltrasoundOften the initial imaging modality of choice Ultrasound typically shows increased thickness of the fascia and a hypoechoic fascia
Thickened hypoechoic origin of the plantar fascia which has a convex superior margin
Complete avulsion of the plantar fascia from the calcaneal tubercle
Plantar fasciitis
bull LOCATING FOREIGN BODIES AND FRACTURES
As in any other location the ankle
area is also subsidiary host foreign
whose classification location and
existence can be defined perfectly by
ultrasound Being a focused study to
the area of interest and with great
resolution for surface structures can
be considered more resolute
examination to screen these cases
Osseous diseases and fractures | Sonography discovered Medial Malleolus Fracture
Ultrasound examination of left ankle A Longitudinal sonogram left ankle demonstrates a wooden foreign body B Transverse view left ankle Note the hypervascularity in the inflamed area C Corresponding X-ray of left ankle Note the swelling on the lateral aspect No foreign body is visible
Thank You
Thickened hypoechoic origin of the plantar fascia which has a convex superior margin
Complete avulsion of the plantar fascia from the calcaneal tubercle
Plantar fasciitis
bull LOCATING FOREIGN BODIES AND FRACTURES
As in any other location the ankle
area is also subsidiary host foreign
whose classification location and
existence can be defined perfectly by
ultrasound Being a focused study to
the area of interest and with great
resolution for surface structures can
be considered more resolute
examination to screen these cases
Osseous diseases and fractures | Sonography discovered Medial Malleolus Fracture
Ultrasound examination of left ankle A Longitudinal sonogram left ankle demonstrates a wooden foreign body B Transverse view left ankle Note the hypervascularity in the inflamed area C Corresponding X-ray of left ankle Note the swelling on the lateral aspect No foreign body is visible
Thank You
Complete avulsion of the plantar fascia from the calcaneal tubercle
Plantar fasciitis
bull LOCATING FOREIGN BODIES AND FRACTURES
As in any other location the ankle
area is also subsidiary host foreign
whose classification location and
existence can be defined perfectly by
ultrasound Being a focused study to
the area of interest and with great
resolution for surface structures can
be considered more resolute
examination to screen these cases
Osseous diseases and fractures | Sonography discovered Medial Malleolus Fracture
Ultrasound examination of left ankle A Longitudinal sonogram left ankle demonstrates a wooden foreign body B Transverse view left ankle Note the hypervascularity in the inflamed area C Corresponding X-ray of left ankle Note the swelling on the lateral aspect No foreign body is visible
Thank You
Plantar fasciitis
bull LOCATING FOREIGN BODIES AND FRACTURES
As in any other location the ankle
area is also subsidiary host foreign
whose classification location and
existence can be defined perfectly by
ultrasound Being a focused study to
the area of interest and with great
resolution for surface structures can
be considered more resolute
examination to screen these cases
Osseous diseases and fractures | Sonography discovered Medial Malleolus Fracture
Ultrasound examination of left ankle A Longitudinal sonogram left ankle demonstrates a wooden foreign body B Transverse view left ankle Note the hypervascularity in the inflamed area C Corresponding X-ray of left ankle Note the swelling on the lateral aspect No foreign body is visible
Thank You
bull LOCATING FOREIGN BODIES AND FRACTURES
As in any other location the ankle
area is also subsidiary host foreign
whose classification location and
existence can be defined perfectly by
ultrasound Being a focused study to
the area of interest and with great
resolution for surface structures can
be considered more resolute
examination to screen these cases
Osseous diseases and fractures | Sonography discovered Medial Malleolus Fracture
Ultrasound examination of left ankle A Longitudinal sonogram left ankle demonstrates a wooden foreign body B Transverse view left ankle Note the hypervascularity in the inflamed area C Corresponding X-ray of left ankle Note the swelling on the lateral aspect No foreign body is visible
Thank You
Osseous diseases and fractures | Sonography discovered Medial Malleolus Fracture
Ultrasound examination of left ankle A Longitudinal sonogram left ankle demonstrates a wooden foreign body B Transverse view left ankle Note the hypervascularity in the inflamed area C Corresponding X-ray of left ankle Note the swelling on the lateral aspect No foreign body is visible
Thank You
Ultrasound examination of left ankle A Longitudinal sonogram left ankle demonstrates a wooden foreign body B Transverse view left ankle Note the hypervascularity in the inflamed area C Corresponding X-ray of left ankle Note the swelling on the lateral aspect No foreign body is visible
Thank You
Thank You