Ultrasound of Mid and Hindfoot Pathology

Ultrasound of Mid and Hindfoot Pathology Levon N. Nazarian, M.D. Professor of Radiology Thomas Jefferson University Hospital

Disclosures None relevant to this presentation

Educational Objective Following the presentation, participant should be able to: Discuss the role of US in imaging the mid and hind foot Identify mid and hind foot pathologies seen on US

Posterior Compartment

Achilles Tendon Most commonly injured tendon No sheath: surrounded by two echogenic lines (paratenon) Normal AP thickness 5-6 mm

Longitudinal Achilles Tendon

Achilles Tendon Insertion

Transverse Achilles Tendon Direct contact Heaped-up scanning gel

Complete Achilles Rupture Weekend warriors Hematoma and fat may occupy torn area Image in plantar flexion to measure retraction

Complete Achilles Rupture Sagittal Transverse

Complete Achilles Tear: Extended Field of View

Complete Achilles Rupture Dorsiflexion Plantar flexion

Pitfall: Do not mistake plantaris tendon for intact Achilles fibers

Achilles Rupture With Refractive Shadowing

Pitfall: Do Not Mistake Thickened Paratenon for Intact Achilles Fibers

High Grade Partial Achilles Tear

Intrasubstance Achilles Tear

Chronic Tendinitis (Tendinosis) Thickened, heterogeneous tendon Nodular hypoechoic areas Partial tears Calcification May or may not see flow

Insertional Achilles Tendinosis

Midsubstance Achilles Tendinosis

Achilles Tendinosis Calc

Retrocalcaneal Bursitis

53 Year Old Man with Foot Pain

Aspiration Performed with 18 G Needle Result: Monosodium Urate Crystals Needle tip

Fluid in Superficial Achilles Bursa

Os Trigonum

Posterior Ankle Impingement With Os Trigonum

Peroneal Tendons: Axial PL PB

Peroneal Tendons: Axial

Peroneal Tendons: Longitudinal PL PB

Peroneal Tenosynovitis

Peroneus Brevis Tendinosis

Dx: Peroneus Brevis Split PB PL PB Tear

Peroneal Retinaculum: Normal

Peroneal Retinaculum: Abnormal

Normal Peroneal Tendon Motion

Peroneal Subluxation Injury to peroneal retinaculum Tendons exit groove anteriorly and laterally Elicited with dorsiflexion and eversion

Peroneal Subluxation

Peroneus Brevis Tear, Subluxation

Intrasheath Subluxation

Peroneal Tendons: Intrasheath Subluxation Type A

Peroneal Tendons: Intrasheath Subluxation Type B

Distal Peroneus Brevis 5 th MT

Lateral Band Plantar Fasciitis

Avulsion Fracture at Base of 5 th Metatarsal

Lateral Ankle Ligaments

Anterior Talofibular Ligament Most commonly injured ankle ligament Spectrum of injury from mild sprain to complete tear May see associated avulsion fracture

ATFL

Normal ATFL

ATFL Sprain

Normal Contralateral ATFL

Chronic ATFL Sprain Fibula Talus

ATFL Sprain

Anterolateral Ankle Impingement

Anterior Ankle Impingement

Anterior Inferior Tibiofibular Ligament

Calcaneofibular Ligament From: Sarrafian SK: Anatomy of the Foot and Ankle, 2 nd Ed., JB Lippincott

CFL Sprain

High Ankle Sprain

Plantar Fasciitis Painful condition, common in runners US diagnosis: Thickening (greater than 3-4mm) Heterogeneity Calcification Partial tears

Plantar Fascia: Anatomic Dissection

C Normal Plantar Fascia

Plantar Fasciitis

Plantar Fibromatosis 44 year-old woman Longitudinal Transverse

Plantar Fibromatosis 44 year-old woman Contralateral side: same abnormality

Ankle Joint Effusion

Degenerative Arthropathy Talonavicular Joint

Rheumatoid Arthritis Talonavicular Joint

Rheumatoid Arthritis

Gouty Arthritis

Gout: Periarticular Erosion

Adventitial Bursitis

Foot Ganglion

Foreign Bodies

Surgical Hardware in Toe

Screw Impales FHL

Conclusions US is an effective tool for a wide range of foot and ankle abnormalities First line modality for: Tendons Plantar fasciitis Ligamentous instability/ impingement Ganglion cysts