Common Ultrasound Guided

Injections of the Foot and Ankle

Jake Sellon, MD

AOCPMR MSK US Course

Jan 16, 2016

©2011 MFMER | slide-1

 Disclosure
Relevant Financial Relationship(s)
None

Off Label Usage

None

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Learning Objectives
• Describe common ultrasound guided
procedures in the foot and ankle

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Ankle (Talocrural) Joint
Anterolateral Approach
• Patient Position
• Side-lying facing physician with towel under
top ankle
• Transducer Position
• Overlying ATFL
• Needle Orientation to Transducer
• In-plane
• Needle Approach
• Distal to proximal, through ATFL
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Ankle (Talocrural) Joint
Anterolateral Approach

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Ankle (Talocrural) Joint
Anterolateral Approach
• Target
• Lateral ankle joint recess between hyaline
cartilage of talus and peri-articular fat

• Pitfalls
• Identify and avoid lateral malleolar artery

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Ankle (Talocrural) Joint
Anterolateral Approach

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Ankle (Talocrural) Joint
Anterior Approach
• Patient Position
• Supine with the foot plantarflexed
• Transducer Position
• Anatomic sagittal plane between AT/EHL
tendons
• Needle Orientation to Transducer
• In-plane
• Needle Approach
• Distal to proximal
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Ankle (Talocrural) Joint
Anterior Approach

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Ankle (Talocrural) Joint
Anterior Approach
• Target
• Anterior ankle joint recess between hyaline
cartilage of talar dome and peri-articular fat

• Pitfalls
• Identify and avoid deep peroneal nerve and
dorsalis pedis artery/veins

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Ankle (Talocrural) Joint
Anterior Approach

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Ankle (Talocrural) Joint
Anteromedial Approach
• Patient Position
• Supine with the knee flexed/foot flat
• Transducer Position
• Anatomic transverse plane over talar dome
• Needle Orientation to Transducer
• In-plane
• Needle Approach
• Medial to lateral, deep to ant tibialis tendon

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Ankle (Talocrural) Joint
Anteromedial Approach

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Ankle (Talocrural) Joint
Anteromedial Approach
• Target
• Ant ankle joint recess between hyaline
cartilage of talar dome and peri-articular fat

• Pitfalls
• Identify and avoid deep peroneal nerve and
dorsalis pedis artery/veins

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Ankle (Talocrural) Joint
Anteromedial Approach

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Subtalar Joint (Posterior Facet)
Anterolateral Approach
• Patient Position
• Side-lying with symptomatic side up
• Transducer Position
• Identify sinus tarsi with an anatomic transverse
plane over dorsolateral foot
• Slide posterior to anterior margin of STJ
posterior facet just anterior to lat malleolus
• Needle Orientation to Transducer
• Out-of-plane
• Needle Approach
• Anterior to posterior
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Subtalar Joint (Posterior Facet)
Anterolateral

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Subtalar Joint (Posterior Facet)
Anterolateral
• Target
• Subtalar joint using walk-down technique

• Pitfalls
• Identify and avoid sural nerve

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Subtalar Joint (Posterior Facet)
Anterolateral

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Peroneal Tendon Sheath
• Patient Position
• Side-lying with symptomatic side up
• Transducer Position
• Anatomic transverse plane over peroneal
tendons just proximal to lateral malleolus
• Needle Orientation to Transducer
• In-plane
• Needle Approach
• Anterior to posterior
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Peroneal Tendon Sheath

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Peroneal Tendon Sheath
• Target
• Peroneal tendon sheath between tendon
and fibula

• Pitfalls
• Avoid intratendinous cortisone injection

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Peroneal Tendon Sheath

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Posterior Tibialis Tendon Sheath
• Patient Position
• Side-lying with symptomatic side down
• Transducer Position
• Anatomic transverse plane over posterior
tibialis tendon at level of medial malleolus
• Needle Orientation to Transducer
• In-plane
• Needle Approach
• Anterior to posterior
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Posterior Tibialis Tendon Sheath

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Posterior Tibialis Tendon Sheath
• Target
• Posterior tibialis tendon sheath between
tendon and medial malleolus

• Pitfalls
• Avoid intratendinous cortisone injection
• Identify and avoid posterior tibial
neurovascular structures

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Posterior Tibialis Tendon Sheath

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Flexor Hallucis Longus Tendon Sheath
• Patient Position
• Prone with foot hanging over end of table
• Transducer Position
• Anatomic transverse plane over FHL
tendon at level of posterior process of talus
• Needle Orientation to Transducer
• In-plane
• Needle Approach
• Lateral to medial (deep to Achilles tendon)
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Flexor Hallucis Longus Tendon Sheath

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Flexor Hallucis Longus Tendon Sheath
• Target
• FHL tendon sheath between tendon and
talus

• Pitfalls
• Identify and avoid sural and posterior tibial
neurovascular structures
• Avoid intratendinous cortisone injection
• Be aware of tibiotalar joint communication

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Flexor Hallucis Longus Tendon Sheath

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Achilles Needle Tenotomy (Fenestration)
• Patient Position
• Prone with foot hanging over end of table
• Alt: Side-lying with symptomatic side down
• Transducer Position
• Long (or short) axis to Achilles tendon
• Needle Orientation to Transducer
• In- and out-of-plane
• Needle Approach
• Proximal to distal (or medial to lateral)
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Achilles Needle Tenotomy (Fenestration)

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Achilles Needle Tenotomy (Fenestration)

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Achilles Needle Tenotomy (Fenestration)
• Target
• Repetitively fenestrate tendinopathic region
• Pitfalls
• Identify and avoid sural nerve
• Pearls
• Prescan crucial for planning approach
• Use in- and out-of-plane views
• "Oblique" LAX allows better ergonomics
• Can combine with biologic agent (eg, PRP)
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Achilles Needle Tenotomy (Fenestration)

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Achilles Needle Tenotomy (Fenestration)

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Achilles Needle Tenotomy (Fenestration)

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Achilles Tendon Scraping

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Retrocalcaneal (or RetroAchilles) Bursa
• Patient Position
• Prone with foot hanging over end of table
• Transducer Position
• Anatomic transverse plane over
retrocalcaneal (retroAchilles) bursa
• Needle Orientation to Transducer
• In-plane
• Needle Approach
• Lateral to medial
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Retrocalcaneal (or RetroAchilles) Bursa

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Retrocalcaneal (or RetroAchilles) Bursa
• Target
• Retrocalcaneal bursa between Achilles
tendon and posterior calcaneus
• RetroAchilles bursa located superficial to
Achilles tendon and deep to subQ tissue

• Pitfalls
• Identify and avoid sural nerve
• Avoid injecting the Achilles tendon
• Do not overfill retrocalcaneal bursa
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Retrocalcaneal Bursa

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RetroAchilles Bursa

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Plantar Fascia
• Patient Position
• Side-lying with symptomatic side down
• Transducer Position
• Anatomic transverse plane over plantar
fascia origin
• Needle Orientation to Transducer
• In-plane
• Needle Approach
• Medial to lateral
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Plantar Fascia

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Plantar Fascia
• Target
• Superficial or deep to plantar fascia origin

• Pitfalls
• Avoid intrafascial cortisone injection
• Identify and avoid the medial ankle
neurovascular structures
• Baxter's nerve passes deep to fascia

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Plantar Fascia (superficial)

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Plantar Fascia (deep)

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First Metatarsophalangeal Joint
(Indirect Sesamoids)
• Patient Position
• Supine
• Transducer Position
• Anatomic sagittal plane over dorsomedial
joint
• Needle Orientation to Transducer
• Out-of-plane
• Needle Approach
• Medial to lateral
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First Metatarsophalangeal Joint
(Indirect Sesamoids)

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First Metatarsophalangeal Joint
(Indirect Sesamoids)
• Target
• Dorsomedial aspect 1st MTP joint
• Use walk-down technique

• Pitfalls
• Stay dorsal to avoid medial hallucal nerve

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First Metatarsophalangeal Joint
(Indirect Sesamoids)

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First Metatarsophalangeal Joint
(Indirect Sesamoids)

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First Metatarsophalangeal Joint
(Indirect Sesamoids)

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Morton Neuroma
• Patient Position
• Prone
• Transducer Position
• Plantar view - anatomic sagittal plane over
neuroma/intermetatarsal space
• Needle Orientation to Transducer
• In-plane
• Needle Approach
• Distal to proximal
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Morton Neuroma

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Morton Neuroma
• Target
• Adjacent to or into neuroma

• Pitfalls
• Identify and avoid adjacent interdigital
artery/veins

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Morton Neuroma

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 Summary

• Practice basic USGI fundamentals

• Find needle in periphery (jiggle/slide)
• Look at your probe/needle alignment
• Tip in view while advancing
• Small footprint, high frequency probe (eg,
hockey stick) nice for foot/ankle injections
• Consider smaller gauge needles (27g) for
patient comfort
• Knowing alternative approaches helps
when access difficult (DJD)
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 References

• Malanga G, Halperin J, Finnoff J, Smith J.

Ultrasound-Guided Lower Extremity
Procedures. Mayo Foundation for Medical
Education and Research 2010.
• Malanga G, Mautner K. Atlas of
Ultrasound-Guided Musculoskeletal
Injections. McGraw-Hill Education 2014.

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