13.1.1 Cause

• 
  

  Osteoarthritis.

  
  
• 
  

  Posttrauma.

13.1.2 Presentation

• 
  

  Pain is described as deep within the anterior aspect of the ankle joint. If osteoarthritis is the cause of pain, then there is often a relatively more limited restriction of plantarflexion than dorsiflexion.

  
  
• 
  

  If pain is due to an impingement, then limitation will be related to the site of the impingement either anterior or posterior.

13.1.3 Equipment

See Table  13‑1.

13.1.4 Anatomical Considerations

The most convenient point of entry to the talocrural joint is immediately distal to the anterior edge of the tibia just above the talar dome. The deep peroneal nerve and dorsalis pedis artery and vein should be visualized prior to injection.

13.1.5 Procedure

• 
  

  The patient is positioned supine with the knee bent to approximately 90 degrees and the foot flat on the couch. This places the foot in a plantar flexed position allowing for easier needle entry into the joint.

  
  
• 
  

  The transducer is placed in the anatomical sagittal plane between the tendons of tibialis anterior and extensor hallucis longus.

  
  
• 
  

  The needle is introduced in the longitudinal plane of the transducer from an inferior to superior direction into the talocrural joint.

  
  
• 
  

  The dome of the talus gives the clinician the needle angle.

  
  
• 
  

  Injection is given as a bolus.

13.1.6 The Injection

See Fig.  13‑1 and Fig.  13‑2.

13.1.7 Notes

The ankle joint is not a joint commonly affected by osteoarthritis unless this is secondary to previous fracture. Even then problems do not usually develop for a number of years. If osteoarthritis is present, injection can provide a good degree of symptomatic relief and facilitate a programme of rehabilitation.

Injection may also be of diagnostic use particularly if an intra-articular swelling is present secondary to anterior impingement.

Prior to injection the possibility of an osteochondral defect should be considered and may require magnetic resonance imaging (MRI) to fully assess for this possibility particularly if pain is present on weight-bearing and the patient describes a history of inversion-like injury.

13.2.1 Cause

• 
  

  Commonly osteoarthritis of the talonavicular, navicular-cuneiform or cuneiform-metatarsal joints.

  
  
• 
  

  Overuse often associated with either an overpronated or supinated foot.

13.2.2 Presentation

Pain is located over the dorsum of the foot. There may be an associated soft tissue or bony prominence which ultrasound demonstrates to be a bony exostosis associated with degenerative change of the underlying joint or an arthrosynovial cyst.

13.2.3 Equipment

See Table  13‑2.

13.2.4 Anatomical Considerations

There are several joints in the midtarsal region any one of which or a combination of which may be painful. The joint to be injected should be identified using both careful palpation of the region and ultrasound to identify the most symptomatic. Injection may be required at more than one joint and given on separate occasions can be a useful diagnostic tool.

13.2.5 Procedure

• 
  

  The patient is positioned supine with the knee bent to approximately 90 degrees and the foot flat on the couch, placing the foot in a plantar flexed position allowing for easier needle entry into the joint identified as being the problem.

  
  
• 
  

  The transducer is placed in the anatomical sagittal plane over the joint to be injected.

  
  
• 
  

  The needle is introduced in the longitudinal plane of the transducer from an inferior to superior direction into the joint to be injected.

  
  
• 
  

  Injection is given as a bolus.

13.2.6 The Injection

See Fig.  13‑3 and Fig.  13‑4.

13.2.7 Notes

Injection of the midtarsal joints can provide good symptomatic relief in patients with osteoarthritis of this region. However, the patient’s foot position should always be considered and corrected where possible with the appropriate supportive shoe and orthotic. This is also the case of the patient who presents with overuse problems in this area related for example to overpronation of the foot.

13.3.1 Cause

• 
  

  Commonly overuse.

  
  
• 
  

  May be related to an acute or chronic inversion injury of the ankle.

13.3.2 Presentation

• 
  

  Pain is located over the lateral aspect of the ankle posterior and below the lateral malleolus.

  
  
• 
  

  Pain may be reproduced with resisted eversion of the ankle and foot and end-range inversion and plantar flexion.

13.3.3 Equipment

See Table  13‑3.

13.3.4 Anatomical Considerations

The tendons of peroneus brevis and longus run together within a common synovial sheath behind and then below the lateral malleolus. They then divide at the peroneal tubercle on the lateral aspect of the calcaneum. The tendon of peroneus longus then passes under the foot while peroneus brevis continues laterally to insert onto the base of the fifth metatarsal.

The point at which the tendons divide is a useful entry point for the needle. Clinically, this division can be felt as a “V-shaped” fork between the tendons on the lateral aspect of the calcaneum.

13.3.5 Procedure

• 
  

  The patient is positioned in side-lying with the symptomatic side uppermost.

  
  
• 
  

  The transducer is placed in an oblique coronal plane longitudinally over the peroneal tendons below and posterior to the lateral malleolus.

  
  
• 
  

  The needle is introduced in the longitudinal plane of the transducer from an anterior and inferior to posterior and superior direction into the space between the two tendons.

  
  
• 
  

  Injection is given as a bolus.

  
  
• 
  

  If the condition is acute and inflamed indicating a fairly acute tenosynovitis, the injection is given as a relatively low-volume bolus typically with 20-mg Depo-Medrone and 2-mL 1% local anesthetic. However, if the condition is more chronic and if the ultrasound demonstrates significant synovial thickening within the peroneal sheath, a higher-volume injection may be given with 20-mg Depo-Medrone and 2-mL 1%local anesthetic and up to 20-mL normal saline. It is suggested that a connecting tube is used if this procedure is undertaken.

13.3.6 The Injection

See Fig.  13‑5 and Fig.  13‑6.

13.3.7 Notes

Careful consideration should be given to the foot position particularly in cases of chronic overuse. Occasionally, the peroneus brevis insertion onto the base of the fifth metatarsal is the problem and ultrasound of this area demonstrates an insertional tendinopathy. If this is the case, an injection may be given here using a fenestration technique.

13.4.1 Cause

• 
  

  Commonly overuse and related to overpronation of the foot in both the athlete and nonathlete.

13.4.2 Presentation

Pain is located around the medial aspect of the ankle posterior and below the medial malleolus. If the patient has an insertional tendinopathy, then the pain may be located at the medial aspect of the midfoot at the insertion of the tendon of tibialis posterior onto the medial aspect of the navicular and medial cuneiform. Pain may also be reproduced with resisted inversion of the foot.

13.4.3 Equipment

See Table  13‑4.

13.4.4 Anatomical Considerations

The tendon of tibialis posterior is the tendon positioned most anteriorly within the tarsal tunnel and is immediately behind the medial malleolus. Running directly behind tibialis posterior in the tarsal tunnel is the tendon of flexor digitorum longus. Moving further posteriorly is the neurovascular bundle consisting of the tibial nerve and posterior tibial artery and vein. Finally and most posteriorly the tendon of flexor hallucis longus can found as it runs between the medial and lateral posterior talar tubercles. This forms the so-called Tom (tibialis posterior), Dick (flexor digitorum longus), and Harry (flexor hallucis longus) of the tarsal tunnel.

13.4.5 Procedure

• 
  

  The patient is positioned in supine with the symptomatic leg externally rotated and the knee bent to 90 degrees. The lateral aspect of the ankle is supported on a pillow.

  
  
• 
  

  The transducer is placed in the oblique coronal plane longitudinally over the tibialis tendon posterior to the medial malleolus.

  
  
• 
  

  The needle is introduced in the longitudinal plane of the transducer from an inferior to superior direction so that it rests against the tendon.

  
  
• 
  

  Injection is given as a bolus.

  
  
• 
  

  If the condition is acute and inflamed indicating a fairly acute tenosynovitis, the injection is given as a relatively low-volume bolus typically with 20-mg Depo-Medrone and 2-mL 1% local anesthetic. However, if the condition is more chronic and if the ultrasound demonstrates significant synovial thickening within the tendon sheath, a higher-volume injection may be given with 20-mg Depomedrone and 2-mL 1%local anesthetic and up to 10-mL normal saline. It is suggested that a connecting tube is used if this procedure is undertaken.

13.4.6 The Injection

See Fig.  13‑7 and Fig.  13‑8.