Ankle Ultrasound
Ankle Ultrasound
Ankle Ultrasound
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<strong>Ankle</strong> <strong>Ultrasound</strong><br />
ligaments, tendons and retinacula<br />
Carlo Martinoli, MD<br />
Radiologia – DISSAL, Università di Genova, Italy<br />
Maribel Miguel-Pérez, MD<br />
Department of Human Anatomy<br />
University of Barcelona, Spain<br />
Check-list<br />
! Anterior Aspect<br />
! Lateral Aspect<br />
! Medial Aspect<br />
! Posterior Aspect (Achilles excluded)<br />
22 nd Annual Conference on Musculoskeletal <strong>Ultrasound</strong><br />
MUSCULOSKELETAL ULTRASOUND SOCIETY<br />
Leuven - September 19-22, 2012
Anterior <strong>Ankle</strong><br />
ta<br />
edl<br />
OSL<br />
*<br />
OSM<br />
ehl<br />
inferior extensor<br />
retinaculum<br />
OIM<br />
frondiform<br />
22 nd Annual Conference on Musculoskeletal <strong>Ultrasound</strong><br />
MUSCULOSKELETAL ULTRASOUND SOCIETY<br />
Leuven - September 19-22, 2012
Tibialis Anterior – tear<br />
! Tendon exposed to minor mechanical stress Æ straight course<br />
! Spontaneous rupture is rare (patients over the age of 45-50 years)<br />
! footdrop, lump related to the protrusion of the tendon end above the inferior retinaculum<br />
! history of swelling and pain at the dorsomedial aspect of the midfoot<br />
tibialis anterior<br />
tibia<br />
*<br />
talus<br />
22 nd Annual Conference on Musculoskeletal <strong>Ultrasound</strong><br />
MUSCULOSKELETAL ULTRASOUND SOCIETY<br />
Leuven - September 19-22, 2012
Tibialis Anterior – tendinopathy<br />
inferior<br />
extensor<br />
retinaculum<br />
ta<br />
Tendinosis and Partial Tear<br />
! ! the tendon tibialis thickness anterior tendon >5mm inserts (
Lateral <strong>Ankle</strong><br />
LM<br />
*<br />
frondiform<br />
Talus<br />
PL<br />
pt<br />
PB<br />
22 nd Annual Conference on Musculoskeletal <strong>Ultrasound</strong><br />
MUSCULOSKELETAL ULTRASOUND SOCIETY<br />
Leuven - September 19-22, 2012
Peroneus brevis – longitudinal splits<br />
! Longitudinal splits are most often seen in athletes due to repetitive trauma<br />
! Pathogenesis related to contraction of the PL muscle causing compression and splaying of<br />
the PB tendon over the fibula<br />
LM<br />
! subluxation, spurring at the lateral malleolus, peroneus quartus LM<br />
Peroneus brevis<br />
pl<br />
pl pb pl<br />
pl<br />
pb 1<br />
pb pb 1<br />
pb<br />
pb<br />
2<br />
2<br />
*<br />
pb<br />
LM<br />
LM<br />
pl<br />
pb<br />
PB 2<br />
pb<br />
Peroneus longus<br />
LM<br />
PB 1<br />
PB<br />
PL<br />
LM<br />
PB<br />
22 nd Annual Conference on Musculoskeletal <strong>Ultrasound</strong><br />
MUSCULOSKELETAL ULTRASOUND SOCIETY<br />
Leuven - September 19-22, 2012
Peroneal Tendons - instability<br />
! In dislocation, the peroneal tendons are seen moving anteriorly over the<br />
lateral malleolus<br />
! posttraumatic (flat or convex fibular groove predisposing)<br />
! >90% athletic injuries (skiing, skating, running …)<br />
! The instability of tendons may result in peroneal tendon tears<br />
! Association of SPR injury with lateral collateral ligament lesions (78%)<br />
! ODEN’S CLASSIFICATION è four steps scale<br />
*<br />
pl<br />
LM<br />
pb<br />
TYPE-II<br />
TYPE-II<br />
TYPE-I<br />
pl<br />
pb<br />
*<br />
PB LM<br />
*<br />
pb<br />
pl<br />
PB<br />
LM<br />
Dorsiflexion & pb Eversion<br />
pl<br />
! In acute and chronic recurrent subluxation, the tendons are<br />
LM<br />
often not subluxed when at rest<br />
*<br />
*<br />
pl<br />
pl pb<br />
*<br />
LM<br />
TYPE-III<br />
pb<br />
LM<br />
TYPE-IV
Peroneal Tendons - instability<br />
TYPE-III<br />
*<br />
pl<br />
pb<br />
pb<br />
pl<br />
*<br />
LM<br />
TYPE-III<br />
T1wSE T2wtSE T2*GRE<br />
*<br />
pl<br />
pb<br />
22 nd Annual Conference on Musculoskeletal <strong>Ultrasound</strong><br />
MUSCULOSKELETAL ULTRASOUND SOCIETY<br />
Leuven - September 19-22, 2012
<strong>Ankle</strong> Sprains – lateral ligament injuries<br />
LIGAMENTS<br />
HINDFOOT<br />
! Anterior TaloFibular<br />
! CalcaneoFibular<br />
! Anterior TibioFibular<br />
Anterior TaloFibular Ligament – PARTIAL TEARS<br />
LM<br />
*<br />
Talus<br />
Partial tear<br />
! primary stabilizer to ankle inversion injuries with the ankle in<br />
the unloaded position<br />
! the first ligament to be injured in sequence<br />
! adults Æ tear in the midsubstance<br />
! adolescents Æ avulsion injuries<br />
22 nd Annual Conference on Musculoskeletal <strong>Ultrasound</strong><br />
MUSCULOSKELETAL ULTRASOUND SOCIETY<br />
Leuven - September 19-22, 2012
<strong>Ankle</strong> Sprains – lateral ligament injuries<br />
LIGAMENTS<br />
HINDFOOT<br />
! Anterior TaloFibular<br />
! CalcaneoFibular<br />
! Anterior TibioFibular<br />
Anterior TaloFibular Ligament – COMPLETE TEARS<br />
LM<br />
*<br />
<br />
LM<br />
*<br />
<br />
talus<br />
talus<br />
! A complete tear (grade III) can be diagnosed when a<br />
Sonographic hypoechoic gap anterior cleft is drawer seen through test the substance of the<br />
! ligament Passive assisted movements can be helpful<br />
by ! enhancing wavy contour the of separation the ligament of instead the torn of its taut appearance<br />
! ATL è continuous but lax<br />
ends ! an acute tear of the ligament results in a capsular tear with<br />
leakage of fluid into the soft-tissues around the ligament<br />
22 nd Annual Conference on Musculoskeletal <strong>Ultrasound</strong><br />
MUSCULOSKELETAL ULTRASOUND SOCIETY<br />
Leuven - September 19-22, 2012
CalcaneoFibular Ligament<br />
LIGAMENTS<br />
! the peronal tendons are just superficial to<br />
the calcaneofibular ligament<br />
LM LM<br />
HINDFOOT<br />
! Anterior TaloFibular<br />
! CalcaneoFibular<br />
! Anterior TibioFibular<br />
! this ligament becomes tense in dorsiflexion Æ<br />
pushing the peroneal tendons toward surface<br />
Neutral<br />
LM<br />
LM<br />
Dorsiflexion<br />
Talus Talus<br />
Calcaneus<br />
Calcaneus<br />
pb pb<br />
pl pl<br />
90°<br />
22 nd Annual Conference on Musculoskeletal <strong>Ultrasound</strong><br />
MUSCULOSKELETAL ULTRASOUND SOCIETY<br />
Leuven - September 19-22, 2012
<strong>Ankle</strong> Sprains – lateral ligament injuries<br />
LIGAMENTS<br />
HINDFOOT<br />
! Anterior TaloFibular<br />
! CalcaneoFibular<br />
! Anterior TibioFibular<br />
CalcaneoFibular Ligament Tears<br />
! the passage peronals of joint are effusion no longer<br />
pushed into the toward peroneal surface tendon but<br />
fall sheath deeply into the groove<br />
Healthy<br />
Talus<br />
LM<br />
*<br />
pb<br />
pl<br />
Calcaneus<br />
*<br />
LM<br />
pb<br />
pl<br />
Torn<br />
22 nd Annual Conference on Musculoskeletal <strong>Ultrasound</strong><br />
MUSCULOSKELETAL ULTRASOUND SOCIETY<br />
Leuven - September 19-22, 2012
<strong>Ankle</strong> Sprains – high ankle sprains<br />
LIGAMENTS<br />
HINDFOOT<br />
! Anterior TaloFibular<br />
! CalcaneoFibular<br />
! Anterior TibioFibular<br />
Distal Syndesmosis Injury<br />
! forced external rotation of the foot with<br />
internal rotation of the leg<br />
! twisting mechanism (football, skiing)<br />
! longer recovery time, often with poor<br />
outcome and chronic ankle dysfunction<br />
! associated with Weber B & C ankle<br />
fractures<br />
Fibula<br />
Tibia<br />
Fibula<br />
Tibia<br />
Weber C<br />
22 nd Annual Conference on Musculoskeletal <strong>Ultrasound</strong><br />
MUSCULOSKELETAL ULTRASOUND SOCIETY<br />
Leuven - September 19-22, 2012
Medial <strong>Ankle</strong><br />
n<br />
v<br />
fdl<br />
tp<br />
MM<br />
22 nd Annual Conference on Musculoskeletal <strong>Ultrasound</strong><br />
MUSCULOSKELETAL ULTRASOUND SOCIETY<br />
Leuven - September 19-22, 2012
Tibialis Posterior – splits<br />
! Tendon exposed to stress due to compression within the retromalleolar groove,<br />
to hyperpronation of the foot or to flatfoot deformity<br />
! osteophytes in the medial malleolus<br />
MM<br />
* *<br />
MM<br />
*<br />
*<br />
Neutral<br />
Inversion<br />
*<br />
* *<br />
22 nd Annual Conference on Musculoskeletal <strong>Ultrasound</strong><br />
MUSCULOSKELETAL ULTRASOUND SOCIETY<br />
Leuven - September 19-22, 2012
Tibialis Posterior – tears<br />
! The posterior tibial tendon tears usually occur with an elongation mechanism<br />
! reduced tendon width<br />
! loss of fibrillar echotexture<br />
* *<br />
*<br />
tp<br />
fdl<br />
tp<br />
MM<br />
MM<br />
*<br />
fdl<br />
tp<br />
tp<br />
22 nd Annual Conference on Musculoskeletal <strong>Ultrasound</strong><br />
MUSCULOSKELETAL ULTRASOUND SOCIETY<br />
Leuven - September 19-22, 2012
Posterior Impingement Syndrome<br />
! “Nutcracker” mechanism with the posterior talus and surrounding<br />
soft-tissues compressed between the tibia and the calcaneus during<br />
extreme plantar flexion of the foot ➙ ballet dancers<br />
os trigonum (7% of individuals), elongated lateral tubercle of the talus<br />
(Stieda's process), downward sloping posterior lip of the tibia, prominent<br />
posterior process of the calcaneus<br />
FHL TENOSYNOVITIS, TIBIOTALAR AND SUBTALAR SYNOVITIS, POSTERIOR<br />
INTERMALLEOLAR LIGAMENT INJURY<br />
22 nd Annual Conference on Musculoskeletal <strong>Ultrasound</strong><br />
MUSCULOSKELETAL ULTRASOUND SOCIETY<br />
Leuven - September 19-22, 2012
Os Trigonum Syndrome<br />
MR imaging<br />
! fluid extending across the synchondrosis<br />
! loculated sheath effusion of the FHL tendon above the level of the posterior talar pulley<br />
! synovitis in the posterior recess of the tibiotalar and subtalar joint<br />
! oedematous changes and inflammation in the peritendinous tissues<br />
*<br />
22 nd Annual Conference on Musculoskeletal <strong>Ultrasound</strong><br />
MUSCULOSKELETAL ULTRASOUND SOCIETY<br />
Leuven - September 19-22, 2012
Ligaments – medial ankle<br />
LIGAMENTS<br />
HINDFOOT<br />
! Deltoid Complex<br />
! TibioTalar<br />
! TibioCalcanear<br />
! TibioNavicular<br />
Deltoid Ligament Tears<br />
! Association with lateral collateral ligament or syndesmotic<br />
injuries<br />
! Inherent strength Æ avulsion fractures of the medial malleolus<br />
more common<br />
MM<br />
tibia<br />
tibia<br />
Deep tibiotalar<br />
talus<br />
! US appearance of a deltoid<br />
ligament injury depends on<br />
which component was<br />
injured and to what extent<br />
! thickening, discontinuity<br />
Partial tear<br />
talus<br />
calcaneus<br />
TibioCalcanear<br />
22 nd Annual Conference on Musculoskeletal <strong>Ultrasound</strong><br />
MUSCULOSKELETAL ULTRASOUND SOCIETY<br />
Leuven - September 19-22, 2012
Posterior <strong>Ankle</strong><br />
22 nd Annual Conference on Musculoskeletal <strong>Ultrasound</strong><br />
MUSCULOSKELETAL ULTRASOUND SOCIETY<br />
Leuven - September 19-22, 2012
Plantaris Tendon – tear<br />
! TENNIS LEG è medial head of gastrocnemius tears (66.7%), gemellary vein thrombosis<br />
(9.9%), plantaris tears (1.4%), soleus ACHILLES tears (0.7%), TENDON or TEAR a combination WITH INTACT PLANTARIS thereof Delgado et al., 2002<br />
a pitfall to avoid<br />
compared to MHG tear<br />
! less severe injury<br />
! occurs more proximal or distal<br />
* *<br />
cranial<br />
…<br />
transverse planes<br />
*<br />
caudal<br />
…<br />
22 nd Annual Conference on Musculoskeletal <strong>Ultrasound</strong><br />
MUSCULOSKELETAL ULTRASOUND SOCIETY<br />
Leuven - September 19-22, 2012