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CHRONIC AND INTERVENTIONAL PAIN

REVIEW ARTICLE

Ultrasound-Guided Interventional Procedures
in Pain Medicine: A Review of Anatomy,
Sonoanatomy, and Procedures
Part VI: Ankle Joint
Neilesh Soneji, MD, FRCPC and Philip W. H. Peng, MBBS, FRCPC, Founder (Pain Medicine)
ANATOMY

Abstract: Ultrasound-guided injections in pain medicine are emerging as
a popular technique for pain interventions. Ultrasound can be applied for
procedures of the ankle joint and surrounding structures. This review describes the anatomy and sonoanatomy of the ankle joint, subtalar joint,
and surrounding extra-articular structures relevant for intra-articular injection. Second, it reviews injection techniques and the accuracy and efficacy
of these intra-articular ankle injections.
(Reg Anesth Pain Med 2016;41: 99–116)

F

oot and ankle pain is a common reason for presentation to primary care physicians. Studies suggest that ankle pain affects
approximately 15% of individuals older than 55 years.1 The foot
and ankle region is anatomically complex, and identification of
pain triggers can be clinically challenging.2,3 Pain may be related to various structures with multiple contributing etiologies
(Table 1). In this review, we narrow the scope to interventions of
the tibiotalar and subtalar joints.
The first objective of this review is to describe the anatomy and
sonoanatomy of ankle structures relevant to tibiotalar and subtalar
joint interventions. The second objective is to examine the role of
image-guided injections for those joints, specifically the accuracy
and efficacy of ultrasound (US)–guided injection techniques.

METHODS
A literature search of the MEDLINE database was performed
from January 1980 to December 2014 using the search terms
“ultrasound,” “ultrasound-guided,” “pain management,” and different ankle structures relevant to this review, such as “ankle,”
“ankle joint,” “tibiotalar joint,” “subtalar joint,” “ankle block,”
“tibial nerve,” “saphenous nerve,” “superficial peroneal nerve,”
“deep peroneal nerve,” and “sural nerve.” Only literature published in English was included.

From the Department of Anesthesia and Pain Management, University of
Toronto and University Health Network–Toronto Western Hospital, and Wasser
Pain Management Centre–Mount Sinai Hospital, Toronto, Ontario, Canada.
Accepted for publication September 24, 2015.
Address correspondence to Philip W. H. Peng, MBBS, FRCPC, Founder
(Pain Medicine), Toronto Western Hospital McL 2-405, Department of
Anesthesia and Pain Management, Toronto Western Hospital, University
Health Network, 399 Bathurst St, Toronto, Ontario, Canada M5T 2S8
(e‐mail: philip.peng@uhn.ca).
Equipment support was provided by Fujifilm Sonosite Canada. Internal funding
was received from the Department of Anesthesia and Pain Management,
University Health Network.
The authors declare no conflict of interest.
Copyright © 2015 by American Society of Regional Anesthesia and Pain
Medicine
ISSN: 1098-7339
DOI: 10.1097/AAP.0000000000000344

Articular Structures
The ankle is made up of 3 main articulations, which can be
evaluated with US: the tibiotalar joint (talocrural joint), the
subtalar joint (talocalcaneal joint), and the distal tibiofibular joint
(syndesmotic joint) (Fig. 1).
The tibiotalar joint is a hinged synovial joint formed by the
distal ends of the tibia and fibula with the talus. A fibrous joint
capsule covers the anterior and posterior recesses. The tibiotalar
joint allows approximately 30-degree dorsiflexion and 50-degree
plantar flexion of the foot,4 and ankle stability is primarily provided by the medial (MCL) and lateral collateral ligament
(LCL) complexes.
The LCL is composed of the 3 ligaments: the anterior
talofibular, calcaneofibular (CFL), and posterior talofibular ligaments (Fig. 2). The anterior talofibular ligament runs a horizontal
course connecting the lateral malleolus to the lateral aspect of the
talus. It primarily restricts internal rotation of the talus in the mortise and is taut in plantar flexion. It is more susceptible to inversion
injury compared with the other 2 ligaments of LCL. The CFL connects the lateral malleolus with the calcaneus and has a vertical
oblique angulation (Fig. 2). It is taut in the dorsiflexed position
and serves to prevent excessive dorsiflexion. The posterior
talofibular ligament is the deepest and strongest of the 3 ligaments
(Fig. 2). It has a horizontal direction and connects the posterior aspect of the lateral malleolus with the talus. It acts to prevent posterior talar shift.
The MCL, also known as the deltoid ligament, is a composition of ligaments with superficial and deep layers (Table 2, Fig. 3).
The main biomechanical function of the MCL is medial ankle stability, primarily preventing abduction and lateral translation. The
MCL originates on the medial malleolus and inserts onto the navicular, calcaneum, and talus.5 The most common description of
the MCL describes 6 components, 3 of which are always present
including the superficial tibiospring and superficial tibionavicular
ligaments, as well as the deep posterior tibiotalar ligament.6 The
presence of the additional 3 ligaments is variable and includes
the superficial posterior tibiotalar and superficial tibiocalcaneal
ligaments, as well as the deep anterior tibiotalar ligament.
The subtalar joint allows for combined range of motion, which
includes plantar flexion-inversion-adduction and dorsiflexioneversion-abduction. It is divided into 2 components, the anterior
and posterior parts, which function interdependently (Fig. 1).
The posterior subtalar joint (posterior talocalcaneal joint) is
formed by the posterior facet of the inferior aspect of the talus
and the associated posterior facet of the calcaneus. The posterior
subtalar joint is supported structurally by the anterior, medial, lateral, and posterior talocalcaneal ligaments. There is a communication between the posterior subtalar joint and the tibiotalar joint in
approximately 10% to 20% of people.7,8 The posterior subtalar
joint is separated from the anterior subtalar joint by the structures

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Soneji and Peng

TABLE 1. Causes of Chronic Ankle Pain
Structures
Articular

Bone

Tendon

Nerve

Ligament
Other

Examples
Osteoarthritis
Rheumatoid arthritis
Septic arthritis
Gout or pseudogout
Reactive arthritis
Osteochrondral lesions of the talus
Posterior ankle impingement
(os trigonum or Stieda process)
Occult fractures of hindfoot
Fracture (nonunion)
Posterior tibial tendon dysfunction
(adult-acquired flat-foot deformity)
Flexor halluces longus tendinitis
Achilles tendinitis or retrocalcaneal bursitis
Peroneal tendon pathology
Tarsal tunnel syndrome
DPN entrapment
Posttraumatic or postsurgical neuritis
Chronic lateral instability
Chronic medial instability
Sinus tarsi syndrome
Anterior ankle impingement (osseous or ligament)
Malignancy

housed in the sinus tarsi (Fig. 1). The anterior subtalar joint
(talocalcaneonavicular joint) facilitates inversion and eversion of
the hindfoot.
The inferior tibiofibular joint is the distal-most articulation
between the tibia and fibula and is formed by an upward projection of the ankle joint synovial recess. The inferior tibiofibular joint is supported by the anterior, posterior, and transverse
tibiofibular ligaments as well as the interosseous tibiofibular
ligament, which is a continuation of the interosseous membrane (Fig. 2).

Extra-Articular Structures
The extra-articular structures of the ankle can be divided into
anterior, medial, lateral, and posterior compartments.

Anterior Compartment Extra-Articular Structures
The structures of interest in the anterior compartment include
the tibialis anterior (TA) tendon, the extensor hallucis longus
(EHL) tendon, the extensor digitorum longus (EDL) tendon,
and anterior tibial artery, as well as the superficial (SPN) and
deep peroneal nerves (DPN) (Fig. 4).
The details of the anterior compartment muscles are summarized in Table 3. The TA tendon is the most medial and prominent
tendon on the dorsum of the ankle (Fig. 4). The EHL tendon lies
lateral to the TA tendon at the level of the ankle and is palpable at
this location on dorsiflexion of the great toe. The EDL tendon lies
lateral to the EHL tendon, passes beneath the extensor retinaculum, and splits into 4 slips, which insert onto the 4 toes.
The SPN and DPN are branches of the common peroneal
nerve, which is a branch of the sciatic nerve. In the middle third
of the leg, the SPN typically emerges in the lateral (peroneal) compartment between the peroneus brevis (PB)/longus (PL) muscles
and anterior crural intermuscular septum, which separates the
PB/PL and EDL muscles. The SPN is often in contact with the deep
surface of this crural fascia (Figs. 4, 5).9–12 However, the SPN
can be found either in the anterior compartment or in separate
branches in both anterior and lateral compartment in up to
one-third of patients (Fig. 5).11,13 In the lower leg, the SPN is
purely sensory and divides into the medial and intermediate
dorsal cutaneous nerves.14,15 Collectively, the branches of the
SPN provide sensation to the dorsum of the foot aside from the
webspace between the first and second digits, which is innervated
by the DPN.
The DPN crosses the ankle joint deep to the extensor retinaculum adjacent to the anterior tibial artery. At the distal
end of tibia, the DPN lies between the EHL and EDL tendons
lateral to the anterior tibial artery (Fig. 4).16 After providing a
branch to the ankle joint, the DPN terminates to provide sensation to the webspace between the first and second digits and a
motor branch to extensor digitorum brevis muscle.17

Medial Compartment Extra-Articular Structures
The important structures in the medial compartment include
the saphenous nerve (SaN) and the contents of the tarsal tunnel.
The SaN is the longest branch of the femoral nerve and is the only
nerve that innervates the foot and ankle other than the sciatic
nerve. In the distal lower extremity, the SaN runs posterior to the
medial aspect of the tibia adjacent to the greater saphenous vein
(Fig. 6). Approximately 3 cm above the medial malleolus, the
SaN divides into anterior and posterior branches in relation to
the greater saphenous vein.18 The terminal branches provide

FIGURE 1. Ankle joint anatomy. A, Anterior view. B, Lateral view. C, Medial view. Reproduced with permission from Philip Peng
Educational Series.

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Regional Anesthesia and Pain Medicine • Volume 41, Number 1, January-February 2016

Ultrasound Guidance for Ankle Injections

FIGURE 2. Lateral collateral ligament complex and ligaments for the lower tibiofibular joint. A, Lateral view. B, Posterior view. *Sinus tarsi.
Reproduced with permission from Philip Peng Educational Series.

sensation to skin around the medial malleolus and the medial
aspect of the foot. Recent anatomic studies have suggested that
the SaN also provides sensation to the periosteum of the medial
malleolus and the medial ankle joint capsule.19,20
The tarsal tunnel lies posterior to the medial malleolus and is
roofed by the flexor retinaculum (Fig. 7). Its contents from anterior to posterior include the tibialis posterior (TP) tendon, the
flexor digitorum longus tendon, the posterior tibial artery and
veins, tibial nerve (TN), and the flexor hallucis longus (FHL)
tendon (Fig. 7).
The TN is a branch of the sciatic nerve. At the level of the
ankle, the TN is usually identified posteromedial to the posterior tibial artery. The TN gives off a calcaneal nerve proximal
to the medial malleolus and then continues to split into 2 terminal
branches: the medial and lateral plantar nerves (Fig. 7). Collectively, the TN provides sensory innervation to the plantar aspect
of the foot and also supplies all of the intrinsic muscles of the foot
with the exception of extensor digitorum brevis (by DPN).

Lateral Compartment Extra-Articular Structures
The structures of interest in the lateral compartment of the ankle
include the sural nerve (SuN) and the PB and PL tendons (Fig. 8).
The SuN is a purely sensory nerve that is formed by branches
from the TN (medial sural) and the common peroneal nerve (lateral sural). In the distal third of the leg, the SuN runs adjacent to
the lesser saphenous vein between the peroneus tendons and
Achilles tendon, providing sensation to the lateral aspect of the
distal leg, the lateral side of the foot, and the lateral border of the
fifth digit (Fig. 8).21 Distally, the SuN may anastomose with the distal branches of the SPN and can contribute innervation to the
dorsal aspect of the third and fourth toes.22
The PB and PL muscles are the 2 muscles/tendons in the lateral compartment of the leg (Fig. 8). The PB and PL tendons pass
immediately posterior to the lateral malleolus with the smaller PB
tendon in a more anterior position. The PB tendon inserts onto the
lateral aspect of the base of the fifth metatarsal. The PL tendon
continues distally to the lateral malleolus inferior to the PB and
courses along the plantar aspect of the foot obliquely to insert onto
the lateral aspect of the base of the first metatarsal and lateral surface of medial cuneiform. The peroneus muscles collectively evert
the foot and contribute to plantar flexion of the ankle joint.

Posterior Compartment Extra-Articular Structures
The extra-articular structures of interest in the posterior compartment of the ankle include the Achilles tendon, retrocalcaneal
bursa and Kager fat pad. The Achilles tendon is the largest and
strongest tendon in the body (Fig. 8). It is formed through fusion
of the gastrocnemius aponeurosis and the deeper soleus tendon
© 2015 American Society of Regional Anesthesia and Pain Medicine

and inserts onto the calcaneus. The distal Achilles tendon is separated from the calcaneus by the retrocalcaneal bursa.

SONOANATOMY
The ankle and surrounding structures are amenable to visualization using US. This review focuses on US-guided interventions
of the foot and ankle including tibiotalar and subtalar joint injections as well as perineural ankle nerve injections.

Sonoanatomy Tibiotalar Joint and Subtalar Joint
The tibiotalar and subtalar joints are reliably imaged with US.
A linear array transducer at frequencies of 6 to 15 MHz is usually
ideal for the examination of these structures. Higher frequencies
may be required to examine more superficial structures in detail.

Sonoanatomy Tibiotalar Joint
The anterior ankle joint is examined with the patient in the
supine or semirecumbent position and the knee flexed 90 degrees.
The foot is placed flat on the examination table such that plantar
flexion widens the tibiotalar joint space. The US is placed transverse to the tibia, just above the intermalleolar line. Structures visualized from medial to lateral include the TA tendon, EHL tendon,
anterior tibial artery, DPN, and EDL tendon (Fig. 9A). The tendons
appear round and fibrillar, whereas the artery is pulsatile and anechoic. The TA tendon is placed in the center of the screen, and
the probe is rotated 90 degrees. This allows visualization of the
tibiotalar joint and anterior fat pad (Fig. 9B). The anterior synovial
recess is visualized between the distal tibia and the talar dome.

Sonoanatomy Subtalar Joint
The posterior subtalar joint can be imaged using the anterolateral, posterolateral, and posteromedial approaches.

TABLE 2. Medial Collateral (Deltoid) Ligament Anatomy
Ligament Components
Superficial layer
Tibiospring
Tibionavicular
Superficial posterior tibiotalar
Tibiocalcaneal
Deep layer
Deep posterior tibiotalar ligament
Deep anterior tibiotalar ligament

Comments
Constant component
Constant component
Presence variable
Presence variable
Constant component, largest
band in deltoid
Presence variable

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Regional Anesthesia and Pain Medicine • Volume 41, Number 1, January-February 2016

FIGURE 3. Medial collateral (deltoid) ligament. A, Deep layer. B, Superficial layer. Reproduced with permission from Philip Peng
Educational Series.

For the anterolateral approach, the patient is placed in the
partial lateral decubitus position with the target leg in the nondependent position. The ankle is inverted to widen the subtalar joint.
The sinus tarsi is identified 1 finger-breadth anterior to the lateral
malleolus, and a linear probe is placed with the proximal aspect of
the probe just anterior to the lateral malleolus and the distal probe
oriented toward the calcaneus (Fig. 10A). The US probe is translated toward the lateral malleolus such that the final probe position
is just anterior and parallel to the CFL (Fig. 10B). The peroneal
tendons can be visualized just caudal to the subtalar joint in this
view. The SuN also runs caudal to the joint at this location but
may not be visualized with this probe position.
For the posterolateral approach to subtalar joint, the patient
is placed in the prone position with the foot overlying the examination table. The ankle is dorsiflexed and inverted to open the
subtalar joint. The probe is placed in long axis to the Achilles tendon with the distal end of the probe over the calcaneus. The probe
is translated just lateral to the Achilles tendon and angled medially
to identify the subtalar joint (Fig. 11).
For the posteromedial approach to subtalar joint, the patient
is placed in the lateral decubitus position with the affected leg in
the dependent position. The ankle is everted to allow access to

the medial aspect of the subtalar joint. The probe is placed in a coronal plane with the cephalad aspect of the probe over the medial
malleolus and the distal end of the probe over the sustentaculum
tali of the calcaneus (Fig. 12). It is imperative to be aware of the
associated structures of the tarsal tunnel at this location (Fig. 7).
The flexor digitorum longus tendon can be visualized in long axis
overlying the joint. The TP tendon typically is slightly anterior,
whereas the posterior tibial artery, TN, and FHL tendon are typically posterior at this level.

Sonoanatomy Ankle Nerves
The ankle nerves are relatively superficial structures well visualized with US. A linear array transducer at frequencies of 8 to
12 MHz is usually ideal for the examination of these structures.
Higher frequencies may be required to examine more superficial
structures in detail.

Superficial Peroneal Nerve
The SPN is visualized with the patient in the supine position
and the hip internally rotated in order to allow access to the anterolateral aspect of the lower extremity. The probe is placed in the

FIGURE 4. Anterior view of the ankle. Reproduced with permission from Philip Peng Educational Series.

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Ultrasound Guidance for Ankle Injections

TABLE 3. Anterior Ankle Compartment Muscles
Muscle

Main Function

Origin

Insertion
Medial surface medial cuneiform,
medial base 1st metatarsal
Distal phalynx great toe

TA

Ankle dorsiflexion, foot inversion

Superior condyle tibia and lateral tibia

EHL

Great toe extension, ankle dorsiflexion

EDL

Lateral four digit extension,
ankle dorsiflexion
Ankle dorsiflexion,
foot eversion

Anteromedial fibula and
interosseous membrane
Lateral condyle tibia, upper anterior
interosseous membrane
Inferior 3rd of anterior surface of fibula
and interosseus membrane

Peroneus tertius

transverse orientation to the fibula approximately 4 to 8 cm above
the lateral malleolus. The fibula is seen as a peaked structure,
whereas the tibia is flat (Fig. 13). The SPN is typically found in
contact with the deep surface of the crural fascia between the
PB/PL and EDL muscles.9–12,23 As the nerve travels distally, it
becomes more superficial and penetrates the crural fascia at a variable distance from the lateral malleolus and becomes a subcutaneous structure (Fig. 13). Studies have demonstrated the nerve
can also lie within the anterior compartment of the lower extremity
or within both the lateral and anterior compartments via branching
(Fig. 5).10,13 Thus, if the nerve is difficult to identify, consideration can be given to tracing more anteriorly or posteriorly.

Deep Peroneal Nerve
The DPN is visualized with the patient in the supine position.
The US probe is placed in transverse orientation to the tibia. The
hyperechoic nerve can be scanned above the intermalleolar line

Lateral 4 digits
Dorsum of base of 5th metatarsal

where it lies on the flat tibia adjacent to the pulsatile anterior tibial
artery (Fig. 9). Below the intermalleolar line, the DPN lies on the
surface of the talus, often just lateral to the dorsalis pedis artery.

Saphenous Nerve
In order to optimize scanning of the SaN, the patient is positioned so that the medial malleolus is accessible. This is accomplished with the patient in the supine position, hip externally
rotated, knee flexed 25 degrees with a pillow under the ankle to
be scanned. The US probe is placed in transverse position proximal
to the medial malleolus. The SaN commonly lies adjacent to the
greater saphenous vein in this location; however, this relationship
is not constant. The greater saphenous vein is compressible, appears
anechoic, and travels anterior to the medial malleolus at the level of
the intermalleolar line (Fig. 14). If the vein is not identified, a tourniquet can be applied to enhance engorgement. The SaN appears
hyperechoic and can be traced more proximally once identified.

FIGURE 5. Three variations of the location of SPN. Intermuscular septum is located between the anterior compartment and lateral
(peroneal) compartment. Reproduced with permission from Philip Peng Educational Series.
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Regional Anesthesia and Pain Medicine • Volume 41, Number 1, January-February 2016

FIGURE 6. Anteromedial view of the ankle. Reproduced with permission from Philip Peng Educational Series.

Tibial Nerve
The patient is positioned so that the medial malleolus is accessible similar to the SaN scanning position. The probe is placed
transverse to the tibia at the level of the medial malleolus such that
the anterior part of the probe is in contact with the medial
malleolus, and the posterior part of the probe is directed toward
the Achilles tendon. This allows visualization of all structures of
the tarsal tunnel (Fig. 15). The flexor retinaculum appears as a distinct layer (hypoechoic layer sandwiched between 2 hyperechoic
layers). The TN is a hyperechoic round structure that is often,
but not always, posterior to the posterior tibial artery, which is pulsatile.24 The TN is scanned proximal and distal to the medial
malleolus in short axis to attempt to identify the calcaneal, medial,
and lateral branches, which are not always visible (Fig. 7). The
FHL tendon can be differentiated from the TN with dynamic scanning by asking the patient to flex the great toe.

Sural Nerve
To scan the SuN, the patient is placed in the lateral decubitus
position to allow access to the lateral malleolus. The US probe is
placed in transverse orientation to the fibula with the anterior part

of the probe just cephalad to the lateral malleolus and the posterior part of the probe over the Achilles tendon. The SuN is a
hyperechoic round structure, which lies within a subcutaneous
fascial plane posterior to the peroneus tendon (Fig. 16). The
SuN consistently lies adjacent to the lesser saphenous vein, which
appears as an anechoic, compressible structure.21,25 A tourniquet
can be applied to enhance visualization of the lesser saphenous
vein. The probe can be translated cephalad and caudad to optimize
identification of the SuN.

INTERVENTION TO THE TIBIOTALAR AND
SUBTALAR JOINT
Patient Selection
Joint injections have historically played a role in the management of musculoskeletal somatic foot and ankle pain. Tibiotalar
and subtalar joint injections may be offered for either diagnostic
or therapeutic purposes. In view of the wide array of pain generators in the foot and ankle, targeted joint injections with local anesthetic help to discern the articular contribution and can facilitate
surgical planning including joint arthrodesis.2,26,27 Administration

FIGURE 7. Medial ankle. A, Medial view. B, Corresponding cross sectional view of ankle. Reproduced with permission from Philip
Peng Educational Series.

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Regional Anesthesia and Pain Medicine • Volume 41, Number 1, January-February 2016

Ultrasound Guidance for Ankle Injections

FIGURE 8. Lateral ankle. A, Lateral view. B, Corresponding cross sectional view of ankle. Reproduced with permission from
Philip Peng Educational Series.

of local anesthetic and steroid into the joint may be indicated for
therapeutic purposes in osteoarthritis, rheumatoid arthritis, posttraumatic arthritis. and ankle impingement.28

Tibiotalar Joint Injection: Accuracy
Historically, clinicians performed tibiotalar joint injections
using anatomic guidance. Confirmation of needle tip location in
these cases is either by aspiration of synovial fluid or fluoroscopic
confirmation. Techniques for anatomically guided tibiotalar joint
injection have been described previously. The accuracy of anatomically guided techniques have been examined and vary from 81%
to 100%29–31 in cadaver studies and 66% to 77% in clinical studies.32,33 Three recent studies have evaluated the accuracy of US
guidance for tibiotalar joint injection. All were cadaver studies
with reported US accuracies of 100%.30,31,34 Wisniewski et al30
directly compared anatomical versus US guidance for tibiotalar
joint injection and demonstrated the superior success rate of US
guidance technique (85% anatomical guidance vs 100% US
guidance). These studies suggest that US guidance is an accurate
modality for tibiotalar joint injection.

Tibiotalar Joint Injection: US-Guided
Injection Technique
The patient is placed in either a supine or semirecumbent
position with the knee 90 degrees flexed and the foot flat on the
examination table. A high-frequency linear US probe (6–15 MHz)
is used for this procedure. The target is the anterior joint recess

between the distal tibia and the talar dome. The first step is to
identify the TA tendon either by palpation or by US. The US
probe is placed over the long axis of the TA tendon and translated
slightly medially. For an out-of-plane technique, a 25-gauge, 1.5inch needle (larger size for hyaluronic acid injection) is inserted
into the joint (Figs. 17, 18) using hydrolocalization.35 The spread
of injectate is monitored throughout injection to ensure appropriate spread within the joint space instead of the fat pad. For an inplane technique, a 22-gauge, 3.5-inch needle is used and inserted
from the caudal to cephalad direction (Fig. 19) using hydrolocalization. The ankle joint volume is 15 to 30 mL.36 The volume
of injectate is 3 to 4 mL of local anesthetic and steroid such as
2% lidocaine and 40 mg methylprednisolone acetate.28,30,37

Subtalar Joint Injection: Accuracy
Similar to the ankle joint, subtalar joint injection has historically been performed using anatomic guidance. The techniques
for landmark and fluoroscopic guidance for subtalar joint injections have been reviewed previously.37 All validation studies for
the landmark-guided technique were performed in cadavers, and
accuracy rates have ranged from 68% to 100%.31,38,39 Kraus et al38
compared the anterolateral versus the posterolateral approach and
found that the posterolateral approach was more accurate than the
anterolateral approach (success rates of 91% posterolateral vs
68% anterolateral, P = 0.016). In another study in which the anterolateral approach was used, Kirk et al39 reported an accuracy
rate of 97%. However, he also noted extravasation outside the
subtalar joint in 27% of the injections (either within the ankle joint

FIGURE 9. Sonoanatomy of the anterior aspect of the ankle. A, Short-axis view. B, Long-axis view. *Fat pad. Reproduced with permission
from Philip Peng Educational Series.
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Regional Anesthesia and Pain Medicine • Volume 41, Number 1, January-February 2016

FIGURE 10. Sonoanatomy of the anterolateral approach to subtalar joint. A, The US probe is first placed over the sinus tarsi.
B, The probe is then tilted toward the lateral malleolus. The top left diagram shows the anatomy. The top right diagram shows the
position of the patient and US probe. *Peroneus tendons. Bold arrow points to the entrance to subtalar joint. Reproduced with permission
from Philip Peng Educational Series.

or the peroneal tendon sheath). Fluoroscopic guidance techniques
for subtalar joint injection have also been evaluated with accuracy
rates ranging from 85% to 100%.40,41 Spread to adjacent structures was also a concern in fluoroscopically guided injection.
In a study by Ruhoy et al,41 up to 30% of fluoroscopic-guided
posteromedial subtalar joint injections were associated with
spread to adjacent structures in the tarsal tunnel including the
TN and tendon sheaths.
Ultrasound has emerged as an alternative image-guided modality for subtalar joint injection. Cadaveric studies examining accuracy of US-guided subtalar joint injections have demonstrated

accuracy rates of 90% to 100%.34,42 Smith et al42 compared the
accuracy of US-guided subtalar joint injections using 3 different
approaches in a cadaveric model: anterolateral, posterolateral,
and posteromedial. All 3 approaches were associated with intraarticular medication placement rates of 100%. However, 19% of
injections overall were found to have injectate involving surrounding structures including the tibiotalar joint, peroneal sheath, FHL
sheath, and outside the posterior subtalar joint. Reach et al34 studied US-guided injection of feet in 10 cadaver specimens. This cadaveric study reported a 90% accuracy of injecting the subtalar
joint with sonographic guidance. The 1 missed injection in this

FIGURE 11. Sonoanatomy of the posterolateral approach to subtalar joint. The top left diagram shows the position of the patient and
US probe. The top right diagram shows the anatomy. Cal indicates calcaneus; Ta, talus. Bold arrow points to the entrance to subtalar joint.
Reproduced with permission from Philip Peng Educational Series.

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Regional Anesthesia and Pain Medicine • Volume 41, Number 1, January-February 2016

Ultrasound Guidance for Ankle Injections

FIGURE 12. Sonoanatomy of the posteromedial approach to subtalar joint. Top right diagram shows the patient position.
Bottom right diagram shows the anatomy and probe position. Bottom left sonogram shows the posterior tibial artery. M indicates medial m.
Single line arrow points to TP tendon; double line arrows, flexor digitorum longus tendon; bold arrow, entrance to subtalar joint.
Reproduced with permission from Philip Peng Educational Series.

FIGURE 13. Sonoanatomy of the SPN at different locations as shown in the left diagram SPN was indicated by the line arrow. A, SPN is deep
to the crural fascia (bold arrows). B, SPN is enclosed in the crural fascia. C, SPN is superficial to the crural fascia. **PB tendon. F indicates
fibula. Arrowheads point to the intermuscular septum. Reproduced with permission from Philip Peng Educational Series.
© 2015 American Society of Regional Anesthesia and Pain Medicine

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Soneji and Peng

Regional Anesthesia and Pain Medicine • Volume 41, Number 1, January-February 2016

FIGURE 14. Sonoanatomy of the saphenous nerve. The left diagram shows the anatomy and the position of the probe. SV indicates
saphenous vein. Line arrows point to SaN. Reproduced with permission from Philip Peng Educational Series.

study demonstrated dye primarily in sinus tarsi. However, this
study did not specify the approach of the injection or the experience of the person who performed the injection. A recent cadaveric study by Smith et al43 evaluated US-guided injection of the
subtalar joint via the sinus tarsi and found accuracy rates of
100%. The review of studies suggests that US guidance is an
acceptable modality for injection of the subtalar joint. Rates of
extravasation outside the joint are comparable for US, FL, and
anatomically guided subtalar joint injections.

Subtalar Joint Injection—US-Guided
Injection Technique
The subtalar joint can be injected using the anterolateral, posterolateral, or posteromedial techniques as outlined previously.
The authors prefer the anterolateral approach because of ease of

probe position as well as lack of proximity to neurovascular structures in the tarsal tunnel.
The patient is placed in the lateral decubitus position with
the affected leg in the nondependent position. A high-frequency
linear US probe (6–15 MHz) is used for this procedure. The target is the posterior subtalar joint between the talus and the calcaneus, posterior to the sinus tarsi. An out-of-plane technique is the
preferred approach.
The first step is to place the probe in long axis to the fibula
with the proximal aspect of the probe just anterior to the lateral
malleolus and the distal probe oriented toward the calcaneus
(Figs. 20, 21). A 1.5-inch, 25-gauge needle (larger size for
hyaluronic acid injection) is inserted out-of-plane into the joint
using hydrolocalization. The spread of injectate is monitored
throughout injection to ensure appropriate spread within the joint.
The volume of injectate is 3 to 4 mL of local anesthetic and steroid
such as 2% lidocaine and 40 mg methylprednisolone acetate.37,43

FIGURE 15. Sonoanatomy of the tarsal tunnel. The flexor retinaculum (bold arrows) classically appears as a 3-layer structure (hypoechoic layer
sandwiched between 2 hyperechoic layers). Note the neurovascular bundle typically “rests” on the fascial layer (line arrows) overlying the
FHL muscle and tendon (*). The TN can be differentiated from FHL tendon seen by extending and flexing the big toe. FDL indicates flexor
digitorum longus; A and V, posterior tibial artery and vein. Reproduced with permission from Philip Peng Educational Series.

108

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Regional Anesthesia and Pain Medicine • Volume 41, Number 1, January-February 2016

Ultrasound Guidance for Ankle Injections

FIGURE 16. Sonoanatomy of the SuN. Top left and right diagram show the anatomy and probe position. Line arrows point to SuN;
bold arrows, fascia enclosing the compartment where the SuN and lesser saphenous vein are located. v Indicates small saphenous vein;
P brevis, peroneus brevis. Reproduced with permission from Philip Peng Educational Series.

Tibiotalar and Subtalar Joint Injection: Efficacy
Diagnostic Role
Intra-articular injections are commonly performed for diagnostic purposes and to facilitate surgical decision making. Literature generally supports the correlation of a positive local

anesthetic intra-articular injection with a successful surgical outcome.44,45 Specific to foot and ankle injections, Khoury et al27 reported that intra-articular injection of local anesthetic in painful
foot and ankle joints helped to confirm source of pain in 20 of
22 patients, which in turn led to successful arthrodesis outcomes.
Another study showed that the result of diagnostic foot and ankle

FIGURE 17. Out-of-plane needle insertion to the tibiotalar joint. Sonogram shows the long-axis scan of the tibiotalar joint. Left diagram shows
the anatomy and probe position. Bold arrow points to the joint entrance; line arrows, needle. Reproduced with permission from Philip Peng
Educational Series.
© 2015 American Society of Regional Anesthesia and Pain Medicine

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Soneji and Peng

Regional Anesthesia and Pain Medicine • Volume 41, Number 1, January-February 2016

FIGURE 18. Lateral and posterolateral fluoroscopy of the ankle following US-guided injection of the tibiotalar joint. Contrast can be seen
retained in the tibiotalar joint. Reproduced with permission from Philip Peng Educational Series.

blocks could influence the surgeon's perception of the source of
pain and alter surgical decision making in 82% of patients.46
However, a recent well-designed study by Stegeman et al47 refuted the positive diagnostic value of intra-articular foot and
ankle injections. This study concluded that surgery, irrespective of presence of pain reduction with diagnostic block, was
the most important predictor for improvement of pain and foot
function scores. Despite this controversy, clinicians regularly
utilize diagnostic injections to clarify etiology of foot and ankle
pain and to support surgical decision making.

Therapeutic Role
The majority of publications on the therapeutic efficacy of
intra-articular corticosteroids are confined to the knee and hip regions, with very few studies examining the efficacy of injections
in the foot and ankle. A summary of studies assessing efficacy
of foot and ankle steroid injections can be found in Table 4. Only
1 study has been performed on the adult population (osteoarthritis

or rheumatic arthritis),48 and the other 3 were on the pediatric population (juvenile idiopathic arthritis [JIA]).40,49,50 Ward et al48 performed a study on adult patients receiving various fluoroscopic
guided joint injections in the foot and ankle. This study found significant improvement in Foot and Ankle Outcome Score (FAOS,
40%–65%) up to 6 months following corticosteroid injection. The
FAOS is a 42-item patient self-administered questionnaire validated
for the assessment of pain, function, and quality of life. While this
study concluded that intra-articular corticosteroid was associated
with improved foot and ankle scores, the duration of response
was varied, and patient factors affecting response were unclear.
Three other pediatric studies evaluated the role of subtalar
and tibiotalar injections with a specific focus on JIA or juvenile
chronic arthritis.40,49,50 The injections were all performed under
image guidance (fluoroscopy, n = 2; US, n = 1). All concluded a
positive response (Table 4). Outcome measurements varied in different studies. Remedios et al49 used subjective clinical improvement, and “remission” was reported in two-thirds of the patients
for at least 6 months. Cahill et al40 found improvement of foot

FIGURE 19. In-plane needle insertion to the tibiotalar joint. Sonogram shows the long-axis scan of the tibiotalar joint. Left diagram shows
the anatomy and probe position. Bold arrow-joint entrance. Reproduced with permission from Philip Peng Educational Series.

110

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Regional Anesthesia and Pain Medicine • Volume 41, Number 1, January-February 2016

Ultrasound Guidance for Ankle Injections

FIGURE 20. Out-of-plane needle insertion to the subtalar joint. Sonogram shows the anterolateral approach to the subtalar joint. Bottom right
diagram shows the anatomy and probe position. Line arrows point to the needle; bold arrows, joint entrance. Reproduced with permission
from Philip Peng Educational Series.

eversion/inversion in 89% of the patients with resolution of
symptoms in 44% of the patients for an average of 3.25 months.
Laurell et al50 measured the objective improvement with change
of mean synovial thickness (MST). The vast majority of patients
showed significant reduction of MST, and 72% showed absence
of active arthritis. No major complications were reported in any
of these studies. However, there has been a wide range of minor
adverse effects reported after steroid injection (ie, local
subcutaneous atrophy and hypopigmentation) ranging from less
than 2% to 53%.40,51
In summary, intra-articular corticosteroid injections are
widely utilized for foot and ankle arthritis. Several small studies
have reported short-term benefit of intra-articular foot and ankle
injections; however, there are limited good-quality studies that
have assessed their long-term efficacy.52 Larger randomized controlled trials are required to better evaluate efficacy and safety of
intra-articular foot and ankle steroid injections, particularly for
long-term outcomes in the adult population.

More recently, alternate injection options for tibiotalar and
subtalar joints have also been studied including viscosupplementation and platelet-rich plasma. A summary of studies evaluating
the efficacy of viscosupplementation for ankle joint injection
can be found in Tables 5 and 6. Five randomized controlled trials
and 6 prospective cohort studies have evaluated the efficacy of
viscosupplementation for ankle arthritis.
Three randomized double-blind controlled studies have compared viscosupplementation to saline.54,55,57 Studies by Cohen
et al55 and Salk et al57 both included a series of 5 injections separated by 7-day intervals. Cohen et al55 used fluoroscopic guidance
and demonstrated greater improvement in Ankle Osteoarthritis
Scale (AOS) in the hyaluronic acid group at the 3-month mark
compared with control (−17.4 ± 5 vs −5.1 ± 4; P = 0.0407). Ankle
Osteoarthritis Scale is a patient-administered questionnaire with
9-item pain subscale and 9-item disability subscale used to evaluate pain and disability related to ankle osteoarthritis. Salk et al57
used anatomic guidance and demonstrated improvement in both

FIGURE 21. Lateral and oblique fluoroscopy of ankle following the US-guided injection of the subtalar joint. Contrast can be seen retaining
in the subtalar joint. Reproduced with permission from Philip Peng Educational Series.
© 2015 American Society of Regional Anesthesia and Pain Medicine

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112

JCA/10

JIA/6.7

JIA/6.5

Remedios et al,49 1997/PC

Cahill et al,40 2007/RC

Laurell et al,50 2011/PC

30/US

38/F

9/F

18/F

85/TA

55/TA

13/TA

36/MP

No. Patients/Image
No.
Method
Injections/Injectate
Outcome

TT/ST 11; ST/TN 2; FAOS†
TT/TN 2; ST 2;
MT 1
TT 7 ST 6
Subjective clinical
improvement
ST
Improved foot
inversion/eversion;
clinical resolution‡
TT 31, ST 26
MST§; AAA§

Joints Injected

1

3.3

≤16

12

Follow-up, mo

Adverse Events

MST ↓ TT, 87%;
ST, 95%; AAA
(overall) 72%

SC atrophy 4.7%

Improve average
None
FAOS 40%–65%
≤6 mo after injection
Remission in 66.7%
None
≥6 mo
89% Patients improved Local SC atrophy or skin
for average 1.2 y; 44% ↓ pigmentation 53%

Effect

*Age provided either mean or median age as reported in original study.
†FAOS, a patient administered 42-item questionnaire on the pain, function and quality of life assessment; FU: follow up months.
‡Resolution was defined as normal range of motion without pain and limping 13 weeks after injection;
§The result showed the number of joints with either normalization of MST (≥80% decrease) or regression (20%–80% decrease).
AAA indicates absence of active arthritis; F, fluoroscopy; JIA or JCA, juvenile idiopathic or chronic arthritis; MP, methylprednisolone; MT, metatarsal; OA/RA, osteoarthritis/rheumatoid arthritis; PC, prospective cohort; RC, retrospective cohort; SC, subcutaneous; ST, subtalar; TA, triamcinolone; TN, talonavicular; TT, tibiotalar.

OA/RA/66

Cause/Age,* y

Ward et al, 2008/PC

48

Study/Study Type

TABLE 4. Efficacy of Intra-Articular Foot and Ankle Steroid Injections

Soneji and Peng
Regional Anesthesia and Pain Medicine • Volume 41, Number 1, January-February 2016

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© 2015 American Society of Regional Anesthesia and Pain Medicine

49.8

55.1

Cohen et al,55
2008

Karatosun et al,56
2008

N/17

N/30

F/30

F/64

N/75

Image Method/
No. Patients

Hyalgan 500–730 kd
vs saline

Adant 900 kd vs
exercise therapy

Hyalgan 500–730 kd
vs saline

Supartz 620–1170 kd
vs saline

Hyalgan 500–730 kd
+ PT 12 wk vs BoNT-A

Injectate

5/7 d

3/7 d

5/7 d

1

1

No.
Doses/Interval
Effect

AOS‡ total/6 mo Negative, no difference
between groups; change
AOS; HA 4.7 ± 1.0
→ 2.7 ± 1.0 BoNT-A
4.9 ± 1.5 → 2.6 ± 1.2
AMD between groups
(95% confidence interval);
−0.2 (−0.5 to 0.2), P = 0.39
AOFAS§/12 wk Negative—no difference
between groups; change
AOFAS; HA 4.97 ± 10.3
(1.6–8.3); saline 5.43 ± 16.3
(−1.6 to 12.4); between-group
difference; P = 0.897
AOS total/3 mo Positive change AOS;
HA: −17.4 ± 5.0; saline:
−5.1 ± 4.0 between-group
difference; P = 0.041
AOFAS/12 mo Negative—no difference
between groups; change
AOFAS HA: 61.6 (16.8)
→ 90.1 (9.7), P < 0.01,
ET: 72.1 (16.6),
87.5 (17.5), P < 0.01
AOS total/6 mo Negative—no difference
between groups; change
AOS; within-group
difference both groups;
F = 17.62, P < 0.01
between-group difference;
F =1.05, P = 0.3210

Outcome/
Follow-up

None

None

1 Patient ankle effusion,
pseudogout

1 Patient enlarged
inguinal lymph node

Transient swelling 5.9%

Adverse Events

2/−

2/+

4/−

5/+

2/−

Quality†/Allocation
Concealment

*Age: mean.
†Quality: Jadad scores for randomized controlled trial.
‡Patient-administered questionnaire with 9-item pain subscale and 9 item disability subscale.
§100-Point score combines subjective patient data on pain and mobility with objective data from the physical examination of the ankle and hindfoot.
AMD indicates adjusted mean difference; BoNT-A, botulinum toxin type A; ET, exercise therapy; F, fluoroscopic guidance; HA, hyaluronic acid; N, anatomic guidance; VAS, visual analog scale.

58.8 ± 14.4

54.1 ± 14.5

DeGroot et al,54
2012

Salk et al,57
2006

50.6 ± 10.3

Age,* y

Sun et al,53
2014

Study

TABLE 5. Efficacy of Viscosupplementation Ankle Joint Randomized Controlled Trials

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52% transient
pain/erythema <48 h
17 (30.9%) mild to moderate
local adverse effects
6.7% local adverse effects

1 (0.01%) local pain

None

AOFAS/6 mo
5/7 d
N/75
Sun et al,63 2006

50.2 ± 14.3

Artz 620–1170 kd

VAS pain/6 mo
1 or 2/1–3 mo
N/55
Witteveen et al,62 2008

41 ± 12.3

Synvisc 6000 kd

AOS pain/18 mo
3/7 d
N/21
Luciani et al,61 2008

45 ± 15.9

Synvisc 6000 kd

VAS pain/32 wk
5/7 d
N/16
Mei-Dan et al,60 2010

43

Adant 600–1200 kd

AOS total/6 mo
3/7 d
Hyalgan 500–730 kd
N/46
Sun et al,59 2011

51.7 ± 14.4

3/15 d
F/18
58

Hernandez et al, 2013

60

Synvisc 6000 kd

AOFAS/12 mo

Positive change AOFAS
61.8 ± 15.0 → 73.7 ± 16.6
Positive change AOS
5.5 ± 2.1 → 3.2 ± 1.9, P < 0.05
Positive change VAS pain
5.29 → 3.05, P < 0.001
Positive change AOS pain
44.5 ± 19.9 → 34.4 ± 20.8, P < 0.001
Positive change VAS pain
68 → 34.2, P < 0.001
Positive change AOFAS
64 ± 17 → 78 ± 14, P < 0.001

None

Adverse Events
Effect
Outcome/
Follow-up
No. Doses/
Interval
Injectate
Image Method/
No. Patients
Age, y
Study

TABLE 6. Efficacy of Viscosupplementation Ankle Joint Prospective Cohort Studies

114

Age: Mean.
Image Method: F – fluoroscopic guidance, N – anatomic guidance, Pts: Number of patients, Outcome: AOS – Ankle osteoarthritis scale score, patient administered questionnaire with 9 item pain subscale and 9
item disability subscale. AOFAS - American Orthopaedic Foot & Ankle Society clinical rating score, 100 point score combines subjective patient data on pain and mobility with objective data from the physical
examination of the ankle and hindfoot. VAS – Visual analog scale.

Regional Anesthesia and Pain Medicine • Volume 41, Number 1, January-February 2016

Soneji and Peng

the hyaluronic acid and saline control groups at 6 months. While
this study has been quoted as having a positive result in prior reviews, the primary outcome comparing AOS between groups
was negative. The study by DeGroot et al54 was anatomically
guided and used 1 injection only. This study demonstrated improvement in the American Orthopedic Foot and Ankle Society
(AOFAS) clinical rating score at 12 weeks; however, there was
no difference between groups at this time point. The AOFAS is
the American Orthopaedic Foot & Ankle Society clinical rating
score, a 100-point score that combines subjective patient data on
pain and mobility with objective data from the physical examination of the ankle and hindfoot. Two additional randomized controlled trials compared viscosupplementation with botulinum
toxin and/or exercise therapy.53,56 Neither of these studies demonstrated a difference between groups with both study arms demonstrating benefit at 6 and 12 months, respectively.
All 6 prospective cohort studies evaluating viscosupplementation for osteoarthritis have demonstrated therapeutic efficacy ranging from 6 to 18 months, with the majority of studies
including a series of 3 or more injections.58–63 A meta-analysis examining efficacy of viscosupplementation for ankle arthritis concluded that intra-articular hyaluronic acid can significantly reduce
pain in ankle osteoarthritis and is likely superior to reference therapy.64 Viscosupplementation for subtalar joint arthritis has been
evaluated in 1 pilot prospective cohort study, which demonstrated
analgesic benefit at 28 weeks (AOFAS scores: 54.5 at baseline,
73.7 at week 28; P < 0.01).65 No major adverse events were reported in any of the prospective studies, and minor local adverse
effects ranged widely from 0.01% to 51%.60,61
In summary, while viscosupplementation continues to be an
option for management of patients with ankle arthritis, studies
have reported conflicting results with regard to primary outcomes
of pain and disability. Larger randomized controlled trials using
image guidance for injection are required to better evaluate safety
and efficacy of this treatment modality. The efficacy of plateletrich plasma for foot and ankle pathology is beyond the scope of
this article.

CONCLUSIONS
The anatomical structures of the foot and ankle can be readily identified using US. Intra-articular injection of the tibiotalar
and subtalar joints can be reliably performed with image-guided
techniques including fluoroscopy and US. Anatomic guidance
alone for tibiotalar and subtalar joint injections is associated with
lower accuracy rates.
The evidence for efficacy of intra-articular steroid injection
for tibiotalar and subtalar joint arthritis is moderate, with studies
primarily demonstrating short-term benefit. Viscosupplementation for ankle arthritis continues to be a controversial treatment
modality. Further randomized controlled trials are required to
better evaluate the safety and efficacy of intra-articular foot and
ankle injections.
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