Ultrasound Evaluation of Posteromedial Ankle Pathology Andrew C Cordle, M.D., Ph.D. 9/21/2018
Overview: Pathology of the Posteromedial Ankle Flexor Tendon Pathology Accessory Navicular Bone Pathology Tarsal Tunnel Syndrome
Flexor Tendon Anatomy
Flexor Tendon Anatomy A P PT FDL SAX Normal sonographic appearance of the flexor tendons Uniform fibrillar echotexture Hyperechoic
Flexor Tendon Anatomy A Tibia P SAX Posterior Tibialis Most anterior tendon Largest of the flexor tendons (2x the size of FHL tendon) Main insertion on the medial navicular tuberosity. Additional slips to the cuneiforms, cuboid and the bases of the 2 nd through 4 th metatarsals
Flexor Tendon Anatomy Posterior Tibialis Video provided by Dr. Jay Smith Most anterior tendon Largest of the flexor tendons (2x the size of FHL tendon) Main insertion on the medial navicular tuberosity. Additional slips to the cuneiforms, cuboid and the bases of the 2 nd through 4 th metatarsals
Flexor Tendon Anatomy Posterior Tibialis Image provided by Dr. Jay Smith Most anterior tendon Largest of the flexor tendons (2x the size of FHL tendon) Main insertion on the medial navicular tuberosity. Additional slips to the cuneiforms, cuboid and the bases of the 2 nd through 4 th metatarsals
Flexor Tendon Anatomy A Tibia P SAX Flexor Digitorum Longus Posterior to PT tendon Inserts on the planar bases of the 2 nd through 4 th distal phalanges
Flexor Tendon Anatomy A Tibia P SAX Flexor Hallucis Longus Most posterior and lateral tendon Deep to the NVB Inserts on the plantar base of the 1 st distal phalanx
Flexor Tendon Anatomy Flexor Hallucis Longus Image provided by Dr. Jay Smith Most Posterior and lateral tendon Deep to the NVB Inserts on the plantar base of the 1 st distal phalanx
Flexor Tendon Anatomy Talus Flexor Hallucis Longus Most Posterior and lateral tendon Deep to the NVB Inserts on the plantar base of the 1 st distal phalanx Can also be evaluated using a posterior approach De Maeseneer et al. AJR: 192:487-495, February 2009
Flexor Tendon Anatomy A Tibia P SAX Neuro-Vascular Bundle Posterior tibial artery Posterior tibial vein Posterior tibial nerve
Flexor Tendon Anatomy A Tibia P SAX Flexor retinaculum Thickening of crural fascia Extends from medial malleolus to the medial calcaneus
Flexor Tendon Anatomy MRI correlation
Flexor Tendon Anatomy A Tibia P SAX MRI correlation PT tendon FDL tendon FHL tendon NVB Flexor retinaculum A P
Deltoid Ligament Complex Deep components Posterior tibiotalar Anterior tibiotalar Superficial components Tibiocalcaneal Tibiospring Tibionavicular http://radsource.us/deltoid-ligament-injuries/
Deltoid Ligament Complex The deep and superficial components of the deltoid ligamentous complex can be visualized with ultrasound The components can be difficult to visualize following injury and other modalities are better suited for evaluation
Flexor Tendon Pathology: Tendinosis
Flexor Tendon Pathology: Tendinosis 45 year old female presents with several years of posteromedial ankle pain
Flexor Tendon Pathology: Tendinosis A Tibia P SAX Focal region of hypoechogenicity with indistinctness of the fiber architecture, compatible with tendinosis
Flexor Tendon Pathology: Tendinosis A Tibia P SAX Focal region of hypoechogenicity with indistinctness of the fiber architecture, compatible with tendinosis
Flexor Tendon Pathology: Tendinosis A P LAX Focal region of hypoechogenicity with indistinctness of the fiber architecture, compatible with tendinosis No evidence of partial or full thickness tear
Flexor Tendon Pathology: Tendinosis A Tibia P LAX Focal region of hypoechogenicity with indistinctness of the fiber architecture, compatible with tendinosis No evidence of partial or full thickness tear
Flexor Tendon Pathology: Tendinosis A P LAX Talus Focal region of hypoechogenicity with indistinctness of the fiber architecture, compatible with tendinosis No evidence of partial or full thickness tear
Flexor Tendon Pathology: Tendinosis Navicular A P Talus LAX Focal region of hypoechogenicity with indistinctness of the fiber architecture, compatible with tendinosis No evidence of partial or full thickness tear
Flexor Tendon Pathology: Tendinosis MRI Correlation demonstrates tendinosis of the PT tendon
Flexor Tendon Pathology: Tendinosis
Flexor Tendon Pathology: Tendinosis Companion case Video provided by Dr. Jay Smith Marked thickening of the PT tendon with areas of hypoechogenicity High-grade tendinosis
Flexor Tendon Pathology: Tenosynovitis
Flexor Tendon Pathology: Tenosynovitis CEPH Tenosynovitis Distension of the PT tendon sheath (beyond 4mm) Synovial hypertrophy Associated hyperemia PTT LAX Image provided by Dr. Jay Smith
Flexor Tendon Pathology: Tenosynovitis Image provided by Dr. Jay Smith Tenosynovitis Tendon sheath distension at the Knot of Henry
Flexor Tendon Pathology: Tendinosis with Interstitial Tear
Flexor Tendon Pathology: Tendinosis with Interstitial Tear 75 year old female with posteromedial ankle pain and concern for PT tendon tear
Flexor Tendon Pathology: Tendinosis with Interstitial Tear A P SAX Image provided by Dr. Gene Kitamura Focal areas of hypoechoic signal consistent with a combination of tendinosis and interstitial tearing
Flexor Tendon Pathology: Tendinosis with Interstitial Tear A P SAX Image provided by Dr. Gene Kitamura Focal areas of hypoechoic signal consistent with a combination of tendinosis and interstitial tearing
Flexor Tendon Pathology: Tendinosis with Interstitial Tear A P SAX Image provided by Dr. Gene Kitamura Focal areas of hypoechoic signal consistent with a combination of tendinosis and interstitial tearing
Flexor Tendon Pathology: Tendinosis with Interstitial Tear A P SAX Image provided by Dr. Gene Kitamura Focal areas of hypoechoic signal consistent with a combination of tendinosis and interstitial tearing
Flexor Tendon Pathology: Tendinosis with Interstitial Tear A P SAX Image provided by Dr. Gene Kitamura Focal areas of hypoechoic signal consistent with a combination of tendinosis and interstitial tearing Fluid distention of the tendon sheath
Flexor Tendon Pathology: Tendinosis with Interstitial Tear A P LAX Image provided by Dr. Gene Kitamura Focal areas of hypoechoic signal consistent tendinosis
Flexor Tendon Pathology: Tendinosis with Interstitial Tear
Flexor Tendon Pathology: Tendinosis with Interstitial Tear Companion case Video provided by Dr. Jay Smith Thickening with prominent areas of hypoechogenicity consistent with high-grade tendinosis and interstitial/split tearing
Flexor Tendon Pathology: Tendinosis with Interstitial Tear Companion case Video provided by Dr. Jay Smith Thickening with prominent areas of hypoechogenicity consistent with high-grade tendinosis and interstitial/split tearing Prominent hyperemia associated with the tendon pathology
Flexor Tendon Pathology: Full Thickness Tear
Flexor Tendon Pathology: Full Thickness Tear 62 year old male status post triple arthrodesis with concern for PT rupture
Flexor Tendon Pathology: Full Thickness Tear CT evaluation compromised due to streak artifact from hardware FDL and FHL tendons identified without full thickness disruption PT tendon poorly characterized with concern for high-grade to complete disruption Ultrasound recommended for further evaluation
Flexor Tendon Pathology: Full Thickness Tear A P SAX Tendinosis, characterized by hypo-echogenicity and heterogeneity of the fiber architecture
Flexor Tendon Pathology: Full Thickness Tear A P SAX Tendinosis, characterized by hypo-echogenicity and heterogeneity of the fiber architecture
Flexor Tendon Pathology: Full Thickness Tear A P SAX Tendinosis, characterized by hypo-echogenicity and heterogeneity of the fiber architecture
Flexor Tendon Pathology: Full Thickness Tear A P SAX Tendinosis, characterized by hypo-echogenicity and heterogeneity of the fiber architecture Attenuation of the fibers, consistent with partial thickness tearing
Flexor Tendon Pathology: Full Thickness Tear A P SAX Tendinosis, characterized by hypo-echogenicity and heterogeneity of the fiber architecture Attenuation of the fibers, consistent with partial thickness tearing Absence of the tendon at the level of the medial malleolus, consistent with full thickness disruption
Flexor Tendon Pathology: Full Thickness Tear
Flexor Tendon Pathology: Full Thickness Tear Companion case Video provided by Dr. Jay Smith Full thickness tear of the PT tendon
Flexor Tendon Pathology: Full Thickness Tear Companion case Video provided by Dr. Jay Smith Full thickness tear of the PT tendon
Flexor Tendon Pathology: PT Tendon Instability/Subluxation
Flexor Tendon Pathology: PT Tendon Instability/Subluxation Rare Injury +/- visualization of small avulsion fracture at the insertion of the flexor retinaculum on the medial malleolus +/- intrinsic PT tendon pathology Dynamic ultrasound can aid in the diagnosis
Flexor Tendon Pathology: PT Tendon Instability/Subluxation Video provided by Dr. Jay Smith Asymptomatic ankle demonstrates no evidence of subluxation/instability
Flexor Tendon Pathology: PT Tendon Instability/Subluxation Video provided by Dr. Jay Smith Anterior subluxation of the PT tendon Striping of the flexor retinaculum at the medial malleolus
Flexor Tendon Pathology: PT Tendon Instability/Subluxation Video provided by Dr. Jay Smith Anterior subluxation of the PT tendon Striping of the flexor retinaculum at the medial malleolus
Accessory Navicular Bone Anatomy Image provided by Dr. Jay Smith Case courtesy of Dr Matt Skalski, Radiopaedia.org, rid: 47594
Accessory Navicular Bone Anatomy Classification Type I Os tibiale externum 2-3 mm Sesamoid in the posterior tibialis tendon Separated from the navicular tuberosity by up to 5mm asx Case courtesy of Dr Matt Skalski, Radiopaedia.org, rid: 47594
Accessory Navicular Bone Anatomy Classification Type II Os naviculare Most common variant (50-60%) Secondary ossification center (typical fusion age: females: 12.5, males: 14.1) ~12 mm triangular or heartshaped ossicle Separated from navicular tuberosity by 1-2 mm by fibro/hyaline cartilage +/- Sx Case courtesy of Dr Matt Skalski, Radiopaedia.org, rid: 47594
Accessory Navicular Bone Anatomy Classification Type III Prominent navicular tuberosity (cornuate naviculare) Fused type II Less likely to cause Sx Case courtesy of Dr Matt Skalski, Radiopaedia.org, rid: 47594
Accessory Navicular Bone Anatomy Video provided by Dr. Jay Smith Sonographic appearance of os tibiale externum
Accessory Navicular Bone Pathology: Symptomatic Os Naviculare
Accessory Navicular Bone Pathology: Symptomatic Os Naviculare 13 year old male with medial mid foot/ankle pain. Clinical concern for PT injury
Accessory Navicular Bone Pathology: Symptomatic Os Naviculare P A SAX Intact PT tendon Image provided by Dr. Aaron Wyse
Accessory Navicular Bone Pathology: Symptomatic Os Naviculare P D LAX Intact PT tendon Image provided by Dr. Aaron Wyse
Accessory Navicular Bone Pathology: Symptomatic Os Naviculare P Os Nav D LAX Intact PT tendon Image provided by Dr. Aaron Wyse Irregularity of the cortical margins of the Type II os naviculare and the navicular tuberosity at the synchondrosis
Accessory Navicular Bone Pathology: Symptomatic Os Naviculare P D Os Nav LAX Intact PT tendon Image provided by Dr. Aaron Wyse Irregularity of the cortical margins of the Type II os naviculare and the navicular tuberosity at the synchondrosis
Accessory Navicular Bone Pathology: Symptomatic Os Naviculare asx D Os P Nav LAX Image provided by Dr. Aaron Wyse Smooth cortical margins of the os naviculare and navicular tuberosity of the asx contralateral foot
Accessory Navicular Bone Pathology: Symptomatic Os Naviculare Sx asx Os Nav Os Nav LAX Image provided by Dr. Aaron Wyse Comparison between Sx and asx sides Cortical irregularity at the margins of the Synchrondrosis Symptomatic os naviculare
Accessory Navicular Bone Pathology: Symptomatic Os Naviculare Radiographic correlation: irregularity of the cortical margins at the synchondrosis Symptomatic os naviculare
Tarsal Tunnel Syndrome
Tarsal Tunnel Syndrome Entrapment neuropathy of the posterior tibial nerve within the tarsal tunnel Clinical presentation Burning pain +/- parasthesias with radiation into toes Medial foot numbness Atrophy of intrinsic muscles of the foot Can be caused by any space occupying process in the tarsal tunnel Ganglion cyst Tumor Synovitis/tenosynovitis Enlarged vessels/varicosities Accessory muscles
Tarsal Tunnel Syndrome A Tibia P SAX Tarsal Tunnel Medial border: flexor retinaculum Lateral border: Osseous structures of the hindfoot A P
Tarsal Tunnel Syndrome A Tibia P SAX Tarsal Tunnel Contents PT tendon FDL tendon FHL tendon NVB A P
Tarsal Tunnel Syndrome: FDAL Flexor Digitorum Accessorius Longus Origin: variable (any structure in the posterior compartment) Medial margin of tibia Fascia of the deep posterior compartment Lateral margin of fibula distal to FHL origin Insertion: Quadratus plantae FDL tendon Sookur, P, et al. Radiographics 2008; 28:481-499
Tarsal Tunnel Syndrome: FDAL Flexor Digitorum Accessorius Longus Posterior and superficial to the posterior tibial nerve +/- muscular component in the tarsal tunnel Deep to the flexor retinaculum in the tarsal tunnel Sookur, P, et al. Radiographics 2008; 28:481-499
Tarsal Tunnel Syndrome: FDAL Image provided by Dr. Jay Smith FDAL present within the tarsal tunnel, intimately associated with the NVB
Tarsal Tunnel Syndrome: FDAL Video provided by Dr. Jay Smith FDAL present within the tarsal tunnel, intimately associated with the NVB
Questions Contact information: Cordleac@upmc.edu