Ultrasound Guided Interventional Procedures in.16 (1)

CHRONIC AND INTERVENTIONAL PAIN

REVIEWARTICLE

Ultrasound-Guided Interventional Proceduresin Pain Medicine: A Review of Anatomy,

Sonoanatomy, and ProceduresPart VI: Ankle Joint

Neilesh Soneji, MD, FRCPC and Philip W. H. Peng, MBBS, FRCPC, Founder (Pain Medicine)

Abstract: Ultrasound-guided injections in pain medicine are emerging asa popular technique for pain interventions. Ultrasound can be applied forprocedures of the ankle joint and surrounding structures. This review de-scribes the anatomy and sonoanatomy of the ankle joint, subtalar joint,and surrounding extra-articular structures relevant for intra-articular injec-tion. Second, it reviews injection techniques and the accuracy and efficacyof these intra-articular ankle injections.

(Reg Anesth Pain Med 2016;41: 99–116)

Foot and ankle pain is a common reason for presentation to pri-mary care physicians. Studies suggest that ankle pain affects

approximately 15% of individuals older than 55 years.1 The footand ankle region is anatomically complex, and identification ofpain triggers can be clinically challenging.2,3 Pain may be re-lated to various structures with multiple contributing etiologies(Table 1). In this review, we narrow the scope to interventions ofthe tibiotalar and subtalar joints.

The first objective of this review is to describe the anatomy andsonoanatomy of ankle structures relevant to tibiotalar and subtalarjoint interventions. The second objective is to examine the role ofimage-guided injections for those joints, specifically the accuracyand efficacy of ultrasound (US)–guided injection techniques.

METHODSA literature search of theMEDLINE databasewas performed

from January 1980 to December 2014 using the search terms“ultrasound,” “ultrasound-guided,” “pain management,” and dif-ferent 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 pub-lished in English was included.

From the Department of Anesthesia and Pain Management, University ofToronto and University Health Network–TorontoWestern Hospital, andWasserPain Management Centre–Mount Sinai Hospital, Toronto, Ontario, Canada.Accepted for publication September 24, 2015.Address correspondence to Philip W. H. Peng, MBBS, FRCPC, Founder

(Pain Medicine), Toronto Western Hospital McL 2-405, Department ofAnesthesia and Pain Management, Toronto Western Hospital, UniversityHealth Network, 399 Bathurst St, Toronto, Ontario, Canada M5T 2S8(e‐mail: [email protected]).

Equipment support was provided by Fujifilm Sonosite Canada. Internal fundingwas received from the Department of Anesthesia and Pain Management,University Health Network.

The authors declare no conflict of interest.Copyright © 2015 by American Society of Regional Anesthesia and Pain

MedicineISSN: 1098-7339DOI: 10.1097/AAP.0000000000000344

Regional Anesthesia and Pain Medicine • Volume 41, Number 1, Januar

Copyright © 2015 American Society of Regional Anesthesia and Pain

ANATOMY

Articular StructuresThe ankle is made up of 3 main articulations, which can be

evaluated with US: the tibiotalar joint (talocrural joint), thesubtalar joint (talocalcaneal joint), and the distal tibiofibular joint(syndesmotic joint) (Fig. 1).

The tibiotalar joint is a hinged synovial joint formed by thedistal ends of the tibia and fibula with the talus. A fibrous jointcapsule covers the anterior and posterior recesses. The tibiotalarjoint allows approximately 30-degree dorsiflexion and 50-degreeplantar flexion of the foot,4 and ankle stability is primarily pro-vided by the medial (MCL) and lateral collateral ligament(LCL) complexes.

The LCL is composed of the 3 ligaments: the anteriortalofibular, calcaneofibular (CFL), and posterior talofibular liga-ments (Fig. 2). The anterior talofibular ligament runs a horizontalcourse connecting the lateral malleolus to the lateral aspect of thetalus. It primarily restricts internal rotation of the talus in the mor-tise and is taut in plantar flexion. It is more susceptible to inversioninjury comparedwith the other 2 ligaments of LCL. The CFL con-nects the lateral malleolus with the calcaneus and has a verticaloblique angulation (Fig. 2). It is taut in the dorsiflexed positionand serves to prevent excessive dorsiflexion. The posteriortalofibular ligament is the deepest and strongest of the 3 ligaments(Fig. 2). It has a horizontal direction and connects the posterior as-pect of the lateral malleolus with the talus. It acts to prevent pos-terior talar shift.

The MCL, also known as the deltoid ligament, is a composi-tion of ligaments with superficial and deep layers (Table 2, Fig. 3).The main biomechanical function of the MCL is medial ankle sta-bility, primarily preventing abduction and lateral translation. TheMCL originates on the medial malleolus and inserts onto the na-vicular, calcaneum, and talus.5 The most common description ofthe MCL describes 6 components, 3 of which are always presentincluding the superficial tibiospring and superficial tibionavicularligaments, as well as the deep posterior tibiotalar ligament.6 Thepresence of the additional 3 ligaments is variable and includesthe superficial posterior tibiotalar and superficial tibiocalcanealligaments, as well as the deep anterior tibiotalar ligament.

The subtalar joint allows for combined range of motion, whichincludes plantar flexion-inversion-adduction and dorsiflexion-eversion-abduction. It is divided into 2 components, the anteriorand posterior parts, which function interdependently (Fig. 1).The posterior subtalar joint (posterior talocalcaneal joint) isformed by the posterior facet of the inferior aspect of the talusand the associated posterior facet of the calcaneus. The posteriorsubtalar joint is supported structurally by the anterior, medial, lat-eral, and posterior talocalcaneal ligaments. There is a communica-tion between the posterior subtalar joint and the tibiotalar joint inapproximately 10% to 20% of people.7,8 The posterior subtalarjoint is separated from the anterior subtalar joint by the structures

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TABLE 1. Causes of Chronic Ankle Pain

Structures Examples

Articular OsteoarthritisRheumatoid arthritisSeptic arthritisGout or pseudogoutReactive arthritis

Bone Osteochrondral lesions of the talusPosterior ankle impingement(os trigonum or Stieda process)

Occult fractures of hindfootFracture (nonunion)

Tendon Posterior tibial tendon dysfunction(adult-acquired flat-foot deformity)

Flexor halluces longus tendinitisAchilles tendinitis or retrocalcaneal bursitisPeroneal tendon pathology

Nerve Tarsal tunnel syndromeDPN entrapmentPosttraumatic or postsurgical neuritis

Ligament Chronic lateral instabilityChronic medial instability

Other Sinus tarsi syndromeAnterior ankle impingement (osseous or ligament)Malignancy

Soneji and Peng Regional Anesthesia and Pain Medicine • Volume 41, Number 1, January-February 2016

housed in the sinus tarsi (Fig. 1). The anterior subtalar joint(talocalcaneonavicular joint) facilitates inversion and eversion ofthe hindfoot.

The inferior tibiofibular joint is the distal-most articulationbetween the tibia and fibula and is formed by an upward projec-tion of the ankle joint synovial recess. The inferior tibiofibu-lar joint is supported by the anterior, posterior, and transversetibiofibular ligaments as well as the interosseous tibiofibularligament, which is a continuation of the interosseous mem-brane (Fig. 2).

Extra-Articular StructuresThe 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, MeEducational Series.

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Anterior Compartment Extra-Articular StructuresThe structures of interest in the anterior compartment include

the tibialis anterior (TA) tendon, the extensor hallucis longus(EHL) tendon, the extensor digitorum longus (EDL) tendon,and anterior tibial artery, as well as the superficial (SPN) anddeep peroneal nerves (DPN) (Fig. 4).

The details of the anterior compartment muscles are summa-rized in Table 3. The TA tendon is the most medial and prominenttendon on the dorsum of the ankle (Fig. 4). The EHL tendon lieslateral to the TA tendon at the level of the ankle and is palpable atthis location on dorsiflexion of the great toe. The EDL tendon lieslateral to the EHL tendon, passes beneath the extensor retinacu-lum, and splits into 4 slips, which insert onto the 4 toes.

The SPN and DPN are branches of the common peronealnerve, which is a branch of the sciatic nerve. In the middle thirdof the leg, the SPN typically emerges in the lateral (peroneal) com-partment between the peroneus brevis (PB)/longus (PL) musclesand anterior crural intermuscular septum, which separates thePB/PL and EDLmuscles. The SPN is often in contact with the deepsurface of this crural fascia (Figs. 4, 5).9–12 However, the SPNcan be found either in the anterior compartment or in separatebranches in both anterior and lateral compartment in up toone-third of patients (Fig. 5).11,13 In the lower leg, the SPN ispurely sensory and divides into the medial and intermediatedorsal cutaneous nerves.14,15 Collectively, the branches of theSPN provide sensation to the dorsum of the foot aside from thewebspace between the first and second digits, which is innervatedby the DPN.

The DPN crosses the ankle joint deep to the extensor ret-inaculum adjacent to the anterior tibial artery. At the distalend of tibia, the DPN lies between the EHL and EDL tendonslateral to the anterior tibial artery (Fig. 4).16 After providing abranch to the ankle joint, the DPN terminates to provide sensa-tion to the webspace between the first and second digits and amotor branch to extensor digitorum brevis muscle.17

Medial Compartment Extra-Articular StructuresThe important structures in the medial compartment include

the saphenous nerve (SaN) and the contents of the tarsal tunnel.The SaN is the longest branch of the femoral nerve and is the onlynerve that innervates the foot and ankle other than the sciaticnerve. In the distal lower extremity, the SaN runs posterior to themedial aspect of the tibia adjacent to the greater saphenous vein(Fig. 6). Approximately 3 cm above the medial malleolus, theSaN divides into anterior and posterior branches in relation tothe greater saphenous vein.18 The terminal branches provide

dial view. Reproduced with permission from Philip Peng

© 2015 American Society of Regional Anesthesia and Pain Medicine


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.

Regional Anesthesia and Pain Medicine • Volume 41, Number 1, January-February 2016 Ultrasound Guidance for Ankle Injections

sensation to skin around the medial malleolus and the medialaspect of the foot. Recent anatomic studies have suggested thatthe SaN also provides sensation to the periosteum of the medialmalleolus and the medial ankle joint capsule.19,20

The tarsal tunnel lies posterior to the medial malleolus and isroofed by the flexor retinaculum (Fig. 7). Its contents from ante-rior to posterior include the tibialis posterior (TP) tendon, theflexor digitorum longus tendon, the posterior tibial artery andveins, tibial nerve (TN), and the flexor hallucis longus (FHL)tendon (Fig. 7).

The TN is a branch of the sciatic nerve. At the level of theankle, the TN is usually identified posteromedial to the poste-rior tibial artery. The TN gives off a calcaneal nerve proximalto the medial malleolus and then continues to split into 2 terminalbranches: the medial and lateral plantar nerves (Fig. 7). Collec-tively, the TN provides sensory innervation to the plantar aspectof the foot and also supplies all of the intrinsic muscles of the footwith the exception of extensor digitorum brevis (by DPN).

TABLE 2. Medial Collateral (Deltoid) Ligament Anatomy

Ligament Components Comments

Superficial layerTibiospring Constant component

Lateral Compartment Extra-Articular StructuresThe structures of interest in the lateral compartment of the ankle

include the sural nerve (SuN) and the PB and PL tendons (Fig. 8).The SuN is a purely sensory nerve that is formed by branches

from the TN (medial sural) and the common peroneal nerve (lat-eral sural). In the distal third of the leg, the SuN runs adjacent tothe lesser saphenous vein between the peroneus tendons andAchilles tendon, providing sensation to the lateral aspect of thedistal leg, the lateral side of the foot, and the lateral border of thefifth digit (Fig. 8).21 Distally, the SuNmay anastomosewith the dis-tal branches of the SPN and can contribute innervation to thedorsal aspect of the third and fourth toes.22

The PB and PL muscles are the 2 muscles/tendons in the lat-eral compartment of the leg (Fig. 8). The PB and PL tendons passimmediately posterior to the lateral malleolus with the smaller PBtendon in a more anterior position. The PB tendon inserts onto thelateral aspect of the base of the fifth metatarsal. The PL tendoncontinues distally to the lateral malleolus inferior to the PB andcourses along the plantar aspect of the foot obliquely to insert ontothe lateral aspect of the base of the first metatarsal and lateral sur-face of medial cuneiform. The peroneus muscles collectively evertthe foot and contribute to plantar flexion of the ankle joint.

Tibionavicular Constant componentSuperficial posterior tibiotalar Presence variableTibiocalcaneal Presence variable

Deep layerDeep posterior tibiotalar ligament Constant component, largest

band in deltoidDeep anterior tibiotalar ligament Presence variable

Posterior Compartment Extra-Articular StructuresThe extra-articular structures of interest in the posterior com-

partment of the ankle include the Achilles tendon, retrocalcanealbursa and Kager fat pad. The Achilles tendon is the largest andstrongest tendon in the body (Fig. 8). It is formed through fusionof the gastrocnemius aponeurosis and the deeper soleus tendon



and inserts onto the calcaneus. The distal Achilles tendon is sepa-rated from the calcaneus by the retrocalcaneal bursa.

SONOANATOMYThe ankle and surrounding structures are amenable to visual-

ization using US. This review focuses on US-guided interventionsof the foot and ankle including tibiotalar and subtalar joint injec-tions as well as perineural ankle nerve injections.

Sonoanatomy Tibiotalar Joint and Subtalar JointThe tibiotalar and subtalar joints are reliably imaged with US.

A linear array transducer at frequencies of 6 to 15 MHz is usuallyideal for the examination of these structures. Higher frequenciesmay be required to examine more superficial structures in detail.

Sonoanatomy Tibiotalar JointThe anterior ankle joint is examined with the patient in the

supine or semirecumbent position and the knee flexed 90 degrees.The foot is placed flat on the examination table such that plantarflexion widens the tibiotalar joint space. The US is placed trans-verse to the tibia, just above the intermalleolar line. Structures visu-alized from medial to lateral include the TA tendon, EHL tendon,anterior tibial artery, DPN, and EDL tendon (Fig. 9A). The tendonsappear round and fibrillar, whereas the artery is pulsatile and an-echoic. The TA tendon is placed in the center of the screen, andthe probe is rotated 90 degrees. This allows visualization of thetibiotalar joint and anterior fat pad (Fig. 9B). The anterior synovialrecess is visualized between the distal tibia and the talar dome.

Sonoanatomy Subtalar JointThe posterior subtalar joint can be imaged using the antero-

lateral, posterolateral, and posteromedial approaches.

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FIGURE 3. Medial collateral (deltoid) ligament. A, Deep layer. B, Superficial layer. Reproduced with permission from Philip PengEducational Series.


For the anterolateral approach, the patient is placed in thepartial lateral decubitus position with the target leg in the nonde-pendent position. The ankle is inverted towiden the subtalar joint.The sinus tarsi is identified 1 finger-breadth anterior to the lateralmalleolus, and a linear probe is placed with the proximal aspect ofthe probe just anterior to the lateral malleolus and the distal probeoriented toward the calcaneus (Fig. 10A). The US probe is trans-lated toward the lateral malleolus such that the final probe positionis just anterior and parallel to the CFL (Fig. 10B). The peronealtendons can be visualized just caudal to the subtalar joint in thisview. The SuN also runs caudal to the joint at this location butmay not be visualized with this probe position.

For the posterolateral approach to subtalar joint, the patientis placed in the prone position with the foot overlying the exami-nation table. The ankle is dorsiflexed and inverted to open thesubtalar joint. The probe is placed in long axis to the Achilles ten-don with the distal end of the probe over the calcaneus. The probeis translated just lateral to the Achilles tendon and angled mediallyto identify the subtalar joint (Fig. 11).

For the posteromedial approach to subtalar joint, the patientis placed in the lateral decubitus position with the affected leg inthe dependent position. The ankle is everted to allow access to

FIGURE 4. Anterior view of the ankle. Reproduced with permission from

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themedial aspect of the subtalar joint. The probe is placed in a cor-onal plane with the cephalad aspect of the probe over the medialmalleolus and the distal end of the probe over the sustentaculumtali of the calcaneus (Fig. 12). It is imperative to be aware of theassociated structures of the tarsal tunnel at this location (Fig. 7).The flexor digitorum longus tendon can be visualized in long axisoverlying the joint. The TP tendon typically is slightly anterior,whereas the posterior tibial artery, TN, and FHL tendon are typi-cally posterior at this level.

Sonoanatomy Ankle NervesThe ankle nerves are relatively superficial structures well vi-

sualized with US. A linear array transducer at frequencies of 8 to12 MHz is usually ideal for the examination of these structures.Higher frequencies may be required to examine more superficialstructures in detail.

Superficial Peroneal NerveThe SPN is visualized with the patient in the supine position

and the hip internally rotated in order to allow access to the antero-lateral aspect of the lower extremity. The probe is placed in the

Philip Peng Educational Series.



TABLE 3. Anterior Ankle Compartment Muscles

Muscle Main Function Origin Insertion

TA Ankle dorsiflexion, foot inversion Superior condyle tibia and lateral tibia Medial surface medial cuneiform,medial base 1st metatarsal

EHL Great toe extension, ankle dorsiflexion Anteromedial fibula andinterosseous membrane

Distal phalynx great toe

EDL Lateral four digit extension,ankle dorsiflexion

Lateral condyle tibia, upper anteriorinterosseous membrane

Lateral 4 digits

Peroneus tertius Ankle dorsiflexion,foot eversion

Inferior 3rd of anterior surface of fibulaand interosseus membrane

Dorsum of base of 5th metatarsal


transverse orientation to the fibula approximately 4 to 8 cm abovethe lateral malleolus. The fibula is seen as a peaked structure,whereas the tibia is flat (Fig. 13). The SPN is typically found incontact with the deep surface of the crural fascia between thePB/PL and EDL muscles.9–12,23 As the nerve travels distally, itbecomes more superficial and penetrates the crural fascia at a var-iable distance from the lateral malleolus and becomes a subcuta-neous structure (Fig. 13). Studies have demonstrated the nervecan also liewithin the anterior compartment of the lower extremityor within both the lateral and anterior compartments via branching(Fig. 5).10,13 Thus, if the nerve is difficult to identify, consider-ation can be given to tracing more anteriorly or posteriorly.

Deep Peroneal NerveThe DPN is visualized with the patient in the supine position.

The US probe is placed in transverse orientation to the tibia. Thehyperechoic nerve can be scanned above the intermalleolar line

FIGURE 5. Three variations of the location of SPN. Intermuscular septum(peroneal) compartment. Reproduced with permission from Philip Peng



where it lies on the flat tibia adjacent to the pulsatile anterior tibialartery (Fig. 9). Below the intermalleolar line, the DPN lies on thesurface of the talus, often just lateral to the dorsalis pedis artery.

Saphenous NerveIn order to optimize scanning of the SaN, the patient is posi-

tioned so that the medial malleolus is accessible. This is accom-plished with the patient in the supine position, hip externallyrotated, knee flexed 25 degrees with a pillow under the ankle tobe scanned. The US probe is placed in transverse position proximalto the medial malleolus. The SaN commonly lies adjacent to thegreater saphenous vein in this location; however, this relationshipis not constant. The greater saphenous vein is compressible, appearsanechoic, and travels anterior to the medial malleolus at the level ofthe intermalleolar line (Fig. 14). If the vein is not identified, a tour-niquet can be applied to enhance engorgement. The SaN appearshyperechoic and can be traced more proximally once identified.

is located between the anterior compartment and lateralEducational Series.

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FIGURE 6. Anteromedial view of the ankle. Reproduced with permission from Philip Peng Educational Series.


Tibial NerveThe patient is positioned so that the medial malleolus is ac-

cessible similar to the SaN scanning position. The probe is placedtransverse to the tibia at the level of the medial malleolus such thatthe anterior part of the probe is in contact with the medialmalleolus, and the posterior part of the probe is directed towardthe Achilles tendon. This allows visualization of all structures ofthe tarsal tunnel (Fig. 15). The flexor retinaculum appears as a dis-tinct layer (hypoechoic layer sandwiched between 2 hyperechoiclayers). The TN is a hyperechoic round structure that is often,but not always, posterior to the posterior tibial artery, which is pul-satile.24 The TN is scanned proximal and distal to the medialmalleolus in short axis to attempt to identify the calcaneal, medial,and lateral branches, which are not always visible (Fig. 7). TheFHL tendon can be differentiated from the TNwith dynamic scan-ning by asking the patient to flex the great toe.

Sural NerveTo scan the SuN, the patient is placed in the lateral decubitus

position to allow access to the lateral malleolus. The US probe isplaced in transverse orientation to the fibula with the anterior part

FIGURE 7. Medial ankle. A, Medial view. B, Corresponding cross sectionPeng Educational Series.

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of the probe just cephalad to the lateral malleolus and the poste-rior part of the probe over the Achilles tendon. The SuN is ahyperechoic round structure, which lies within a subcutaneousfascial plane posterior to the peroneus tendon (Fig. 16). TheSuN consistently lies adjacent to the lesser saphenous vein, whichappears as an anechoic, compressible structure.21,25 A tourniquetcan be applied to enhance visualization of the lesser saphenousvein. The probe can be translated cephalad and caudad to optimizeidentification of the SuN.

INTERVENTION TO THE TIBIOTALAR ANDSUBTALAR JOINT

Patient SelectionJoint injections have historically played a role in the manage-

ment of musculoskeletal somatic foot and ankle pain. Tibiotalarand subtalar joint injections may be offered for either diagnosticor therapeutic purposes. In view of the wide array of pain genera-tors in the foot and ankle, targeted joint injections with local anes-thetic help to discern the articular contribution and can facilitatesurgical planning including joint arthrodesis.2,26,27 Administration

al view of ankle. Reproduced with permission from Philip



FIGURE 8. Lateral ankle. A, Lateral view. B, Corresponding cross sectional view of ankle. Reproduced with permission fromPhilip Peng Educational Series.


of local anesthetic and steroid into the joint may be indicated fortherapeutic purposes in osteoarthritis, rheumatoid arthritis, post-traumatic arthritis. and ankle impingement.28

Tibiotalar Joint Injection: AccuracyHistorically, clinicians performed tibiotalar joint injections

using anatomic guidance. Confirmation of needle tip location inthese cases is either by aspiration of synovial fluid or fluoroscopicconfirmation. Techniques for anatomically guided tibiotalar jointinjection have been described previously. The accuracy of anatom-ically guided techniques have been examined and vary from 81%to 100%29–31 in cadaver studies and 66% to 77% in clinical stud-ies.32,33 Three recent studies have evaluated the accuracy of USguidance for tibiotalar joint injection. All were cadaver studieswith reported US accuracies of 100%.30,31,34 Wisniewski et al30

directly compared anatomical versus US guidance for tibiotalarjoint injection and demonstrated the superior success rate of USguidance technique (85% anatomical guidance vs 100% USguidance). These studies suggest that US guidance is an accuratemodality for tibiotalar joint injection.

Tibiotalar Joint Injection: US-GuidedInjection Technique

The patient is placed in either a supine or semirecumbentposition with the knee 90 degrees flexed and the foot flat on theexamination table. A high-frequency linear US probe (6–15 MHz)is used for this procedure. The target is the anterior joint recess

FIGURE 9. Sonoanatomy of the anterior aspect of the ankle. A, Short-axfrom Philip Peng Educational Series.



between the distal tibia and the talar dome. The first step is toidentify the TA tendon either by palpation or by US. The USprobe is placed over the long axis of the TA tendon and translatedslightly medially. For an out-of-plane technique, a 25-gauge, 1.5-inch needle (larger size for hyaluronic acid injection) is insertedinto the joint (Figs. 17, 18) using hydrolocalization.35 The spreadof injectate is monitored throughout injection to ensure appropri-ate spread within the joint space instead of the fat pad. For an in-plane technique, a 22-gauge, 3.5-inch needle is used and insertedfrom the caudal to cephalad direction (Fig. 19) using hydrolo-calization. The ankle joint volume is 15 to 30 mL.36 The volumeof injectate is 3 to 4 mL of local anesthetic and steroid such as2% lidocaine and 40 mg methylprednisolone acetate.28,30,37

Subtalar Joint Injection: AccuracySimilar to the ankle joint, subtalar joint injection has histori-

cally been performed using anatomic guidance. The techniquesfor landmark and fluoroscopic guidance for subtalar joint injec-tions have been reviewed previously.37 All validation studies forthe landmark-guided technique were performed in cadavers, andaccuracy rates have ranged from68% to 100%.31,38,39 Kraus et al38

compared the anterolateral versus the posterolateral approach andfound that the posterolateral approach was more accurate than theanterolateral approach (success rates of 91% posterolateral vs68% anterolateral, P = 0.016). In another study in which the an-terolateral approach was used, Kirk et al39 reported an accuracyrate of 97%. However, he also noted extravasation outside thesubtalar joint in 27% of the injections (either within the ankle joint

is view. B, Long-axis view. *Fat pad. Reproduced with permission

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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 theposition of the patient and US probe. *Peroneus tendons. Bold arrow points to the entrance to subtalar joint. Reproduced with permissionfrom Philip Peng Educational Series.


or the peroneal tendon sheath). Fluoroscopic guidance techniquesfor subtalar joint injection have also been evaluated with accuracyrates ranging from 85% to 100%.40,41 Spread to adjacent struc-tures was also a concern in fluoroscopically guided injection.In a study by Ruhoy et al,41 up to 30% of fluoroscopic-guidedposteromedial subtalar joint injections were associated withspread to adjacent structures in the tarsal tunnel including theTN and tendon sheaths.

Ultrasound has emerged as an alternative image-guided mo-dality for subtalar joint injection. Cadaveric studies examining ac-curacy of US-guided subtalar joint injections have demonstrated

FIGURE 11. Sonoanatomy of the posterolateral approach to subtalar joUS probe. The top right diagram shows the anatomy. Cal indicates calcaReproduced with permission from Philip Peng Educational Series.

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accuracy rates of 90% to 100%.34,42 Smith et al42 compared theaccuracy of US-guided subtalar joint injections using 3 differentapproaches in a cadaveric model: anterolateral, posterolateral,and posteromedial. All 3 approaches were associated with intra-articular medication placement rates of 100%. However, 19% ofinjections overallwere found to have injectate involving surround-ing structures including the tibiotalar joint, peroneal sheath, FHLsheath, and outside the posterior subtalar joint. Reach et al34 stud-ied US-guided injection of feet in 10 cadaver specimens. This ca-daveric study reported a 90% accuracy of injecting the subtalarjoint with sonographic guidance. The 1 missed injection in this

int. The top left diagram shows the position of the patient andneus; Ta, talus. Bold arrow points to the entrance to subtalar joint.



FIGURE 12. Sonoanatomy of the posteromedial approach to subtalar joint. Top right diagram shows the patient position.Bottom right diagram shows the anatomyandprobe position. Bottom left sonogram shows the posterior tibial artery.M indicatesmedialm.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 deepto the crural fascia (bold arrows). B, SPN is enclosed in the crural fascia. C, SPN is superficial to the crural fascia. **PB tendon. F indicatesfibula. Arrowheads point to the intermuscular septum. Reproduced with permission from Philip Peng Educational Series.


© 2015 American Society of Regional Anesthesia and Pain Medicine 107

Copyright © 2015 American Society of Regional Anesthesia and Pain Medicine. Unauthorized reproduction of this article is prohibited.

FIGURE 14. Sonoanatomy of the saphenous nerve. The left diagram shows the anatomy and the position of the probe. SV indicatessaphenous vein. Line arrows point to SaN. Reproduced with permission from Philip Peng Educational Series.


study demonstrated dye primarily in sinus tarsi. However, thisstudy did not specify the approach of the injection or the experi-ence of the person who performed the injection. A recent cadav-eric study by Smith et al43 evaluated US-guided injection of thesubtalar joint via the sinus tarsi and found accuracy rates of100%. The review of studies suggests that US guidance is anacceptable modality for injection of the subtalar joint. Rates ofextravasation outside the joint are comparable for US, FL, andanatomically guided subtalar joint injections.

Subtalar Joint Injection—US-GuidedInjection Technique

The subtalar joint can be injected using the anterolateral, pos-terolateral, or posteromedial techniques as outlined previously.The authors prefer the anterolateral approach because of ease of

FIGURE15. Sonoanatomy of the tarsal tunnel. The flexor retinaculum (bsandwiched between 2 hyperechoic layers). Note the neurovascular bunFHL muscle and tendon (*). The TN can be differentiated from FHL tenddigitorum longus; A and V, posterior tibial artery and vein. Reproduced

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probe position as well as lack of proximity to neurovascular struc-tures in the tarsal tunnel.

The patient is placed in the lateral decubitus position withthe affected leg in the nondependent position. A high-frequencylinear US probe (6–15 MHz) is used for this procedure. The tar-get is the posterior subtalar joint between the talus and the calca-neus, posterior to the sinus tarsi. An out-of-plane technique is thepreferred approach.

The first step is to place the probe in long axis to the fibulawith the proximal aspect of the probe just anterior to the lateralmalleolus and the distal probe oriented toward the calcaneus(Figs. 20, 21). A 1.5-inch, 25-gauge needle (larger size forhyaluronic acid injection) is inserted out-of-plane into the jointusing hydrolocalization. The spread of injectate is monitoredthroughout injection to ensure appropriate spread within the joint.The volume of injectate is 3 to 4mL of local anesthetic and steroidsuch as 2% lidocaine and 40 mg methylprednisolone acetate.37,43

old arrows) classically appears as a 3-layer structure (hypoechoic layerdle typically “rests” on the fascial layer (line arrows) overlying theon seen by extending and flexing the big toe. FDL indicates flexorwith permission from Philip Peng Educational Series.



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.


Tibiotalar and Subtalar Joint Injection: Efficacy

Diagnostic RoleIntra-articular injections are commonly performed for diag-

nostic purposes and to facilitate surgical decision making. Lit-erature generally supports the correlation of a positive local

FIGURE 17. Out-of-plane needle insertion to the tibiotalar joint. Sonograthe anatomy and probe position. Bold arrow points to the joint entrance;Educational Series.



anesthetic intra-articular injection with a successful surgical out-come.44,45 Specific to foot and ankle injections, Khoury et al27 re-ported that intra-articular injection of local anesthetic in painfulfoot and ankle joints helped to confirm source of pain in 20 of22 patients, which in turn led to successful arthrodesis outcomes.Another study showed that the result of diagnostic foot and ankle

mshows the long-axis scan of the tibiotalar joint. Left diagram showsline arrows, needle. Reproducedwith permission from Philip Peng

109


FIGURE 18. Lateral and posterolateral fluoroscopy of the ankle following US-guided injection of the tibiotalar joint. Contrast can be seenretained in the tibiotalar joint. Reproduced with permission from Philip Peng Educational Series.


blocks could influence the surgeon's perception of the source ofpain and alter surgical decision making in 82% of patients.46

However, a recent well-designed study by Stegeman et al47 re-futed the positive diagnostic value of intra-articular foot andankle injections. This study concluded that surgery, irrespec-tive of presence of pain reduction with diagnostic block, wasthe most important predictor for improvement of pain and footfunction scores. Despite this controversy, clinicians regularlyutilize diagnostic injections to clarify etiology of foot and anklepain and to support surgical decision making.

Therapeutic RoleThe majority of publications on the therapeutic efficacy of

intra-articular corticosteroids are confined to the knee and hip re-gions, with very few studies examining the efficacy of injectionsin the foot and ankle. A summary of studies assessing efficacyof foot and ankle steroid injections can be found in Table 4. Only1 study has been performed on the adult population (osteoarthritis

FIGURE 19. In-plane needle insertion to the tibiotalar joint. Sonogram sthe anatomy and probe position. Bold arrow-joint entrance. Reproduced

110


or rheumatic arthritis),48 and the other 3 were on the pediatric pop-ulation (juvenile idiopathic arthritis [JIA]).40,49,50Ward et al48 per-formed a study on adult patients receiving various fluoroscopicguided joint injections in the foot and ankle. This study found sig-nificant improvement in Foot and Ankle Outcome Score (FAOS,40%–65%) up to 6 months following corticosteroid injection. TheFAOS is a 42-item patient self-administered questionnaire validatedfor the assessment of pain, function, and quality of life. While thisstudy concluded that intra-articular corticosteroid was associatedwith improved foot and ankle scores, the duration of responsewas varied, and patient factors affecting response were unclear.

Three other pediatric studies evaluated the role of subtalarand tibiotalar injections with a specific focus on JIA or juvenilechronic arthritis.40,49,50 The injections were all performed underimage guidance (fluoroscopy, n = 2; US, n = 1). All concluded apositive response (Table 4). Outcome measurements varied in dif-ferent studies. Remedios et al49 used subjective clinical improve-ment, and “remission” was reported in two-thirds of the patientsfor at least 6 months. Cahill et al40 found improvement of foot

hows the long-axis scan of the tibiotalar joint. Left diagram showswith permission from Philip Peng Educational Series.



FIGURE20. Out-of-plane needle insertion to the subtalar joint. Sonogram shows the anterolateral approach to the subtalar joint. Bottom rightdiagram shows the anatomy and probe position. Line arrows point to the needle; bold arrows, joint entrance. Reproduced with permissionfrom Philip Peng Educational Series.


eversion/inversion in 89% of the patients with resolution ofsymptoms in 44% of the patients for an average of 3.25 months.Laurell et al50 measured the objective improvement with changeof mean synovial thickness (MST). The vast majority of patientsshowed significant reduction of MST, and 72% showed absenceof active arthritis. No major complications were reported in anyof these studies. However, there has been a wide range of minoradverse effects reported after steroid injection (ie, localsubcutaneous atrophy and hypopigmentation) ranging from lessthan 2% to 53%.40,51

In summary, intra-articular corticosteroid injections arewidely utilized for foot and ankle arthritis. Several small studieshave reported short-term benefit of intra-articular foot and ankleinjections; however, there are limited good-quality studies thathave assessed their long-term efficacy.52 Larger randomized con-trolled trials are required to better evaluate efficacy and safety ofintra-articular foot and ankle steroid injections, particularly forlong-term outcomes in the adult population.

FIGURE 21. Lateral and oblique fluoroscopy of ankle following the US-gin the subtalar joint. Reproduced with permission from Philip Peng Educ



More recently, alternate injection options for tibiotalar andsubtalar joints have also been studied including viscosupplemen-tation and platelet-rich plasma. A summary of studies evaluatingthe efficacy of viscosupplementation for ankle joint injectioncan be found in Tables 5 and 6. Five randomized controlled trialsand 6 prospective cohort studies have evaluated the efficacy ofviscosupplementation for ankle arthritis.

Three randomized double-blind controlled studies have com-pared viscosupplementation to saline.54,55,57 Studies by Cohenet al55 and Salk et al57 both included a series of 5 injections sepa-rated by 7-day intervals. Cohen et al55 used fluoroscopic guidanceand demonstrated greater improvement in Ankle OsteoarthritisScale (AOS) in the hyaluronic acid group at the 3-month markcompared with control (−17.4 ± 5 vs −5.1 ± 4; P = 0.0407). AnkleOsteoarthritis Scale is a patient-administered questionnaire with9-item pain subscale and 9-item disability subscale used to evalu-ate pain and disability related to ankle osteoarthritis. Salk et al57

used anatomic guidance and demonstrated improvement in both

uided injection of the subtalar joint. Contrast can be seen retainingational Series.

111


TABLE

4.Efficacyof

Intra-Artic

ular

Foot

andAn

kleSteroidInjections

Stud

y/Stud

yTyp

eCau

se/Age,*yNo.Patients/Im

age

Metho

dNo.

Injections/Injectate

JointsInjected

Outcome

Follow-up,mo

Effect

Adverse

Events

Wardetal,482008/PC

OA/RA/66

18/F

36/M

PTT/ST11;S

T/TN2;

TT/TN2;

ST2;

MT1

FAOS†

12Im

proveaverage

FAOS40%–65%

≤6moafterinjection

None

Rem

ediosetal,49

1997/PC

JCA/10

9/F

13/TA

TT7ST

6Su

bjectiveclinical

improvem

ent

≤16

Rem

ission

in66.7%

≥6mo

None

Cahill

etal,402007/RC

JIA/6.7

38/F

55/TA

STIm

proved

foot

inversion/eversion;

clinicalresolutio

n‡

3.3

89%

Patientsimproved

foraverage1.2y;44%

LocalSC

atrophyor

skin

↓pigm

entation53%

Laurelletal,502011/PC

JIA/6.5

30/US

85/TA

TT31,S

T26

MST

§;AAA§

1MST

↓TT,87%;

ST,95%

;AAA

(overall)

72%

SCatrophy4.7%

*Age

provided

either

meanor

medianageas

reported

inoriginalstudy.

†FAOS,

apatient

administered42-item

questio

nnaire

onthepain,functionandquality

oflifeassessment;FU

:followup

months.

‡Resolutionwas

definedas

norm

alrangeof

motionwith

outp

ainandlim

ping

13weeks

afterinjection;

§The

resultshow

edthenumberof

jointswith

either

norm

alizationof

MST

(≥80%

decrease)or

regression

(20%

–80%

decrease).

AAAindicatesabsenceof

activearthritis;F,fluoroscopy;JIA

orJC

A,juvenile

idiopathicor

chronicarthritis;M

P,methylprednisolone;MT,metatarsal;OA/RA,osteoarthritis/rheum

atoidarthritis;P

C,prospec-

tivecohort;R

C,retrospectivecohort;S

C,subcutaneous;ST

,subtalar;TA

,triam

cinolone;T

N,talonavicular;T

T,tib

iotalar.


112 © 2015 American Society of Regional Anesthesia and Pain Medicine


TABLE

5.Efficacyof

Viscosup

plem

entatio

nAn

kleJointRa

ndom

ized

Con

trolledTrials

Stud

yAge,*y

ImageMetho

d/No.Patients

Injectate

No.

Doses/Interval

Outcome/

Follow-up

Effect

Adverse

Events

Qua

lity†/Allo

cation

Con

cealment

Sunetal,53

2014

50.6±10.3

N/75

Hyalgan

500–730kd

+PT

12wkvs

BoN

T-A

1AOS‡

total/6

mo

Negative,no

difference

betweengroups;change

AOS;

HA4.7±1.0

→2.7±1.0BoN

T-A

4.9±1.5→

2.6±1.2

AMDbetweengroups

(95%

confidence

interval);

−0.2(−0.5to

0.2),P

=0.39

Transient

swellin

g5.9%

2/−

DeG

root

etal,54

2012

54.1±14.5

F/64

Supartz620–1170

kdvs

salin

e1

AOFA

S§/12wk

Negative—

nodifference


AOFA

S;HA4.97

±10.3

(1.6–8.3);salin

e5.43

±16.3

(−1.6to

12.4);between-group

difference;P

=0.897

1Patient

enlarged

inguinallymph

node

5/+

Cohen

etal,55

2008

49.8

F/30

Hyalgan

500–730kd

vssalin

e5/7d

AOStotal/3

mo

Positivechange

AOS;

HA:−

17.4±5.0;

salin

e:−5

.1±4.0between-group

difference;P

=0.041

1Patient

ankleeffusion,

pseudogout

4/−

Karatosun

etal,56

2008

55.1

N/30

Adant

900kd

vsexercise

therapy

3/7d

AOFA

S/12

mo

Negative—

nodifference


AOFA

SHA:6

1.6(16.8)

→90.1

(9.7),P<0.01,

ET:7

2.1(16.6),

87.5

(17.5),P

<0.01

None

2/+

Salk

etal,57

2006

58.8±14.4

N/17

Hyalgan

500–730kd

vssalin

e5/7d

AOStotal/6

mo

Negative—

nodifference


AOS;

with

in-group

difference

both

groups;

F=17.62,P<0.01

between-groupdifference;

F=1.05,P

=0.3210

None

2/−

*Age:m

ean.

†Quality:

Jadadscores

forrandom

ized

controlledtrial.

‡Patient-adm

inisteredquestio

nnairewith

9-item

pain

subscaleand9item

disabilitysubscale.

§100-Point

scorecombinessubjectivepatient

dataon

pain

andmobility

with

objectivedatafrom

thephysicalexam

inationof

theankleandhindfoot.

AMDindicatesadjusted

meandifference;B

oNT-A,botulinum

toxintype

A;E

T,exercise

therapy;

F,fluoroscopicguidance;H

A,hyaluronicacid;N

,anatomicguidance;V

AS,

visualanalog

scale.


© 2015 American Society of Regional Anesthesia and Pain Medicine 113


TABLE

6.Efficacyof

Viscosup

plem

entatio

nAn

kleJointProspe

ctiveCoh

ortStud

ies

Stud

yAge,y

ImageMetho

d/No.Patients

Injectate

No.Doses/

Interval

Outcome/

Follow-up

Effect

Adverse

Events

Hernandez

etal,582013

60F/18

Synvisc6000

kd3/15

dAOFA

S/12

mo

Positivechange

AOFA

S61.8

±15.0→

73.7

±16.6

None

Sunetal,592011

51.7±14.4

N/46

Hyalgan

500–730kd

3/7d

AOStotal/6

mo

Positivechange

AOS

5.5±2.1→

3.2±1.9,P<0.05

None

Mei-D

anetal,602010

43N/16

Adant

600–1200

kd5/7d

VASpain/32wk

Positivechange

VASpain

5.29

→3.05,P

<0.001

1(0.01%

)localp

ain

Luciani

etal,612008

45±15.9

N/21

Synvisc6000

kd3/7d

AOSpain/18mo

Positivechange

AOSpain

44.5

±19.9→

34.4

±20.8,P

<0.001

52%

transient

pain/erythem

a<48

hWitteveenetal,622008

41±12.3

N/55

Synvisc6000

kd1or

2/1–3mo

VASpain/6

mo

Positivechange

VASpain

68→

34.2,P

<0.001

17(30.9%

)mild

tomoderate

localadverse

effects

Sunetal,632006

50.2±14.3

N/75

Artz620–1170

kd5/7d

AOFA

S/6mo

Positivechange

AOFA

S64

±17

→78

±14,P

<0.001

6.7%

localadverse

effects

Age:M

ean.

ImageMethod:F–fluoroscopicguidance,N

–anatom

icguidance,Pts:N

umbero

fpatients,Outcome:AOS–Ankleosteoarthritisscalescore,patientadministeredquestionnairewith

9itempainsubscaleand9

item

disabilitysubscale.A

OFA

S-American

OrthopaedicFoot

&AnkleSo

cietyclinicalratingscore,100pointscorecombinessubjectivepatient

dataon

pain

andmobility

with

objectivedatafrom

thephysical

exam

inationof

theankleandhindfoot.V

AS–Visualanalogscale.


114


the hyaluronic acid and saline control groups at 6 months. Whilethis study has been quoted as having a positive result in prior re-views, the primary outcome comparing AOS between groupswas negative. The study by DeGroot et al54 was anatomicallyguided and used 1 injection only. This study demonstrated im-provement in the American Orthopedic Foot and Ankle Society(AOFAS) clinical rating score at 12 weeks; however, there wasno difference between groups at this time point. The AOFAS isthe American Orthopaedic Foot & Ankle Society clinical ratingscore, a 100-point score that combines subjective patient data onpain and mobility with objective data from the physical examina-tion of the ankle and hindfoot. Two additional randomized con-trolled trials compared viscosupplementation with botulinumtoxin and/or exercise therapy.53,56 Neither of these studies demon-strated a difference between groups with both study arms demon-strating benefit at 6 and 12 months, respectively.

All 6 prospective cohort studies evaluating viscosupple-mentation for osteoarthritis have demonstrated therapeutic effi-cacy ranging from 6 to 18 months, with the majority of studiesincluding a series of 3 or more injections.58–63 Ameta-analysis ex-amining efficacy of viscosupplementation for ankle arthritis con-cluded that intra-articular hyaluronic acid can significantly reducepain in ankle osteoarthritis and is likely superior to reference ther-apy.64 Viscosupplementation for subtalar joint arthritis has beenevaluated in 1 pilot prospective cohort study, which demonstratedanalgesic benefit at 28 weeks (AOFAS scores: 54.5 at baseline,73.7 at week 28; P < 0.01).65 No major adverse events were re-ported in any of the prospective studies, and minor local adverseeffects ranged widely from 0.01% to 51%.60,61

In summary, while viscosupplementation continues to be anoption for management of patients with ankle arthritis, studieshave reported conflicting results with regard to primary outcomesof pain and disability. Larger randomized controlled trials usingimage guidance for injection are required to better evaluate safetyand efficacy of this treatment modality. The efficacy of platelet-rich plasma for foot and ankle pathology is beyond the scope ofthis article.

CONCLUSIONSThe anatomical structures of the foot and ankle can be read-

ily identified using US. Intra-articular injection of the tibiotalarand subtalar joints can be reliably performed with image-guidedtechniques including fluoroscopy and US. Anatomic guidancealone for tibiotalar and subtalar joint injections is associated withlower accuracy rates.

The evidence for efficacy of intra-articular steroid injectionfor tibiotalar and subtalar joint arthritis is moderate, with studiesprimarily demonstrating short-term benefit. Viscosupplementa-tion for ankle arthritis continues to be a controversial treatmentmodality. Further randomized controlled trials are required tobetter evaluate the safety and efficacy of intra-articular foot andankle injections.

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Ultrasound Guided Interventional Procedures in.16 (1)

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