Transcript Anterior TaloFibular Ligament

Musculoskeletal Ultrasound of the
Foot And Ankle
Arthur Jason De Luigi, DO
Program Director, Sports Medicine Fellowship
Director of Sports Medicine
MedStar National Rehabilitation Hospital
MedStar Georgetown University Hospital
Disclosure
• Nothing to Disclose
OBJECTIVES
•
•
•
•
•
•
General Survey
Anteromedial
Superior
Posterior
Pathology
Injections
TABLE OF CONTENTS
•
•
•
•
•
General survey
Anterior
Lateral
Medial
Posterior
General survey
• Complex anatomy: > 26 bones,
33 joints
• Conceptual construct
– Hindfoot: tibia, fibula, talus,
calcaneus, ankle and subtalar
joint
– Midfoot: cuboid, navicular,
cuneiforms; arches of the foot
supported by static and dynamic
arch stabilizers
– Forefoot: metatarsals, phanges
Functional units
• Ankle
• Transverse tarsal joint
complex
– Calcaneocuboid
– Talocalcaneonavicular
• Tarsometatarsal joint
(Lisfranc)
TABLE OF CONTENT
•
•
•
•
•
•
General survey
Anterior
Lateral
Medial
Posterior
Plantar
Dorsum
•
•
•
•
•
Tibialis anterior
Extensor hallucis longus
Extensor digitorum longus
Deep peroneal nerve and dorsalis pedis artery
Anterior joint recess (effusion, loose bodies,
and synovial thickening)
• Anterior joint capsule
Extensors of ankle
• Crossing anterior to the ankle
–
–
–
–
–
Tibialis anterior (TA)
Extensor hallucis longus (EHL)
Extensor digitorum longus
Dorsalis pedis artery and vein
Deep peroneal nerve
• Place probe in transverse axis to
the tibia on anterior ankle near the
joint line
Anterior ankle
• TA
– Most medial
• EHL
• Dorsalis Vasculature (a,v)
• EDL
– Most lateral
• Each tendon is enclosed
within its own tendon
sheath
• Deep peroneal nerve (s)
– Close proximity to the
vascular bundle
• The inferior extensor
retinaculum (6) lies
superficial
• Both EHL and EDL have low-lying
myotendinous junction.
• Muscle belly comes in view quickly as the
transducer is moved proximally
Tibialis anterior
• Turn transducer to long-axis to tibia and place over TA
at level of the ankle
• TA is superficial to the anterior ankle joint recess,
which is filled with fat (f).
• The cartilage (6) appears as hypo/anechoic layer
superficial to the talar dome (TD)
Tibialis insertion
• Trace probe along the TA tendon to see its
insertion on the inferior aspect of medial
cuneiform and the base of 1st metatarsal
Extensor Hallucis Longus (EHL)
• Origins at anterior surface of
the fibula and interosseous
membrane for about the
middle two-fourths of its
extent, passes under the
inferior extensor retinaculum
(cruciate crural ligament) and
inserts on base of great toe
distal phalanx
• Extends the great toe, invert
and dosiflex the foot
EHL
• Return to distal tibia over TA tendon in long-axis and
move laterally;
• EHL is the next tendon in view
• The body of EHL (**) can be seen in supramalleolar
region
EHL over dorsal midfoot
• Following the EHL over talar neck (T),
navicular (N) and medial cuneiform (MC)
EHL insertion
• Trace distally over the course of the great
toe
• EHL inserts at base of distal phalanx
– An anatomical variation of EDB may send a
tendon and insert on base of proximal
phalanx, known as extensor hallucis brevis,
or EHB (^)
Extensor Digitorum Longus (EDL)
• Originates from anterior lateral
condyle of tibia, anterior shaft of
fibula and superior ¾ of
interosseous membrane
• Tendons contained within single
tendon sheath until divide
superficial to EDB
• Inserts on dorsal surface of
middle, and distal phalanges of
lateral four toes
EDL
• Level of the ankle
joint recess. The
inferior extensor
retinaculum (h) is
superficial to the
tendon
• Joint recess is
visible superficial
to the talar dome
cartilage (6)
Lisfranc Joint
• Important for mid foot stability
• Skeletal elements:
tarsometatarsal, intertarsal,
and intermetatarsal articular
surfaces
• Non-skeletal elements:
articular capsules, the various
ligaments
Lisfranc ligament
• Complex of ligament which extends
from plantar-lateral aspect of medial
cuneiform, passes in front of the
intermediate cuneiform ligament, and
inserts into the plantar-medial of
second metatarsal
• Oblique band connecting 2nd
metatarsals (M2) and intermediate
cuneiform (C2) to the medial
cuneiform (C1) most important
• Reinforces bony stability of base of the
2nd metatarsal between medial and
lateral cuneiforms
Dorsal Lisfranc ligament
• Place transducer in
transverse axis over
dorsal medial foot over
first and second
metatarsal (M1, M2)
Dorsal Lisfranc ligament
• Move proximally until medial cuneiform (C1) is seen, which
appears angular instead of round compared to metatarsals
• Lisfranc ligament (arrow) appears hyperechoic and fibrillar,
with a characteristic notch in C1 at its attachment
• C1 and M2 distance (arrowhead) should be minimal to
none
TABLE OF CONTENT
•
•
•
•
•
•
General survey
Anterior
Lateral
Medial
Posterior
Plantar
Lateral
•
•
•
•
•
Peroneus brevis
Peroneus longus
Superior peroneal retinaculum
Anterior TaloFibular Ligament (ATFL)
Calcaneo-Fibular Ligatment (CFL)
Peroneus groups
• Peroneus longus (PL)
– Originates at head of fibula, wraps
around cuboid laterally and enter
deep space of foot, inserting on
medial cuneiform and 1st metatarsal
• Peroneus brevis (PB)
– Originates at proximal 1/3 of fibula,
inserts on base of 5th metatarsal
• Both tendon wraps around
posterior lateral malleolus before
parting ways at peroneal tubercle
(aka trochlear process) on lateral
aspect of calcaneus
Lateral ankle ligaments
• Anterior talofibular ligament (ATFL)
– Most frequently injured structure in
lateral ankle sprain
– Generally two separate bands
– Loose during foot neutral and taut
when foot plantarflexed and inverted,
subject to injury
• Calcaneofibular ligament (CFL)
– The only ligament bridging both the
talocrural joint and subtalar joint
– Remain taut throughout entire ROM
• Posterior talofibular ligament (PTFL)
– Difficult to visualize on US
– Relaxed in neutral and plantar flexion,
taut in dorsiflexion
1 Tip of the lateral malleolus
2 Tibia
3 Anterior tibiofibular ligament
4 Distal fascicle of the anterior tibiofibular
ligament
5 Superior band of the anterior talofibular
ligament
6 Inferior band of the anterior talofibular
ligament
7 Lateral articular surface of the talus
8 Neck of the talus
9 Head of the talus
10 Calcaneofibular ligament
11 Talocalcaneal interosseous ligament
12 Cervical ligament
13 Talonavicular ligament
14 Navicular
Peroneus group, supramalleolar
• Place transducer on
transverse axis over
lateral ankle just
proximal to lateral
malleolus
• Peroneus longus (PL) is
superficial to the body
of peroneus brevis (PB),
with the PB tendon (^)
forming just deep to PL
tendon
Peroneus group, retromalleolar
• PB
– Condensed into mostly
tendon, and stays deep to
PL as the tendons course
around the malleolus
• Superior peroneal
retinaculum (^)
– connects calcaneus to
fibula (F) and may be
visible
• PTFL (↓) is deep to the
peroneal tendons
Peroneus group, inframalleolar
• Place transducer over
tip of fibula
• Deep to the inferior
peroneal retinaculum
(^), PL and PB may
appear oblique as they
diverge toward
peroneal tubercle
• The calcaneofibular
ligament (6) connects
fibula and calcaneus
Peroneal tubercle
• Move transducer slightly
caudal and locate the
• Peroneal tubercle (*)
– which appears like a peak
on the surface of calcaneus
• Deep to the inferior
peroneal retinaculum (^),
PL (g) and PB (a)
• Generally divides around
PT with PB maintains
superior and PL dives
inferior, as seen in the top
sonogram
Peroneus brevis insertion
• Place transducer
over lateral aspect
of base of 5th
metatarsal (5MT) in
longitudinal axis, PB
can be seen
inserting onto the
base
Peroneus Longus (PL)
• PL (s) tendon dives around cuboid (Cu) and travels deep until reaching 1MT
base, together with TP forming a tendinous stirrup
– Start at the lateral border of foot at cuboid, scan in longitudinal axis with PL
toward 1MT
• Plantar aponeurosis (^) is seen superficial to FDB
• FHL tendon appears hypoechoic given its oblique course in this view
Anterior TaloFibular Ligament (ATFL)
• Place transducer in
transverse axis over
anterior surface of
fibula parallel to
the plantar surface
of the foot
• ATFL (*) connects
between fibula (F)
and talus (T), deep
to the superior
extensor
retinaculum (^)
Anterior tibiofibular ligament
• Move transducer
cephalad until tibia
(T) comes in view
in close proximity
to the fibula
• Anterior
tibiofibular
ligament (*) is flat
and broad,
inserting slightly
obliquely from tibia
onto fibula
TABLE OF CONTENT
•
•
•
•
•
•
General survey
Anterior
Lateral
Medial
Posterior
Plantar
Medial
•
•
•
•
•
Posterior tibialis
Flexor digitorum longus
Posterior tibial nerve
Tibial artery and veins
Flexor hallucis longus
Tarsal tunnel
• Roof: flexor
retinaculum
• Floor: tibia and talus
and more inferiorly
the medial aspects
of the navicular and
calcaneus
• Content: tibialis
posterior (TP), flexor
digitorum longus
(FDL), tibial
vasculature, tibial
nerve, flexor hallucis
longus (FHL)
Tarsal tunnel, proximal ankle
• Transducer in transverse axis posterior to medial malleolus
• From anterior to posterior, TP is followed by FDL, the tibial veins
(v) and artery (a), tibial nerve, then finally FHL
• (Tom, Dick and A Very Nervous Harry).
• Achilles tendon (A) is barely visible at the edge of field
• At this level, most of FHL is hypoechoic muscle belly (dotted
line); the hyperechoic tendon can be difficult to distinguish
Tibialis posterior
• Place transducer in longitudinal axis with TP tendon
• The tendon sheath for TP is clearly visible
• At this level, TP travels with FDL; FHL is lateral to TP
and FDL
Tibialis posterior insertion
• Tracing TP pass the sustentaculum tali (ST) toward
its insertion at navicular (N); note the tendon
appears hypoechoic
• The hyaline cartilage (6) of talar head (Tal) appears
as a hypoechoic layer
Flexor Digitorum Longus (FDL)
• Tracing the FDL distally, the tendon crosses the
joint between talus and sustentaculum tali of
calcaneus before curving and diving deep into
the plantar surface
Flexor Hallucis Longus (FHL)
• Turning the transducer to longitudinal axis in retromalleolar
region, then short-axis slide posteriorly around the TP and FDL
tendons to reveal the FHL tendon
• FHL tendon is surrounded by fat pads (*), and its tendon
sheath appears hyperechoic
TABLE OF CONTENT
•
•
•
•
•
•
General survey
Anterior
Lateral
Medial
Posterior
Plantar
Posterior
•
•
•
•
•
Achilles tendon and paratenon
Plantaris tendon (as indicated)
Retrocalcaneal bursa
Retro-Achilles/Superficial Achilles bursa
Dynamic scanning in of Achilles (as indicated
to assist with tear evaluation)
Achilles tendon
• Confluence of gastrocnemius and
soleus, and inserts on calcaneus
• Also accepts plantaris tendon
• Strongest tendon in the body, and
frequently injured
• Surrounded by paratenon, a thin
layer of vascular tissue, without
tendon sheath—always abnormal
if surrounded by fluid
Gastrocnemius-Soleus longitudinal
• Start with proximal calf in longitudinal axis & scan distally
• Achilles tendon (A) can be seem forming as the
gastrocnemius (G) and soleus (S) converge into tendons
• Traumatic tear of the gastroc may be a source of calf pain
Gastrocnemius-Soleus transverse distal
• Sliding distally, the Achilles tendon (A) starts to converge
superficial to gastroc, and lateral gastroc bulk gives away to
mostly medial gastroc (MG)
• The transverse intermuscular septum (^) separates soleus (S)
from deep posterior compartment muscles (FDL, FHL, TP)
Achilles, longitudinal
• Place transducer in longitudinal axis over Achilles tendon
• Achilles (A) is thick, fibrillar and hyperechoic, inserting on
calcaneus. Hyperechoic paratenon (^) can be observed
• Anterior to the Achilles is Kager’s fat pad (K)
• Retrocalcaneal bursa may exist posterior to Achilles tendon
Achilles, horizontal
• Stand-off gel can help to reduce artifact
• Achilles tendon (A) should be fairly homogeneously
hyperechoic, superficial to the Kager’s fat pad.
Plantaris tendon (*) maybe visible as its distinct entity
TABLE OF CONTENT
•
•
•
•
•
•
General survey
Anterior
Lateral
Medial
Posterior
Plantar
Plantar surface
• Plantar Fascia
• Dynamic scanning
• Applying pressure for Morton’s neuroma,
and/or ultrasonographic Mulder’s click (as
indicated)
Plantar aponeurosis
• Strong fascia, connecting from calcaneus to
plantar plantar plant of metatarsal heads
• Three distinct bands
– Central: thickest, attached to calcaneal tuberosity,
divides into fascicles for each toes distally insert into
MTP and flexor tendons
– Lateral: attaches to medial process of the calcaneus
– Medial: thinnest, covers AbH
• Contribute to maintenance of both longitudinal
and horizontal arches
Plantar aponeurosis, PQ
• Place transducer in long axis over calcaneal
tubercle
• Plantar aponeurosis (s) is robust, superficial
to FDB and PQ
SUMMARY
• Complex anatomy, complicated by the depth
and the crossing of tissue planes
• Dynamic examination of tendons helpful
• Proper selection of transducer to maximize
resolution at depth and maneuverability in
exam
• Practice makes perfect
REFERENCES
•
•
•
•
•
•
•
•
•
•
Ansede G, Lee JC, Healy JC. Musculoskeletal sonography of the normal foot. Skeletal Radiol. 2010 Mar;39(3):225-42.
Epub 2009 May 1.
Hill RV, Gerges L. Unusual accessory tendon connecting the hallucal extensors. Anat Sci Int. 2008 Dec;83(4):298-300.
Bojsen-Møller F. Calcaneocuboid joint and stability of the longitudinal arch of the foot at high and low gear push off. J
Anat. 1979 Aug;129(Pt 1):165-76.
Melão L, Canella C, Weber M, Negrão P, Trudell D, Resnick D. Ligaments of the transverse tarsal joint complex: MRIanatomic correlation in cadavers. AJR Am J Roentgenol. 2009 Sep;193(3):662-71.
Desai KR, Beltran LS, Bencardino JT, Rosenberg ZS, Petchprapa C, Steiner G. The spring ligament recess of the
talocalcaneonavicular joint: depiction on MR images with cadaveric and histologic correlation. AJR Am J Roentgenol.
2011 May;196(5):1145-50.
Castro M, Melão L, Canella C, Weber M, Negrão P, Trudell D, Resnick D. Lisfranc Joint Ligamentous Complex: MRI With
Anatomic Correlation in Cadavers. AJR Am J Roentgenol. 2010 Dec;195(6):W447-55.
HG Potter MD et al. Magnetic resonance imaging of the Lisfranc ligament of the foot. Foot and Ankle International.
Vol 19. No 7. July 1998. p 438.
Woodward S, Jacobson JA, Femino JE, Morag Y, Fessell DP, Dong Q. Sonographic evaluation of Lisfranc ligament
injuries. J Ultrasound Med. 2009 Mar;28(3):351-7.
Witvrouw E, Borre KV, Willems TM, Huysmans J, Broos E, De Clercq D. The significance of peroneus tertius muscle in
ankle injuries: a prospective study. Am J Sports Med. 2006 Jul;34(7):1159-63. Epub 2006 Feb 21.
Chepuri NB, Jacobson JA, Fessell DP, Hayes CW. Sonographic Appearance of the Peroneus Quartus Muscle: Correlation
with MR Imaging Appearance in Seven Patients. Radiology. 2001 Feb;218(2):415-9.
REFERENCES
•
•
•
•
•
•
Golanó P, Vega J, de Leeuw PA, Malagelada F, Manzanares MC, Götzens V, van Dijk CN. Anatomy of
the ankle ligaments: a pictorial essay. Knee Surg Sports Traumatol Arthrosc. 2010 May;18(5):557-69.
Epub 2010 Mar 23.
Kotnis N, Harish S, Popowich T. Medial Ankle and Heel: Ultrasound Evaluation and Sonographic
Appearances of Conditions Causing Symptoms. Semin Ultrasound CT MR. 2011 Apr;32(2):125-41.
Lui TH, Chow FY. "Intersection syndrome" of the foot: treated by endoscopic release
of master knot of Henry. Knee Surg Sports Traumatol Arthrosc. 2011 May;19(5):8502. Epub 2011 Feb 3.
Fessell DP, Jacobson JA. Ultrasound of the Hindfoot and Midfoot. Radiol Clin North
Am. 2008 Nov;46(6):1027-43, vi. Review.
Moraes do Carmo CC, Fonseca de Almeida Melão LI, Valle de Lemos Weber MF,
Trudell D, Resnick D. Anatomical features of plantar aponeurosis: cadaveric study
using ultrasonography and magnetic resonance imaging. Skeletal Radiol. 2008
Oct;37(10):929-35. Epub 2008 Jun 25.
Stainsby GD. Pathological anatomy and dynamic effect of the displaced plantar
plate and the importance of the integrity of the plantar plate-deep transverse
metatarsal ligament tie-bar. Ann R Coll Surg Engl. 1997 Jan;79(1):58-68.
Thank You