Techniques in Regional Anesthesia and Pain Management (2006) 10, 183-188

Ankle block
Daniel P. Monkowski, MD,a Héctor Roberto Egidi, MDb

From the aDivision of Regional Anesthesia, Postgraduate Course in Anesthesia, Buenos Aires University, UBA,
Buenos Aires, Argentina; and the
b
Buenos Aires Regional Anesthesia Group (GARBA)

KEYWORDS: Ankle block is a very useful regional anesthetic technique for foot surgery especially in the ambulatory
Ankle block; setting. Adequate tourniquet management allows performance of most surgeries over the fore- and
Midtarsal; midfoot. Additionally, ankle block provides excellent postoperative analgesia, which is very important,
Foot surgery; because foot surgeries often involve several osteotomies which develop moderate to severe postoper-
Tourniquet ative pain that is difficult to manage with standard oral analgesic regimens.
management; © 2006 Elsevier Inc. All rights reserved.
Postoperative
analgesia

Ankle block is an ideal regional anesthetic technique for
foot surgery, especially in the ambulatory setting. It was
first described by Labat in 19671 and then recommended in
textbooks by Dripp, Eckenhoff, and Vandam2 in 1977 and
Cousins and Bridenbaugh3 in 1980.
Foot innervation
The foot is innervated by five nerves: four of them are
terminal branches of the sciatic nerve and the other one of
the femoral nerve (Table 1; Figure 1).
Posterior tibial nerve
It is one of the two terminal branches of the tibial
nerve. It originates in the leg, at the level of the ring of
the soleus muscle. It descends along the posterior aspect
of the leg, slightly oblique and medially in conjunction
with the posterior tibial artery and vein. At the level of
the ankle, it is located under the deep fascia, and then it
projects posterior and lies between the posterior tibialis
and common flexor tendons (anterior) and the flexor
hallucis tendon (posterior). The posterior tibial artery,
and its two satellite veins, passes exactly above the nerve.
At the level of the medial malleolus (or occasionally,
Address reprint requests and correspondence: Daniel P. Monkowski,
MD, O’Higgins 3715 3° A, Buenos Aires, Argentina 1429.
E-mail address: damonk@fibertel.com.ar.
1084-208X/$ -see front matter © 2006 Elsevier Inc. All rights reserved.
doi:10.1053/j.trap.2006.10.008
before), it is divided into two terminal branches: the
medial and lateral plantar nerves, besides the calcaneal
nerve (collateral branch of the same nerve).
This nerve provides innervation to the deep structures
(bones, muscles, and joints) of the plantar aspect of the
foot and, sensory innervation to the whole sole of the
foot.4
Deep peroneal nerve
It is the medial branch of the common peroneal nerve. It
courses through the lower extremity, down the anterior
aspect of the interosseous membrane. Above the ankle joint,
it lies deep between the anterior tibialis and extensor hal-
lucis longus tendon. At the joint level, it passes below the
tendon of the hallucis longus, and lies between the lateral
border of the tendon and the medial border of the extensor
digitorum longus tendon, usually anterior to the dorsal pedis
artery.5
This nerve innervates the deep structures (bones, mus-
cles, and joints) of the dorsal aspect of the foot and it gives
sensory innervation to the lateral border of the first toe and
the medial border of the second one.
Superficial peroneal nerve
It is the lateral branch of the common peroneal nerve. At
the level of the union of the mid with the inferior third of the
anterior aspect of the leg, the nerve crosses the fascia and
becomes subcutaneous. Above the medial malleolus, it di-
184 Techniques in Regional Anesthesia and Pain Management, Vol 10, No 4, October 2006

Table 1 The terminal branches of the sciatic and femoral

nerves in the foot
Nerve Terminal Branches
Sciatic Posterior tibial nerve (4)
Deep peroneal nerve (3)
Superficial peroneal nerve (1)
Sural nerve (5)
Femoral Saphenous nerve (2)

vides in its terminal branches, which give sensory innerva-

tion to the dorsum of the feet and toes.

Figure 2 Anatomical and functional division of the foot.

Sural nerve

It is a sensory nerve formed by branches of the tibial and

common peroneal nerve. It becomes subcutaneous just dis-
tal to the midlower leg, and provides sensory innervation to
the lateral aspect of the ankle and the foot. It goes down,
along the lateral border of the Achilles tendon. At the level
of the ankle joint, the nerve passes behind and then below
the lateral malleolus.4
Saphenous nerve
Foot
It is divided into three sectors (Figure 2):
● Forefoot: constituted of the phalanges and metatarsals.
● Midfoot: constituted of the cuneiforms, cuboid, and na-
vicular bones.
● Hindfoot: constituted of the calcaneous and talus bones.

It is the terminal branch of the femoral nerve. It becomes Indications

subcutaneous in the medial face of the knee. From there, it
continues parallel to the internal saphenous vein, along the 1) All forefoot and midfoot surgeries.
medial face of the leg. Downwards, it passes before the 2) Hindfoot: infratalar surgeries.
medial malleolus. It finishes in the medial border of the foot. 3) Postoperative analgesia.
This nerve supplies sensory innervation to the medial
face of the leg, the ankle, and the foot.

Figure 1 Foot innervation. Numbers represent corresponding

nerves detailed in Table 1. Figure 3 Tibial nerve block.
Monkowski and Egidi Ankle Block
Figure 4 Deep peroneal nerve block.
Block techniques
Classic technique1 (Figure 3A and B)
Posterior tibial nerve. With the patient in the prone posi-
tion and the ankle supported by a pillow, a cutaneous wheal
of local anesthetic solution (LAS) is delivered at the supe-
rior border of the medial malleolus just anterior to the
185
Achilles tendon. At this point, between the tendon and the
posterior tibial pulse artery, a 23- to 25-G, 1-inch needle is
introduced, parallel to the sole of the foot, until the posterior
portion of the tibia is encountered or a paresthesia is
elicited.
Then, the needle in withdrawn 2 to 3 mm, and after
careful aspiration, 7 to 10 mL of LAS is injected. If possi-
ble, the block should be performed at the level of the pulse
186 Techniques in Regional Anesthesia and Pain Management, Vol 10, No 4, October 2006

needle is introduced perpendicular to the skin at a depth of

1 to 1.5 cm. At this point, 5 to 7 mL of LAS is delivered.
Eliciting paresthesia is not necessary, but if it appears, the
needle must be withdrawn 1 to 2 mm and the LAS injected.
If nerve-stimulation technique is used, the insulated needle
is advanced until a motor response (toes plantar flexion) to
0.5 mA intensity or less is obtained. Then the LAS is
injected.
If localizing the artery pulse is not possible, the index
and mid fingers of the operator may be placed just below the
posterior border of the medial malleolus while the patient is
asked to make dorsi and plantar flexion movements of the
toes. When contraction of the common flexor tendon is
recognized, the tip of the needle is placed behind it (poste-
rior), and the LAS is injected. At the same point, if nerve
stimulation is used, an insulated needle may be introduced
for obtaining a motor response and then proceed as previous
described.
The sensation of pressure under the finger which is
palpating the tibialis posterior pulse artery while the LAS is
being injected means that most of the local anesthetic drug
is delivered in the right place with little diffusion to the
surrounding tissues.5
Once the posterior tibial n. block is well established, the
sole foot becomes redder and warmer.6

Figure 5 Superficial peroneal nerve block.

artery. If nerve-stimulation technique is used, the insulated

needle is advanced until a motor response (toes plantar
flexion) to 0.5 mA intensity or less is obtained. Then the
LAS is injected.

Deep peroneal nerve (Figure 4A and B). With the patient in

the supine position. a 23- to 25-G, 1-inch needle is intro-
duced 3 to 4 cm above the superior border of the medial
malleolus, between the anterior border of the tibia and the
tibialis anterior tendon, perpendicular to the skin. The nee-
dle is advanced approximately 3 cm, and then 7 to 10 mL of
LAS is delivered.
If nerve-stimulation technique is used, the insulated nee-
dle is advanced until a motor response (toes dorsal flexion)
to 0.5 mA intensity or less is obtained. Then the LA is
injected. At the level of the ankle joint, the needle is intro-
duced perpendicularly between the tibialis anterior and ex-
tensor hallucis longus tendons.

Midtarsal technique5 (Sharrock)

Posterior tibial nerve. With the patient in the supine position

and the leg in slightly external rotation, the posterior tibial
pulse artery must be recognized behind the posterior border
of the medial malleolus. Just behind it, a 23- to 25-G, 1-inch Figure 6 Sural nerve block.
Monkowski and Egidi Ankle Block 187

Deep peroneal nerve (Figure 4). With the patient in the

supine position, the ankle is dorsiflexed, to identify the
extensor hallucis longus and extensor digitorum longus ten-
dons. The dorsal pedis artery is identified, too, and then, in
a point 3 to 4 cm caudal to the ankle joint, between both
tendons and preferably medial, or in both sides of the artery,
a 23- to 25-G, 1-inch needle is introduced perpendicular to
the skin and 3 mL of LAS is injected.5-7

Wasseff technique8,9

Posterior tibial nerve. It is a subcalcaneal approach, which

relies on palpation of the sustentaculum tali, a bone prom-
inence below the medial malleolus. At this point, the needle
is introduced for performing the nerve block. It is a useful
technique for patients with peripheral vascular disease
where arterial pulses are difficult to be palpable.
Among the different techniques previously described, we
consider that the midtarsal technique is the best choice
because:
1) The patient may lie in the supine position during the
whole block, in contrast with the classic technique.
2) The anatomical landmarks (posterior tibial artery, ten-
dons) are easier to be recognized.
3) Reaching the nerves is easier due to their superficial
location.
4) The local anesthetic solution volume needed is lower.
The three sensory nerves which supply the foot are
blocked at the ankle level forming an anesthetic ring around
it, independent from the technique selected for blocking the
posterior tibial and deep peroneal nerves.
Figure 7 Saphenous nerve block.

Superficial peroneal nerve (Figure 5)

With the patient in the supine position and the leg ex-
ternally rotated, 3.5 to 5 mL of local anesthetic solution are
subcutaneously infiltrated from the anterior border of the
tibia to the anterior border of the lateral malleolus. Occa-
sionally, with the foot in maximum adduction, it is possible
to observe the itinerary of the nerve.
Sural nerve (Figure 6)
With the patient in the supine position and the leg inter-
nally rotated, 3.5 to 5 mL of LAS is subcutaneously infil-
trated in a midpoint between the lateral malleolus and the
Achilles tendon.
ated by patients and it must not be inflated at a pressure over
200 mm Hg to avoid nerve damage.10
Local anesthetic solution
● Short procedures: lidocaine 1.5% to 2%; mepivacaine
1.5% to 2%.
● Long lasting procedures: bupivacaine to 0.375% to 0.5%;
ropivacaine to 0.5% to 0.75%.
● Postoperative analgesia: bupivacaine to 0.25%; ropiva-
caine to 0.2%.
● Epinephrine as an adjuvant is not recommended to be added
to local anesthetic solution in ankle block anesthesia.

Saphenous nerve (Figure 7)

With the patient in the supine position 3.5 to 5 mL of Onset time

local anesthetic solution are subcutaneously infiltrated, from
the anterior border of the tibia to the posterior border of the
medial malleolus, in the area of the saphenous vein.
Tourniquet management
To use ankle block for foot surgery as a sole technique,
the hemostatic tourniquet may be placed in the last third of
the leg, above the ankle malleolus. It is usually well toler-
Between 10 to 20 minutes, depending on the LAS selected.
Length of postoperative analgesia
The length of the postoperative analgesia depends on the
type, concentration, and the total volume of the local anes-
thetic drug selected.
188 Techniques in Regional Anesthesia and Pain Management, Vol 10, No 4, October 2006
Thus, McLeod and coworkers11 report 11.5 hours using
bupivacaine 0.5% 20 mL, Sarrafian and coworkers12 10 to
25 hours with bupivacaine 0.5% 22 mL, Mineo and cowork-
ers13 17 hours using bupivacaine 0.75% 30 mL for midtarsal
bilateral block, and Monkowski and coworkers14 12 hours
with bupivacaine 0.25% 15 mL.
Complications
● Hematoma
● Compression edema
● Postoperative neuropathy
● Tourniquet
● Direct traumatism needle
Pearls
● Foot surgery usually involves several ostheotomies. The
pain caused may be considered as moderate to severe, for
that reason it is difficult to be controlled only with regular
oral analgesics. Ankle block has shown its efficacy in
postoperative pain control after foot surgery, allowing
most of the procedures to be performed in the ambulatory
setting (hallux valgus, fractures, arthrodesis, etc).
Midtarsal techniques are preferable over classic tech-
niques
● The increase of the foot sole temperature and the change
of its color (red) are predictable signs of success of the
posterior tibial nerve block.
● The sensation of pressure under the finger which is pal-
pating the tibialis posterior pulse artery while the LAS is
being injected means that most of the local anesthetic
drug is delivered in the right place with little diffusion to
the surrounding tissues.
● The use of epinephrine as adjuvant in ankle block is not
recommended.
References
1. Adriani J: Labat’s Regional Anesthesia. Techniques and Clinical Ap-
plications (ed 3). Philadelphia, PA, W.B. Saunders, 1969, pp 321-324
2. Dripps RD, Eckenhoff JE, Vandam LD: Introduction to Anesthesia.
Longnecker DE, Murphy FL (eds): Philadelphia, PA, W.B. Saunders,
1977
3. Bridenbaugh PO: The lower extremity: somatic blockade, in Cousins
MJ, Bridenbaugh PO (eds): Neural Blockade in Clinical Anesthesia
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1988, pp 417-440
4. Hahn M, McQuillan P, Sheplock G: Regional Anesthesia. An Atlas of
Anatomy and Techniques. St. Louis, MO, Mosby, 1996
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forefoot. J Anaesth 58:37-40, 1986
6. Monkowski D, Egidi R: Ankle block. Rev Arg Anesth 62:513-517,
2004
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tomical review. Reg Anesth 24:7, 1999
8. Wassef MR: Posterior tibial nerve block. Anaesthesia 46:841-844,
1991
9. Bollini CA, Wikinski JA, et al: Bloqueo regional combinado para la
cirugía del pié. Rev Arg de Anest 55:154-162, 1988
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with subcutaneous infiltration for analgesia following foot surgery.
Can J Anaesth 8:673-676, 1994
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and fore foot surgery. Foot Ankle Int 4:86-90, 1983
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ambulatoria del pié. XXXIII Congreso Argentino de Anestesiología.
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