Joint Injections
Tibiotalar Joint Injection
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Use of a high-frequency small footprint linear ultrasound transducer, like the “hockey stick,” is recommended for all ankle region and joint injections.
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Various injection approaches exist, and the choice depends on individual anatomy.
Pertinent Anatomy
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The ankle (also known as tibiocrural or tibiotalar) joint is a hinged synovial articulation between the distal tibia and fibula and the talus.
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The joint also allows primarily ankle plantarflexion and dorsiflexion.
Common Pathology
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Ankle joint pathology often presents with a joint effusion, associated with deep and diffuse pain with restricted range of motion.
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Ankle joint injury can be acute or chronic. Etiologic causes include arthritis, synovitis, fracture, chondral lesion, instability from chronic ligament or tendon pathology, or infection.
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On sonographic examination with the foot in slight plantarflexion and imaging the anterior joint recess, distention of the joint with anechoic fluid is the most sensitive location and position to identify an effusion.
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Of note, 1 to 2 mm of anechoic hyaline cartilage covers the talar dome, and it is important not to mistake this for intra-articular fluid.
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Tibiotalar intra-articular loose bodies are hyperechoic and may migrate to the medial ankle tendon sheaths, as these can communicate with the ankle joint.
Equipment
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High-frequency, small footprint, linear ultrasound transducer.
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30 to 25 gauge 1 to 2 inch needle.
Common Injectates
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Local anesthetics for diagnostic injections.
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Corticosteroids, hyaluronic acid, prolotherapy, orthobiologics (platelet-rich plasma [PRP], bone marrow concentrate, etc.).
Injectate Volume
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2 to 4 mL
Patient Position
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Supine or seated on the exam table.
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Knee flexed to approximately 90 degrees and ankle in slight plantarflexion so that the plantar surface of the foot is flat on the exam table.
Clinician Position
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Seated at the foot of the exam table facing the patient and ultrasound machine.
Transducer Orientation
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Preferred approach ( Fig. 22.1A ):
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Begin with the transducer in long axis to the distal tibia.
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Translate the probe distally to identify the joint space.
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Identify the tibialis anterior tendon in long axis; then translate the probe medial to the tibialis anterior tendon.
Fig. 22.1
(A) Ultrasound-guided tibiotalar joint injection setup for an in-plane, anterior to posterior approach. (B) Intra-articular tibiotalar joint injection using an in-plane, anterior to posterior approach. Arrows point to the needle. ANT , Anterior; Tal , talus; Tib , tibia.
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Alternative approach #1:
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The transducer is rotated 90 degrees from the position described above and is positioned in the transverse plane at the level of the joint.
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Alternative approach #2:
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The transducer is positioned as described in the preferred approach and translated laterally with the distal end and slightly rotated medially to view the anterior talofibular ligament (ATFL) in long axis.
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Needle Position
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Preferred approach: In-plane, anterior to posterior ( Fig. 22.1B ). This can also be accomplished using an out-of-plane approach.
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Alternative approach #1: In-plane, medial to lateral or lateral to medial with the needle coursing deep to the overlying tendons.
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Alternative approach #2: In-plane, anterior/distal to posterior/proximal, targeting both the tibiotalar joint and ATFL.
Target
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Anterior joint recess, deep to anterior fat pad, superficial to talar dome cartilage.
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There is risk of perforating tendon or neurovascular structures if they lie within the needle trajectory. The preliminary scan is helpful to identify at-risk structures, including the peroneal nerve branches, dorsalis pedis vessels, and anterior ankle tendons.
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Needle contact with the chondral surface should be avoided, since this can result in damage of the cartilage.
Subtalar Joint Injection
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Various injection approaches exist, and the choice depends on individual anatomy.
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The posterolateral approach is the preferred method by the authors due to less frequent anatomic variations in this region. This targets the posterior subtalar joint (PSTJ).
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Alternate approaches (anterolateral via sinus tarsi and posteromedial approaches) may be used; however, these approaches require careful consideration to avoid nearby tendons, nerves, and vessels and account for more anatomic variations common to these areas.
Pertinent Anatomy
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The subtalar joint (or talocalcaneal joint) is a multiarticulate joint where the talus articulates with the calcaneus through three facets: anterior, middle, and posterior.
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The joint primarily allows for ankle inversion and eversion.
Common Pathology
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Intra-articular subtalar joint pathology often presents with joint effusion.
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Pain is typically in the hindfoot and worse when walking on uneven surfaces. Joint pain is the most common result of post-traumatic arthritis.
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On sonographic examination of a subtalar joint effusion, anechoic intra-articular fluid can be visualized when the talus and calcaneus are both in view with anterolateral, posterolateral, or posteromedial transducer placement.
Equipment
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High-frequency, small footprint, linear ultrasound transducer.
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30 to 25 gauge 1 to 2 inch needle.
Common Injectates
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Local anesthetics for diagnostic injections.
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Corticosteroids, hyaluronic acid, prolotherapy, orthobiologics (PRP, bone marrow concentrate, etc.).
Injectate Volume
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1 to 3 mL
Technique
Patient Position
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Prone with the foot hanging off the edge of the exam table and ankle in dorsiflexion.
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Alternative approach: Lateral decubitus with the lateral ankle of the targeted side facing upward.
Clinician Position
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Seated or standing at the foot of the exam table facing the patient and ultrasound machine.
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Proceduralist knee or an assistant can be used to induce ankle dorsiflexion of the patient.
Transducer Orientation
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Preferred approach, posterolateral joint ( Fig. 22.2A ):
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Begin with a long-axis view of the Achilles tendon.
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Translate the transducer laterally while rotating the distal end of the transducer farther laterally. The final transducer position will be in the parasagittal plane.
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The angle of insonation of the ultrasound beam points toward the medial malleolus and calcaneus.
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Both the talus and calcaneus should be in view.
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In case of severe arthritis or difficulty visualizing the posterior joint recess, further anterior translation around the “corner” of the posterolateral calcaneus while maintaining the angle of insonation may allow for improved visualization (with the peroneal tendons in view superficial to the joint).
Fig. 22.2
(A) Ultrasound-guided subtalar joint injection set-up, for injection into the posterolateral joint. (B) Intra-articular subtalar joint injection using an in-plane, posterior distal to anterior proximal approach. Arrows denote the needle. ANT, Anterior, Calc, calcaneus; PT, peroneal tendons; Tal, talus.
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Alternative approach, anterolateral through the sinus tarsi. To find sinus tarsi:
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Begin at the third web space while visualizing third and fourth metatarsal bones in short axis and translate proximally.
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The first opening you will encounter after the mid-foot bones will be the sinus tarsi.
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Needle Position
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Preferred approach: In-plane, distal lateral to proximal medial ( Fig. 22.2B ).
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Alternative approach: Out-of-plane, anterior to posterior.
Target
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Preferred approach: PSTJ recess.
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Alternative approach: Anterior subtalar joint through the sinus tarsi.
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Use of gel stand-off technique over the posterolateral edge of calcaneus will allow for improved needle visualization during the injection.
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Given the steep angle of the needle in this approach, needle localization software may also be helpful to improve needle visualization.
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In the anterolateral approach through the sinus tarsi, the target is also deep and may require the use of a walk- down technique.
Ligament Injections
Anterior Talofibular Ligament
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The ATFL is the most commonly injured ligament in the ankle ( Figs. 22.3 and 22.4 ).
Fig. 22.3
Anterior Ankle Bony and Ligamentous Anatomy.
Fig. 22.4
Anatomy of the Lateral Ankle Ligaments.
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There have not been any high-quality studies on the ideal injectate volume, type of injectate, or clinical outcomes for ATFL injections.
Pertinent Anatomy
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The ATFL extends from approximately the distal 10 mm of the fibula to the neck of the talus, running 45 to 90 degrees anteriorly to the axis of tibia.
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Anatomic variation exists. ATFL may be single-, double-, or triple-bundled in morphology.
Common Pathology
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Injury typically results from inversion of the ankle and should be suspected in patients with tenderness over the ATFL and a positive anterior drawer test.
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On sonographic examination of an injured ATFL, the typically homogeneous hyperechoic ligament that courses obliquely from the anterior distal fibula to the talus will appear relatively hypoechoic or disrupted.
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It is important to note that the ATFL is prone to anisotrophy due to its nonlinear course and this should not be misinterpreted as a tear.
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Dynamic imaging while performing an anterior drawer test can be helpful in equivocal cases.
Equipment
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High-frequency, small footprint, linear ultrasound transducer.
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30 to 25 gauge 1 to 2 inch needle.
Common Injectates
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Prolotherapy, orthobiologics (PRP, bone marrow concentrate, etc.).
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Avoid intraligamentous corticosteroids.
Injectate Volume
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0.5 to 1 mL
Technique
Patient Position
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Supine or seated on the exam table.
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Knee flexed approximately to 90 degrees and ankle in slight plantarflexion so that the plantar surface of the foot is flat on the exam table.
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Alternatively, the patient can be place in the lateral decubitus position with the lateral aspect of the targeted ankle facing upward.
Clinician Position
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Seated or standing at the foot of the exam table, facing the patient and ultrasound machine.
Transducer Orientation
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The ligament is identified by palpating the distal fibular tip and placing the transducer in the transverse plane at the anterior aspect of the fibula ( Fig. 22.5A ).
Fig. 22.5
(A) Ultrasound-guided ATFL injection setup for an in-plane, anterior to posterior approach. (B) ATFL injection using an in-plane, anterior to posterior approach. ATFL (asterisk) is imaged in long axis. Arrows point to the needle. ATFL , Anterior talofibular ligament; Fib, fibula; PROX, proximal.
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The medial end of the transducer is distally rotated.
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The ligament is identified in long axis, spanning from the anterior distal fibula to the talus.
Needle Position
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Preferred approach: In-plane, anterior to posterior ( Fig. 22.5B ).
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Alternate approach: Out-of-plane, distal lateral to proximal medial.
Target
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Areas of hypoechogenicity or interstitial tears in the ATFL and cortical irregularities of the fibula and talus at the ATFL origin and insertion.
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Anterior ankle structures, such as the lateral tarsal branch of the inferolateral malleolar artery and intermediate dorsal cutaneous branch of the superficial peroneal nerve, should be identified and avoided during the injection.
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Often the anterior lateral malleolar artery travels adjacent to the mid portion of the ligament. An injured ATFL may have increased vascularization superficial to the ligament. Use color flow Doppler to identify vasculature and avoid it.
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Use of a gentle gel stand-off technique may allow for improved needle visualization during the injection. Aggressive stand-off will result in increased anisotropy of the ATFL.
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The injection can be combined with physical therapy, initially focusing on range of motion, then progressing to strengthening and proprioceptive training. A period of plantarflexion limitation can be considered, as dorsiflexion is the position of tension for ATFL.
Calcaneofibular Ligament (CFL)
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The calcaneofibular ligament (CFL) is commonly injured in combination with the ATFL.
Pertinent Anatomy
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The CFL originates from the tip of the lateral malleolus and inserts on the lateral side of the calcaneus (see Figs. 22.3 and 22.4 ).
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The CFL restrains inversion of the calcaneus with respect to the fibula.
Common Pathology
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The CFL is commonly injured with moderate to severe sprains of the ATFL with inversion injury.
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Isolated injuries can occur but are infrequent and occur when the ligament is under maximum strain with the foot in dorsiflexion.
Equipment
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High-frequency, small footprint, linear ultrasound transducer.
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30 to 25 gauge 1 to 2 inch needle.
Common Injectates
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Orthobiologics prolotherapy, orthobiologics (PRP, bone marrow concentrate, etc.).
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Avoid intraligamentous corticosteroids.
Injectate Volume
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0.5 to 1.5 mL
Technique
Patient Position
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Lateral decubitus position with the lateral aspect of the targeted ankle facing upward.
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Dorsiflexion of the ankle.
Clinician Position
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Seated or standing at the foot of the exam table, facing the patient and ultrasound machine.
Transducer Orientation
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Transducer in oblique coronal plane between the fibular tip and the posterior heel.
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The CFL is visualized under the peroneal tendons (seen in short axis) and appears as a hammock ( Fig. 22.6A ).
Fig. 22.6
(A) Ultrasound-guided CFL out-of-plane injection setup. (B) CFL out-of-plave injection.
Asterisk, Needle tip; Ca, calcaneus; CFL, calcaneofibular ligament; LM, lateral malleolus; PT, peroneal tendons.
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Long axis to the ligament.
Needle Position
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Out of plane in either direction ( Fig. 22.6B ).
Target
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Areas of hypoechogenicity or interstitial tears in the CFL.
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Use of gel stand-off technique may allow for improved needle visualization during the injection.
Posterior Talofibular Ligament
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The PTFL is the strongest and least commonly injured lateral ligament in the ankle, at a rate of 5% to 10%.
Pertinent Anatomy
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The posterior talofibular ligament (PTFL) originates from the malleolar fossa, located on the medial surface of the lateral malleolus, coursing almost horizontally to insert in the posterolateral talus (see Fig. 22.4 ).
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The ligament resists posterior displacement of the talus with respect to the fibula and tibia and is under most tension in dorsiflexion.
Common Pathology
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Isolated PTFL injury is rare and is mostly associated with severe ankle inversion injury resulting in tearing of the ATFL and CFL first.
Equipment
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High-frequency, small footprint, linear ultrasound transducer.
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30 to 25 gauge 1 to 2 inch needle.
Common Injectates
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Orthobiologics prolotherapy, orthobiologics (PRP, bone marrow concentrate, etc.).
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Avoid intraligamentous corticosteroids.
Injectate Volume
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0.5 to 1.5 mL
Technique
Patient Position
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Lateral decubitus position with the lateral aspect of the targeted ankle facing upward.
Clinician Position
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Seated or standing at the foot of the exam table facing the patient and ultrasound machine.
Transducer Orientation
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Long axis to the ligament ( Fig. 22.7A ).
Fig. 22.7
(A) Ultrasound-guided PTFL injection setup. (B) PTFL injection out-of-plane ultrasound injection. Asterisk, Needle tip; F, fibular head; PTFL, posterior talofibular ligament; T, talus.
Needle Position
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Out of plane in either direction ( Fig. 22.7B ).
Target
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Areas of hypoechogenicity or interstitial tears in the PTFL and cortical irregularities of the fibula and talus at the PTFL origin and insertion.
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Use of gel stand-off technique may allow for improved needle visualization during the injection.
Inferior Tibiofibular Ligaments Injection
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This injection can be performed using an in-plane or out-of-plane technique.
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Deltoid ligament injury can be associated with the same mechanism of anterior inferior tibiofibular ligament (AITFL) injury as well, so often both need to be evaluated and possibly treated.
Pertinent Anatomy
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The inferior tibiofibular joint is a syndesmotic articulation between the distal tibia and fibula and is stabilized by the AITFL and posterior inferior tibiofibular ligament (PITFL) (see Fig. 22.4 ).
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The interosseous tibiofibular ligament provides additional stabilization to the distal tibiofibular joint and extends between the crest of the fibula medially and proximally to the crest of the tibia, with its most distal portion approximately 1 cm proximal to the tibiotalar joint.
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Variability exists in the number of bundles or fascicles of the AITFL. , The AITFL is a flat ligament that courses superior and medial from the distal fibula to the distal tibia. An accessory AITFL (Bassett’s ligament) may also be identified as a discrete bundle distal to the AITFL, spanning a greater distance between the tibia and fibula in a slightly more horizontal orientation than the AITFL.
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The PITFL courses superior and medial from the posterior aspect of the distal fibula to the distal tibia and is analogous to AITFL. The deep portion of this ligament is referred to as the inferior transverse ligament and is identifiable in 70% of ankles.
Common Pathology
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The AITFL and distal tibiofibular joint are commonly injured by forced external rotation and dorsiflexion at the ankle.
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Isolated injuries to the AITFL can lead to external rotary instability, even with an intact PITFL.
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AITFL injuries can be evaluated with the dorsiflexion external rotation stress test, which causes joint widening.
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On sonographic examination of an injured AITFL, the typical homogeneously hyperechoic structure spanning between the anterior distal tibia and fibula will appear disrupted. Dynamic imaging with dorsiflexion and external rotation stress testing will show widening between the distal tibia and fibula in a grade 3 AITFL tear.
Equipment
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High-frequency, small footprint, linear ultrasound transducer.
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30 to 25 gauge 1 to 2 inch needle.
Common Injectates
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Prolotherapy, orthobiologics (PRP, bone marrow concentrate, etc.).
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Avoid intraligamentous corticosteroids.
Injectate Volume
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0.5 to 1 mL
Technique
Patient Position
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Lateral decubitus with the lateral ankle of the targeted side facing upward.
Clinician Position
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Seated or standing at the foot of the exam table, facing the posterior ankle and ultrasound machine.
Transducer Orientation
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The transducer is placed in short axis across the distal tibia and fibula.
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Identify the most distal aspect of the tibia. The lateral aspect of the transducer is rotated inferiorly on the distal fibula (anterior for AITFL or posterior for PITFL).
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The transducer will be long axis to the AITFL or PITFL ( Figs. 22.8A and 22.9A )
Fig. 22.8
(A) Ultrasound-guided AITFL injection setup for an in-plane, lateral to medial approach. (B) AITFL injection using an in-plane, lateral to medial approach. AITFL (asterisks) is imaged in long axis. Arrows point to the needle. AITFL , Anterior inferior tibiofibular ligament; Fib, fibula; LAT, lateral; Tib, tibia.
Fig. 22.9
(A) PITFL injection setup. (B) PITFL out-of-plane injection. Asterisk, Needle tip in PITFL; F, fibular; posterior inferior tibiofibular ligament; T, tibia.
Needle Position
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In-plane, lateral to medial ( Fig. 22.8B ).
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Alternatively, it can be out of plane in either direction ( Fig. 22.9B ).
Target
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Areas of hypoechogenicity within the ligament and/or area of maximum tenderness on sonopalpation.
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Use of a gel stand-off may allow for improved needle visualization during the injection.
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The superficial peroneal nerve courses superficial to the AITFL and this should be avoided. Out-of-plane injection risks injury to the peroneal nerve branches and is not recommended.
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Injection can be combined with physical therapy focused on range of motion and progressing to strengthening and proprioceptive training.
Deltoid Ligament Complex Injection
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The deltoid ligament consists of up to six bands, each of which can be targeted for injection using a slightly different transducer position and approach.
Pertinent Anatomy
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The deltoid ligament consists of superficial and deep components with up to six bands: (1) tibionavicular; (2) tibiospring, also called the plantar calcaneonavicular ligament; (3) tibiocalcaneal; (4) superficial posterior tibiotalar, (5) deep posterior tibiotalar; and (6) deep anterior tibiotalar ( Fig. 22.10 ).
Fig. 22.10
Anatomy of the Medial Ankle Ligaments.
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It attaches the tibia to the talus, navicular, and calcaneus and resists ankle eversion.
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The spring ligament has two main components: superomedial calcaneonavicular ligament (SMCNL) and inferior calcaneonavicular ligament (ICNL). Some anatomic variants also have a third band, referred to as the medioplantar oblique ligament. The SMCNL originates from the anterior middle facet of the subtalar joint and attaches medial side of the navicular articular margin. The ICNL originates between the anterior and medial subtalar facets and inserts on the lateral navicular break. The third band can originate between the first two and attaches to the navicular tuberosity.
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The SMCNL is intimately connected to the tibialis posterior tendon and superficial component of the deltoid ligament, adding medial stability for the ankle and hindfoot.
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The spring ligament helps to maintain arch height and stability and resists forefoot abduction.
Common Pathology
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Injuries to the deltoid ligament are less common than lateral ankle injuries. They occur with forced ankle eversion combined with external rotation.
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Injuries to the spring ligament accur most often in the SMCNL and are mostly correlated with posterior tibialis injury. One study found that 92% of patients with posterior tibialis dysfunction had damage to the SMCNL.
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Isolated spring ligament injury is rare but has been reported and is associated with loss of the foot arch.
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On sonographic evaluation, injury may be identified by disruption of the normal fibrillar pattern, diffuse hypoechoic enlargement, or discontinuity of the ligament with possible hyperechoic avulsion fracture fragments. ,
Equipment
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High-frequency, small footprint, linear ultrasound transducer.
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30 to 25 gauge 1 to 2 inch needle.
Common Injectates
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Prolotherapy, orthobiologics (PRP, bone marrow concentrate, etc.).
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Avoid intraligamentous corticosteroids.
Injectate Volume
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0.5 to 1.5 mL per ligament.
Technique
Patient Position
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Lateral decubitus with the medial ankle of the targeted side facing upward.
Clinician Position
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Seated or standing at the foot of the exam table, facing the patient and ultrasound machine.
Transducer Orientation
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Each component of the deltoid ligament (listed above) can be visualized spanning between the respective bones it connects ( Figs. 22.11A and 22.12A ).
Fig. 22.11
(A) Ultrasound-guided deltoid ligament injection setup for the deep anterior tibiotalar portion of the deltoid ligament. (B) Deltoid ligament injection using and in-plane, distal to proximal approach. Deep anterior tibiotalar portion of the deltoid ligament (asterisks) is imaged in long axis deep to tibialis posterior (TP) tendon. Arrows point to the needle. PROX, proximal; Tib, tibia.
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The transducer is oriented in long axis to the target ligament component.
Needle Position
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In-plane, distal to proximal ( Fig. 22.11B ).
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Alternatively, inject the ligaments out of plane ( Fig. 22.12B ).
Fig. 22.12
(A) Plantar calcaneal navicular ligament (spring ligament) setup. (B) Plantar calcaneal navicular ligament spring ligament injection. Asterisk, Needle tip; C, calcaneus; N, navicular bone; Sp, spring ligament.
Target
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Areas of hypoechogenicity within the ligament and/or area of greatest tenderness on sonopalpation.
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Evaluate each component of the deltoid ligament and pathologic-appearing bands.
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Care should be taken to identify and avoid the tibialis posterior, extensor digitorum longus (EDL) tendons, and tibial neurovascular bundle, as these structures course around the medial malleolus and run superficial to the posterior components of the deltoid ligament.
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Gel stand-off technique may allow for improved needle visualization during the injection.
Tendon Injections
Achilles Tendon or Paratenon Injection
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Intratendinous or peritendinous injections may be performed.
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Intratendinous injections are typically performed if there is a clear tendon defect, using an orthobiologic.
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If tendinosis or pathologic thickening without obvious tear is present for injection of orthobiologcs, needle passages (needle tenotomy/fenestration) might be needed in order to create space to inject.
Pertinent Anatomy
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The Achilles tendon is the longest, thickest, and strongest tendon in the body.
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It connects the gastrocnemius and soleus muscles to the calcaneus.
Common Pathology
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Tendinopathy or rupture of the Achilles commonly occurs 2 to 6 cm proximal to its insertion at the calcaneus, as this region is relatively hypovascular.
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On sonographic evaluation, tendinosis appears as a hypoechoic fusiform enlargement of the Achilles tendon without significant disruption of the tendon fibers. Increased neovascularity or hyperemia visualized on color or power Doppler is suggestive of tendinopathy and has been found to correlate with patient symptoms; vascularity should be evaluated with light transducer pressure and the foot in a neutral position so as to reduce the tissue tension. ,
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Partial-thickness Achilles tendon tears may initially appear as a more defined hypoechoic or anechoic area or cleft within the tendon.
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Tendinopathy associated with retrocalcaneal bursitis and Haglund’s deformity may occur at the Achilles tendon insertion.
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Haglund’s deformity is an enlargement of the posterior superior aspect of the calcaneus and, when present, has a more guarded prognosis in Achilles tendinopathy.
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On sonographic evaluation, findings may include (1) a hypoechoic region or thickened tendon size that may represent general tendinopathy; (2) an anechoic region within the tendon that may represent a tear; and/or (3) hyperechoic region that is likely due to calcification; finally, (4) calcaneal cortical irregularities representing enthesophyte may be seen.
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Care must be taken to ensure that anisotropy is not mistaken for pathology.
Equipment
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High-frequency linear ultrasound transducer.
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30 to 25 gauge 1 to 2 inch needle.
Common Injectates
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Prolotherapy, orthobiologics (PRP, bone marrow concentrate, etc.).
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Local anesthetic (diagnostic) or corticosteroid (therapeutic) can be used in peritendinous injections.
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Avoid intratendinous corticosteroids.
Injectate Volume
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1 to 3 mL intratendinous, or as much as can be injected without significant resistance.
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1 to 3 mL peritendinous.
Technique of Mid-Portion Achilles Tendon Injection
Patient Position
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Prone with the foot hanging off the edge of the exam table and ankle positioned in slight passive dorsiflexion applied by the clinician.
Clinician Position
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Seated at the foot of the exam table, facing the affected lateral ankle and ultrasound machine.
Transducer Orientation
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The mid-portion Achilles tendon is easily palpable. The Achilles tendon is visualized in short axis by placing the transducer in the anatomic transverse plane and in long axis by placing the transducer in the anatomic longitudinal plane ( Fig. 22.13A ).
Fig. 22.13
(A) Ultrasound-guided mid-portion Achilles tendon injection setup of an in-plane, lateral to medial approach targeting deep to the Achilles tendon. (B) Mid-portion Achilles tendon injection using an in-plane lateral to medial approach. The Achilles tendon (AT) is visualized in short axis. Arrows point to the needle. LAT, lateral.
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The injection can be performed in short axis or long axis to the tendon, whichever minimizes damage to surrounding healthy tissues.
Needle Position
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Preferred approach: In-plane, lateral to medial ( Fig. 22.13B ).
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Alternate approach: Out-of-plane, lateral to medial.
Target
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Intratendinous or peritendinous in regions of tendon hypoechogenicity, thickening, tears, hyperemia, or sonopalpation tenderness.
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When approaching the tendon laterally, care must be taken to avoid the sural nerve and small saphenous vein, which lie lateral to the Achilles.
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Color Doppler can be used to identify areas of neovascularization, a surrogate marker for neonerves, which are thought to contribute to pain in Achilles tendinopathy.
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Orthobiologic injections can be combined with an ultrasound-guided tendon scraping procedure which mechanically separates the deep surface of the Achilles tendon from Kager’s fat pad (as described later in this chapter).
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Procedures are often combined with an eccentric or heavy slow resistance exercise protocol.
Technique of Insertional Achilles Tendon Injection
Patient Position
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Prone with the foot hanging off the edge of the exam table and ankle positioned in slightly passive dorsiflexion applied by the clinician.
Clinician Position
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Seated at the foot of the exam table, facing the plantar aspect of the foot and ultrasound machine.
Transducer Orientation
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The insertional Achilles tendon is visualized in the anatomic longitudinal view by placing the transducer over the posterior aspect of calcaneus ( Fig. 22.14A ).
Fig. 22.14
(A) Ultrasound-guided insertional Achilles tendon injection setup for a distal to proximal approach. (B) Insertional Achilles tendon injection using an in-plane, distal to proximal approach. The Achilles tendon (AT) is visualized in long axis. Arrows point to the needle. Calc, Calcaneus; PROX, proximal.
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Can visualize some of the fibers in the transverse view as well.
Needle Position
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In-plane, distal to proximal ( Fig. 22.14B ).
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For the transverse view can also inject in-plane lateral to medial.
Target
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Areas of tendon hypoechogenicity, calcification/enthesopathy, and cortical irregularities.
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Evaluate for anisotropy, particularly at the calcaneal insertion of the Achilles, to avoid misidentifying a tear.
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Target tendon enthesis as well and excoriate, if desired, if insertional tendinosis is present.
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Percutaneous needle tenotomy/fenestration can also be performed until a change in tissue texture is achieved.
Tibialis Anterior Tendon/Tendon Sheath Injection
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Injury to the tibialis anterior tendon is less common than injury to other tendons about the ankle.
Pertinent Anatomy
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The tibialis anterior originates from the upper two-thirds of the lateral surface of the tibia. The tendinous portion passes beneath the inferomedial band of the extensor retinaculum to insert on the medial surface of the medial cuneiform and the base of the first metatarsal ( Fig. 22.15 ).
Fig. 22.15
Anterior Ankle and Mid Foot Musculature.
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The distal tibialis anterior tendon may have a longitudinal split near its insertion, which is a normal variant.
Common Pathology
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Injuries most commonly occur within 3.5 cm of the insertion.
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On sonographic evaluation, tendinopathy can be identified by loss of the typical hyperechoic and fibrillar echotexture of the tibialis anterior tendon. Anechoic fluid may also be present within the tendon sheath.
Equipment
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High-frequency, small footprint, linear ultrasound transducer.
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30 to 25 gauge 1 to 2 inch needle.
Common Injectates
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Prolotherapy, orthobiologics (PRP, bone marrow concentrate, etc.).
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Local anesthetic (diagnostic) or corticosteroid (therapeutic) can be used in peritendinous injections.
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Avoid intratendinous corticosteroids.
Injectate Volume
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1 to 3 mL intratendinous, or as much as can be injected without significant resistance.
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1 to 3 cc peritendinous.
Technique
Patient Position
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Supine or seated on the exam table.
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Knee flexed to approximately 90 degrees and ankle in slight plantarflexion so that the plantar surface of the foot is flat on the exam table.
Clinician Position
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Seated or standing at the foot of the exam table, facing the affected medial ankle and ultrasound machine.
Transducer Orientation
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The tibialis anterior tendon is visualized in short axis as the most medially located anterior ankle tendon when placing the transducer in the anatomic transverse plane anterior to the ankle joint ( Fig. 22.16A ).
Fig. 22.16
(A) Ultrasound-guided tibialis anterior peritendon injection setup for an in-plane, medial to lateral approach. (B) Tibialis anterior injection using an in-plane, medial to lateral approach. The tibialis anterior (TA) is visualized in short axis, superficial to the talus (Tal) . Arrows point to the needle. MED, Medial.
Needle Position
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In-plane, medial to lateral ( Fig. 22.16 ).
Target
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Tibialis anterior tendon or tendon sheath at site of tendon hypoechogenicity, enlargement, intra-sheath fluid, or sonopalpation tenderness.
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Identify and avoid the dorsalis pedis artery and deep fibular nerve which run laterally to the tendon.
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A longitudinal split of the distal tendon may be a normal variant and should not be mistaken for a split tear.
Extensor Digitorum Tendon/Tendon Sheath Injection
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Injection can be performed anywhere along the tendon from the ankle joint to the distal insertions at the phalanges.
Pertinent Anatomy
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The EDL muscle originates on the anterior tibia, runs down the front of the tibia anterior to the ankle joint and deep to the extensor retinaculum. It inserts on the middle and distal phalanges of digits 2 to 5 (see Fig. 22.15 ).
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The extensor digitorum brevis (EDB) muscle originates from the proximal lateral calcaneus, the interosseous talocalcaneal ligament, and the inferior extensor retinaculum and passes medially over the foot to insert on the lateral side of the EDL on digits 2 to 4.
Common Pathology
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The extensor tendons may become irritated as they course over the dorsal aspect of the foot.
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Tendinopathy of the EDL and EDB is commonly caused by shoes tied too tightly, resulting in compression of the tendons, or due to overuse, such as with running uphill for prolonged periods.
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On sonographic evaluation, each slip of the EDL and EDB can be visualized and evaluated for loss of the normal fibrillar tendon pattern or fluid within the tendon sheath.
Equipment
- •
High-frequency, small footprint, linear ultrasound transducer.
- •
30 to 25 gauge 1 to 2 inch needle.
Common Injectates
- •
Prolotherapy, orthobiologics (PRP, bone marrow concentrate, etc.).
- •
Local anesthetic (diagnostic) or corticosteroid (therapeutic) can be used in peritendinous injections.
- •
Avoid intratendinous corticosteroids.
Injectate Volume
- •
1 to 3 mL intratendinous, or as much as can be injected without significant resistance.
- •
1 to 3 mL peritendinous.
Technique
Patient Position
- •
Supine or seated on the exam table.
- •
Knee flexed approximately to 90 degrees and ankle in slight plantarflexion so that the plantar surface of the foot is flat on the exam table.
Clinician Position
- •
Seated or standing at the foot of the exam table, facing the affected lateral ankle and ultrasound machine.
Transducer Orientation
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The EDL tendon is visualized in short axis by placing the transducer in the axial plane over the anterior ankle ( Fig. 22.17A ).
