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REVIEW ARTICLE
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.
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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Regional Anesthesia and Pain Medicine Volume 41, Number 1, January-February 2016
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.
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
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.
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.
Comments
Constant component
Constant component
Presence variable
Presence variable
Constant component, largest
band in deltoid
Presence variable
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FIGURE 3. Medial collateral (deltoid) ligament. A, Deep layer. B, Superficial layer. Reproduced with permission from Philip Peng
Educational Series.
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.
FIGURE 4. Anterior view of the ankle. Reproduced with permission from Philip Peng Educational Series.
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Main Function
Origin
Insertion
Medial surface medial cuneiform,
medial base 1st metatarsal
Distal phalynx great toe
TA
EHL
EDL
Peroneus tertius
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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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.
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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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
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
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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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.
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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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.
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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.
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 (615 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.
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Regional Anesthesia and Pain Medicine Volume 41, Number 1, January-February 2016
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.
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.
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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.
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.
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Regional Anesthesia and Pain Medicine Volume 41, Number 1, January-February 2016
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.
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.
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112
JCA/10
JIA/6.7
JIA/6.5
30/US
38/F
9/F
18/F
85/TA
55/TA
13/TA
36/MP
No. Patients/Image
No.
Method
Injections/Injectate
Outcome
Joints Injected
3.3
16
12
Follow-up, mo
Adverse Events
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
OA/RA/66
Cause/Age,* y
48
Study/Study Type
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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 500730 kd
vs saline
Adant 900 kd vs
exercise therapy
Hyalgan 500730 kd
vs saline
Supartz 6201170 kd
vs saline
Hyalgan 500730 kd
+ PT 12 wk vs BoNT-A
Injectate
5/7 d
3/7 d
5/7 d
No.
Doses/Interval
Effect
Outcome/
Follow-up
None
None
1 Patient enlarged
inguinal lymph node
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
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Ultrasound Guidance for Ankle Injections
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52% transient
pain/erythema <48 h
17 (30.9%) mild to moderate
local adverse effects
6.7% local adverse effects
None
AOFAS/6 mo
5/7 d
N/75
Sun et al,63 2006
50.2 14.3
Artz 6201170 kd
VAS pain/6 mo
1 or 2/13 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 6001200 kd
AOS total/6 mo
3/7 d
Hyalgan 500730 kd
N/46
Sun et al,59 2011
51.7 14.4
3/15 d
F/18
58
60
Synvisc 6000 kd
AOFAS/12 mo
None
Adverse Events
Effect
Outcome/
Follow-up
No. Doses/
Interval
Injectate
Image Method/
No. Patients
Age, y
Study
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
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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