Ankle Ultrasound

Ankle Ultrasound 

ligaments, tendons and retinacula 

Carlo Martinoli, MD 

Radiologia – DISSAL, Università di Genova, Italy 

Maribel Miguel-Pérez, MD 

Department of Human Anatomy 

University of Barcelona, Spain 

Check-list 

! Anterior Aspect 

! Lateral Aspect 

! Medial Aspect 

! Posterior Aspect (Achilles excluded) 

22 nd Annual Conference on Musculoskeletal Ultrasound 

MUSCULOSKELETAL ULTRASOUND SOCIETY 

Leuven - September 19-22, 2012

Anterior Ankle 

ta 

edl 

OSL 

* 

OSM 

ehl 

inferior extensor 

retinaculum 

OIM 

frondiform 




Tibialis Anterior – tear 

! Tendon exposed to minor mechanical stress Æ straight course 

! Spontaneous rupture is rare (patients over the age of 45-50 years) 

! footdrop, lump related to the protrusion of the tendon end above the inferior retinaculum 

! history of swelling and pain at the dorsomedial aspect of the midfoot 

tibialis anterior 

tibia 

* 

talus 




Tibialis Anterior – tendinopathy 

inferior 

extensor 

retinaculum 

ta 

Tendinosis and Partial Tear 

! ! the tendon tibialis thickness anterior tendon >5mm inserts (

Lateral Ankle 

LM 

* 

frondiform 

Talus 

PL 

pt 

PB 




Peroneus brevis – longitudinal splits 

! Longitudinal splits are most often seen in athletes due to repetitive trauma 

! Pathogenesis related to contraction of the PL muscle causing compression and splaying of 

the PB tendon over the fibula 

LM 

! subluxation, spurring at the lateral malleolus, peroneus quartus LM 

Peroneus brevis 

pl 

pl pb pl 

pl 

pb 1 

pb pb 1 

pb 

pb 

2 

2 

* 

pb 

LM 

LM 

pl 

pb 

PB 2 

pb 

Peroneus longus 

LM 

PB 1 

PB 

PL 

LM 

PB 




Peroneal Tendons - instability 

! In dislocation, the peroneal tendons are seen moving anteriorly over the 

lateral malleolus 

! posttraumatic (flat or convex fibular groove predisposing) 

! >90% athletic injuries (skiing, skating, running …) 

! The instability of tendons may result in peroneal tendon tears 

! Association of SPR injury with lateral collateral ligament lesions (78%) 

! ODEN’S CLASSIFICATION è four steps scale 

* 

pl 

LM 

pb 

TYPE-II 

TYPE-II 

TYPE-I 

pl 

pb 

* 

PB LM 

* 

pb 

pl 

PB 

LM 

Dorsiflexion & pb Eversion 

pl 

! In acute and chronic recurrent subluxation, the tendons are 

LM 

often not subluxed when at rest 

* 

* 

pl 

pl pb 

* 

LM 

TYPE-III 

pb 

LM 

TYPE-IV

Peroneal Tendons - instability 

TYPE-III 

* 

pl 

pb 

pb 

pl 

* 

LM 

TYPE-III 

T1wSE T2wtSE T2*GRE 

* 

pl 

pb 




Ankle Sprains – lateral ligament injuries 

LIGAMENTS 

HINDFOOT 

! Anterior TaloFibular 

! CalcaneoFibular 

! Anterior TibioFibular 

Anterior TaloFibular Ligament – PARTIAL TEARS 

LM 

* 

Talus 

Partial tear 

! primary stabilizer to ankle inversion injuries with the ankle in 

the unloaded position 

! the first ligament to be injured in sequence 

! adults Æ tear in the midsubstance 

! adolescents Æ avulsion injuries 





LIGAMENTS 

HINDFOOT 




Anterior TaloFibular Ligament – COMPLETE TEARS 

LM 

* 

 

LM 

* 

 

talus 

talus 

! A complete tear (grade III) can be diagnosed when a 

Sonographic hypoechoic gap anterior cleft is drawer seen through test the substance of the 

! ligament Passive assisted movements can be helpful 

by ! enhancing wavy contour the of separation the ligament of instead the torn of its taut appearance 

! ATL è continuous but lax 

ends ! an acute tear of the ligament results in a capsular tear with 

leakage of fluid into the soft-tissues around the ligament 




CalcaneoFibular Ligament 

LIGAMENTS 

! the peronal tendons are just superficial to 

the calcaneofibular ligament 

LM LM 

HINDFOOT 




! this ligament becomes tense in dorsiflexion Æ 

pushing the peroneal tendons toward surface 

Neutral 

LM 

LM 

Dorsiflexion 

Talus Talus 

Calcaneus 

Calcaneus 

pb pb 

pl pl 

90° 





LIGAMENTS 

HINDFOOT 




CalcaneoFibular Ligament Tears 

! the passage peronals of joint are effusion no longer 

pushed into the toward peroneal surface tendon but 

fall sheath deeply into the groove 

Healthy 

Talus 

LM 

* 

pb 

pl 

Calcaneus 

* 

LM 

pb 

pl 

Torn 




Ankle Sprains – high ankle sprains 

LIGAMENTS 

HINDFOOT 




Distal Syndesmosis Injury 

! forced external rotation of the foot with 

internal rotation of the leg 

! twisting mechanism (football, skiing) 

! longer recovery time, often with poor 

outcome and chronic ankle dysfunction 

! associated with Weber B & C ankle 

fractures 

Fibula 

Tibia 

Fibula 

Tibia 

Weber C 




Medial Ankle 

n 

v 

fdl 

tp 

MM 




Tibialis Posterior – splits 

! Tendon exposed to stress due to compression within the retromalleolar groove, 

to hyperpronation of the foot or to flatfoot deformity 

! osteophytes in the medial malleolus 

MM 

* * 

MM 

* 

* 

Neutral 

Inversion 

* 

* * 




Tibialis Posterior – tears 

! The posterior tibial tendon tears usually occur with an elongation mechanism 

! reduced tendon width 

! loss of fibrillar echotexture 

* * 

* 

tp 

fdl 

tp 

MM 

MM 

* 

fdl 

tp 

tp 




Posterior Impingement Syndrome 

! “Nutcracker” mechanism with the posterior talus and surrounding 

soft-tissues compressed between the tibia and the calcaneus during 

extreme plantar flexion of the foot ➙ ballet dancers 

os trigonum (7% of individuals), elongated lateral tubercle of the talus 

(Stieda's process), downward sloping posterior lip of the tibia, prominent 

posterior process of the calcaneus 

FHL TENOSYNOVITIS, TIBIOTALAR AND SUBTALAR SYNOVITIS, POSTERIOR 

INTERMALLEOLAR LIGAMENT INJURY 




Os Trigonum Syndrome 

MR imaging 

! fluid extending across the synchondrosis 

! loculated sheath effusion of the FHL tendon above the level of the posterior talar pulley 

! synovitis in the posterior recess of the tibiotalar and subtalar joint 

! oedematous changes and inflammation in the peritendinous tissues 

* 




Ligaments – medial ankle 

LIGAMENTS 

HINDFOOT 

! Deltoid Complex 

! TibioTalar 

! TibioCalcanear 

! TibioNavicular 

Deltoid Ligament Tears 

! Association with lateral collateral ligament or syndesmotic 

injuries 

! Inherent strength Æ avulsion fractures of the medial malleolus 

more common 

MM 

tibia 

tibia 

Deep tibiotalar 

talus 

! US appearance of a deltoid 

ligament injury depends on 

which component was 

injured and to what extent 

! thickening, discontinuity 

Partial tear 

talus 

calcaneus 

TibioCalcanear 




Posterior Ankle 




Plantaris Tendon – tear 

! TENNIS LEG è medial head of gastrocnemius tears (66.7%), gemellary vein thrombosis 

(9.9%), plantaris tears (1.4%), soleus ACHILLES tears (0.7%), TENDON or TEAR a combination WITH INTACT PLANTARIS thereof Delgado et al., 2002 

a pitfall to avoid 

compared to MHG tear 

! less severe injury 

! occurs more proximal or distal 

* * 

cranial 

… 

transverse planes 

* 

caudal 

…

Ankle Ultrasound

You also want an ePaper? Increase the reach of your titles

Delete template?

Save as template?