1. Sonography of the Foot and Ankle
Evan Peck, MD
Section of Sports Health
Department of Orthopaedic Surgery
Cleveland Clinic Florida

2. Disclosures
Financial disclosures: Neither I, Evan Peck, nor any family member(s), have any relevant financial relationships to be discussed, directly or indirectly, referred to or illustrated with or without recognition within the presentation.
Off-label use disclosures: None.

3. Objectives
Understand the proper technique for performance of the diagnostic foot and ankle ultrasound (US) examination.
Be familiar with the structures required for complete diagnostic US evaluation of each region of the ankle and selected structures relevant to sonographic examination of the foot.
Recognize the sonographic appearance of normal foot and ankle structures and common pathology.

4. Before You Start High-frequency (>10 MHz) linear-array transducer.
Bone is your friend.
Beware of anisotropy.

5. General Considerations
Patient supine (anterior), lateral decubitus (medial, lateral), or prone (posterior; possibly medial, lateral).
Pillow or towel roll useful for ankle positioning, particularly for decreasing anisotropy of ligaments.
Utilize generous gel stacking for concave and convex contours of the foot and ankle.
Be mindful of transducer pressure, which can displace (and hide) abnormal fluid collections.

6. What to Scan?
AIUM Practice Guideline for the Performance of a Musculoskeletal Ultrasound Examination and AIUM Diagnostic Musculoskeletal Case Submission Requirements.
May select one quadrant of the ankle for “complete” US evaluation (anterior, medial, lateral, posterior) based on clinical presentation.
Foot US evaluation usually focused on specific structure(s) of primary clinical interest.

7. Anterior Ankle: Checklist
Tibialis anterior tendon (long and short axis).
Extensor hallucis longus tendon (long and short axis).
Extensor digitorum longus tendon (long and short axis).
Anterior joint recess.
Anterior inferior tibiofibular ligament (oblique axial images).
AIUM.org

8. Anterior Ankle: Short Axis

9. Tibialis Anterior Tendon: Long Axis

10. Extensor Hallucis Longus Tendon: Long Axis

11. Extensor Digitorum Longus Tendon: Long Axis

12. Anterior Ankle Joint Recess

13. Anterior Ankle Joint Effusion

14. Anterior Inferior Tibiofibular Ligament

15. Medial Ankle: Checklist
Posterior tibial tendon (long and short axis).
Flexor digitorum longus tendon (long and short axis).
Flexor hallucis longus tendon (long and short axis).
Tibial nerve.
Deltoid ligament (long axis).
AIUM.org

16. Medial Ankle (Tarsal Tunnel): Short Axis

17. Posterior Tibial Tendon: Long Axis

18. Flexor Digitorum Longus Tendon: Long Axis

19. Flexor Hallucis Longus Tendon: Long Axis

20. Tibial Nerve: Long Axis

21. Deltoid Ligament
- Three components of deltoid ligament (A-P): Tibionavicular, tibiocalcanear, tibiotalar.

22. Lateral Ankle: Checklist
Peroneus brevis tendon (long and short axis).
Peroneus longus tendon (long and short axis).
Calcaneofibular ligament.
Anterior talofibular ligament.
Dynamic imaging as indicated.
AIUM.org

23. Peroneal Tendons (Short Axis)

24. Peroneus Brevis (Long Axis)

25. Peroneus Longus (Long Axis)

26. Peroneus Longus Tenosynovitis (Short Axis)

27. Calcaneofibular Ligament

28. Anterior Talofibular Ligament

29. Anterior Talofibular Ligament Tear
- Sensitivity/specificity of US detecting ATFL tear: 98.9%/96.2%.
- Sensitivity/specificity of US detecting CFL tear: 93.8%/90.9%.
Cheng 2014

30. Posterior Ankle: Checklist
Achilles tendon.
Plantaris tendon (may be absent in 20% of population).
Retrocalcaneal bursa (typically visible without pathology).
Retro-Achilles bursa (typically not visible without pathology).
Plantar fascia.
AIUM.org, Delgado 2002

31. Achilles Tendon (Long Axis)
- Retrocalcaneal bursa: Up to 2.5 mm AP stripe of anechoic fluid may be normal.
Nazarian 1995

32. Achilles Tendon (Short Axis)

33. Mid-Portion Achilles Tendinosis (Long Axis)

34. Insertional Achilles Tendinosis (Long Axis)

35. Mid-Portion Achilles Tendinosis (Long Axis, Extended FOV)
Picture courtesy Jay Smith, MD

36. Achilles Tendon Full-Thickness Tear (Long Axis)

37. Plantar Fascia (Long Axis)

38. Plantar Fascia (Short Axis)

39. Plantar Fasciosis (Long Axis)

40. Plantar Fasciosis with Partial-Thickness Tear (Long Axis)

41. Plantar Fasciosis with Partial-Thickness Tear (Short Axis)

42. Foot: As Indicated
Metatarsophalangeal joints (if inflammatory arthritis suspected).
Proximal interphalangeal joints (if inflammatory arthritis suspected).
Interdigital nerves.
Interdigital bursae.
AIUM.org

43. First Metatarsophalangeal Joint Effusion

44. Interdigital Neuroma in First Intermetatarsal Space (Short Axis)

45. Picture courtesy Mederic Hall, MD
Foot Foreign Body
Picture courtesy Mederic Hall, MD

46. Summary Use a systematic approach.
Patient positioning and use of bony landmarks key for optimizing visualization of foot and ankle structures, particularly ligaments.
Be aware of anisotropy, particularly with tendons that change direction about the ankle.
Utilize dynamic imaging as indicated.

47. References
AIUM.org. AIUM Practice Guideline for the Performance of a Musculoskeletal Ultrasound Examination. AIUM.org. Diagnostic Musculoskeletal Case Submission Requirements. Cheng Y et al. Value of ultrasonography for detecting chronic injury of the lateral ligaments of the ankle joint compared with arthroscopy findings. Br J Radiol Jan;87(1033): Delgado GJ et al. Tennis leg: Clinical US study of 141 patients and anatomic investigation of four cadavers with MR imaging and US. Radiology Jul;224(1): Nazarian LN et al. Synovial fluid in the hindfoot and ankle: detection of amount and distribution with US. Radiology Oct;197(1):275-8.

48. Thank You