Shane A. Shapiro, M.D. Assistant Professor, Orthopedic Surgery Mayo Clinic 2012 MFMER slide MFMER slide-3

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Ultrasound Foot and Ankle Pathology Disclosures

Assistant Professor, Orthopedic Surgery Mayo

Foot and Ankle Fundamentals AIUM Practice

usually focused on specific structure(s) of

of the foot is satisfactory for complete US

Medial, Lateral, Posterior ankle Hindfoot,

Tibio-talar joint Anterior recess Hypoechoic

recess Effusion will distend fat pad Tibia Talus

* * Medial Ankle Posterior Tibialis Tendon Flexor

1 Ultrasound Foot and Ankle Pathology Disclosures None relevant Shane A. Shapiro, M.D. Assistant Professor, Orthopedic Surgery Mayo Clinic 2012 MFMER slide-2 Foot and Ankle Fundamentals AIUM Practice Guidelines for MSK US Foot and Ankle Sonography usually focused on specific structure(s) of interest Single quadrant of the ankle or section of the foot is satisfactory for complete US evaluation based on clinical scenario Anterior, Medial, Lateral, Posterior ankle Hindfoot, Midfoot, Forefoot Anterior Ankle Effusion Tibio-talar joint Anterior recess Hypoechoic cartilage Anterior fat pad Physiologic fluid in recess Effusion will distend fat pad Tibia Talus 2012 MFMER slide-3 Tibialis Anterior Tendinopathy * * Medial Ankle Posterior Tibialis Tendon Flexor Digitorum Longus Neurovascular Bundle Artery Vein Nerve (+/- branches) Flexor Halucis Longus 2012 MFMER slide-5 1

enlargement of the tendon With or without

MFMER slide-9 Spring Ligament Ultrasound

2 Medial Ankle Soft Tissues Posterior Tibial Tendonopathy Hypoechoic enlargement of the tendon With or without tear 2012 MFMER slide MFMER slide-8 Accessory Navicular Normal variant Do not mistake for avulsed bone in tendon ruptures Cause of PT Tendinopathy May be symptomatic 2012 MFMER slide-9 Spring Ligament Ultrasound to depict superomedial CNL spring ligament. Thickening, loss of normal echogenic structure = ligament insufficiency. Association between posterior tibial tendinopathy and spring ligament abnormality 2012 MFMER slide-10 Tarsal Tunnel Syndrome ID honeycomb pattern of the tibial nerve Look for compressive pathologies in or around tarsal tunnel Scanning distally in the infra-malleolar region Medial and lateral plantar nerves Calcaneal branch Tarsal Tunnel Syndrome 2012 MFMER slide MFMER slide-12 2

3 Flexor Hallucis Longus Tendinitis Deepest of the medial tendons Use passive flexion of the great toe Lateral Ankle Peroneal Tendons Peroneal Retinaculum Dynamic Exam Anterior Talo-fibular ligament 2012 MFMER slide-13 Peroneal Tendons Peroneal Tendons Peroneal Retinaculum Dynamic Exam Peroneal Tendinopathy Commonly Brevis Low lying belly Ultrasound 100% Sensitive Horeshoe or C Sign Bianchi, S. Martinoli, C. Ultrasound of the Musculoskeletal System Springer; 2012 MFMER slide MFMER slide-16 Peroneal Tendinopathy Peroneal Tendon Subluxation/Dislocation Subluxation or dislocation Dynamic Evaluation Retinaculum disruption 2012 MFMER slide MFMER slide-18 3

4 Chronic ATFL Tear Most Commonly torn Ankle Ligament Inability to Visualize Ligament Use Heel Toe Maneuver Posterior Ankle Achilles Tendonitis Plantaris Tendon Retrocalcaneal Bursitis Posterior Subtalar Joint F T 2012 MFMER slide MFMER slide-20 Achilles Tendon Longitudinal Insertional Tendinopathy and Haglund s Deformity Achilles Tendon Soleus Muscle FHL Retrocalcaneal Bursa K * Posterior Subtalar Joint 2012 MFMER slide MFMER slide-22 Achilles Tendinopathy Achilles Rupture Need long axis us view of tendinopathy And MRI correlation 2012 MFMER slide MFMER slide-24 4

5 Retrocalcaneal Bursitis Plantar Fascitis Float the probe May be present in normal (2.5mm) Retro-Achilles bursa not present normally Retrocalcaneal Bursa 2012 MFMER slide MFMER slide-26 Midfoot Degenerative Joint Disease Hallux Rigidus Tarsal Tarsal Tarsal-Metatarsal Long Axis to the Foot 2012 MFMER slide-27 Morton s Neuroma Dynamic Imaging Dynamic images i. Active motion ii. Passive motion iii. Compression Bianchi, S. Martinoli, C. Ultrasound of the Musculoskeletal System Springer; p MFMER slide-29 5

Ultrasound Guided Foot and Ankle Injections

planning Choose equipment Plot approach (MRI

up (needle selection and ergonomics) 2012 MFMER

slide-33 2012 MFMER slide-34 Injection Technique

structures) Plot approach with smaller gauge

necessary Advance to target Follow needle tip Do

movements, anchor probe Aspirate / inject Out of

probe face Needle appears in cross section within

6 Ultrasound Guided Foot and Ankle Injections Pre-Procedural Considerations Pre-procedural planning Choose equipment Plot approach (MRI correlation) Time allotment Contraindications Set up (needle selection and ergonomics) 2012 MFMER slide-32 Sterile Technique Tegaderm 2012 MFMER slide MFMER slide-34 Injection Technique Appropriate anesthesia (skin, subq, superficial structures) Plot approach with smaller gauge needle Find needle Use tissue harmonics if necessary Advance to target Follow needle tip Do not move needle and probe at the same time Small movements, anchor probe Aspirate / inject Out of Plane Approach Needle Tip/Shaft perpendicular to probe face Needle appears in cross section within joint space / recess Medication fills joint space / recess 2012 MFMER slide MFMER slide-36 6

Gel Standoff with Foot Ankle Injection Patient

Linear array probe Find tibiotalar joint and

In-plane approach from the lateral side or out-of-

Anterior in-plane approach is difficult (Beam

kenalog 2012 MFMER slide-37 2012 MFMER slide-38

Posterior lateral In-plane Lateral approach

guage needle 20mg kenalog 2012 MFMER slide-39 2012

Tibialis Tendon Sheath Injection Lateral Decubitus

7 Gel Standoff with Foot Ankle Injection Patient supine Knee flexed to allow foot flat on bed Linear array probe Find tibiotalar joint and anterior recess in long view 22 or 25 guage needle In-plane approach from the lateral side or out-of- plane approach. Anterior in-plane approach is difficult (Beam Steer and Gel Stand-off) Avoid artery mg of kenalog 2012 MFMER slide MFMER slide-38 Ankle Injection Subtalar Injection Localize joint Posterior lateral In-plane Lateral approach Out-of-plane Medial approach Proximity to nerve 25 guage needle 20mg kenalog 2012 MFMER slide MFMER slide-40 Lateral Subtalar Approach Posterior Tibialis Tendon Sheath Injection Lateral Decubitus Ankle Facing up Trans to Tendon Needle in plane 25G Needle 20mg Kenalog 2012 MFMER slide MFMER slide-42 7

slide-43 2012 MFMER slide-44 Tarsal Tunnel

Injection - Transverse to Joint - Out of

Joint and Tendon Use M/D Cursor Assist 25

8 Peroneal Tendon/Sheath Injection Tibial Nerve Injection/Tarsal Tunnel Similar to set up for PT Lateral Ankle Exposed Injecting Posterior to Anterior 2012 MFMER slide MFMER slide-44 Tarsal Tunnel Ganglion Cyst Tarsal-Tarsal/TMT Midfoot Injection - Transverse to Joint - Out of Plane Approach - Avoid Dorsalis Pedis Artery 2012 MFMER slide MFMER slide-46 Hallux Rigidus 1 st MTP Joint Aspiration and Injection Out-of-Plane needle Approach Probe Longitudinal to Joint and Tendon Use M/D Cursor Assist 25 guage needle to Inject 18 guage to aspirate Consider lavage for dry tap 8

9 1 st MTP Joint Injection Morton s Neuroma Injection In-plane Dorsal Approach Alternative -Out of Plane Webspace approach 2012 MFMER slide MFMER slide-50 Plantar Fasciitis Multiple approaches Superficial Long or Trans Deep Long or Trans Superficial Plantar Fascia Injection Little evidence for CSI after 6 weeks Needle Fasciotomy and PRP incompletely studied 2012 MFMER slide MFMER slide-52 Deep Plantar Fascia Injection Plantar Fascia Needle Tenotomy 2012 MFMER slide MFMER slide-54 9

Platelet Rich Plasma Injections Achilles Tendon PRP 2012 MFMER slide-55 2012 MFMER slide-56 Documentation Procedure: Joint Aspiration / Injection Procedure Indication: Symptomatic relief,

Informed Consent: Prior to starting the procedure, the patient s identity was verified, pertinent available records were reviewed, the nature of the procedure was explained along with risks, benefits

A pre-procedure pause was performed for final verification of all the above. Location: Right shoulder. Preparation and Technique: Skin prep ChoraPrep, sterile preparation of site (in usual fashion).

Approach (lateral, posterior, under continuous ultrasound guidance using a 4S curved array probe at a frequency of 5 mhz, in plane approach, per the protocol originally published by Zwar, et. al.

Procedure tolerated well. No Complications. Patient Instructions: Ice shoulder tonight, gradually resume use as pain permits.

10 Platelet Rich Plasma Injections Achilles Tendon PRP 2012 MFMER slide MFMER slide-56 Documentation Procedure: Joint Aspiration / Injection Procedure Indication: Symptomatic relief, glenohumeral osteoarthritis. Informed Consent: Prior to starting the procedure, the patient s identity was verified, pertinent available records were reviewed, the nature of the procedure was explained along with risks, benefits and alternatives. Consent was signed. The appropriate sites of the procedure were confirmed directly with the patient, verified, and marked. A pre-procedure pause was performed for final verification of all the above. Location: Right shoulder. Preparation and Technique: Skin prep ChoraPrep, sterile preparation of site (in usual fashion). Local anesthesia with lidocaine (1 ml, 1% strength, without epinephrine). An initial pre-injection ultrasound evaluation was performed to survey the relevant anatomy. Approach (lateral, posterior, under continuous ultrasound guidance using a 4S curved array probe at a frequency of 5 mhz, in plane approach, per the protocol originally published by Zwar, et. al. in the American Journal of Roentgenology, July 2004 Vol. 183.). Sterile needle used (size #22 gauge, length 2.5 inch). Joint injected with Kenalog 40mg 4ml 1% Lidocaine without epinephrine. Procedure tolerated well. No Complications. Patient Instructions: Ice shoulder tonight, gradually resume use as pain permits. Billing - CHANGES 1/1/15 Standard Joint, Bursa, Tendon Injections do not accompany CPT US Guidance for Needle Placement when billing Medicare as of January 2015 Ganglion or Nerve procedure injection codes may still US Guidance for Needle Placement in Small, Medium, Large Joints - CPT 20604, 20606, Requires documented indication Requires description of procedure Requires permanently stored image of target localization and needle May be used in combo with Diagnostic Codes if justified and appropriately documented 2012 MFMER slide MFMER slide-58 10

Disclosure. Pre-Procedural Considerations. Transducer Selection. Sterile Procedure. Sterile Procedure. Ultrasound Guided Foot and Ankle Injections

Disclosure. Pre-Procedural Considerations. Transducer Selection. Sterile Procedure. Sterile Procedure. Ultrasound Guided Foot and Ankle Injections Ultrasound Guided Foot and Ankle Injections Disclosure No relevant financial relationships exist Shane A. Shapiro, M.D. Assistant Professor, Orthopedic Surgery Mayo Clinic Florida @ShaneShapiroMD 2012