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150 Chapter 5
b. Dorsal talonavicular ligament: Initially the probe is placed along the LX of the anterior tib-
iotalar joint recess, and then the probe is moved distally until the neck of the talus is visualized as the ligament spans from the neck of the talus to the navicular bone (Figure 5-50).
2
A
C
B
Figure 5-50. Dorsal talonavicular ligament. (A) Probe placement along the
LX of the anterior tibiotalar joint recess. The probe is then moved distally
until the neck of the talus is visualized as the ligament spans from the neck
of the talus to the navicular bone. (B) Dorsal talonavicular ligament (white
arrows) between the talus and the navicular bone. (C) Relevant anatomy and
probe placement.
3. Relevant anatomy: The dorsal calcaneocuboid ligament is the thickening of the dorsolateral
aspect of the capsule of the calcaneocuboid joint. The dorsal talonavicular ligament blends
with the capsule of the talonavicular joint and is covered by the extensor tendons.
2
4. Points to remember: The dorsal talonavicular ligament is not parallel to the skin; therefore,
slight distal tilt is required to avoid anisotropy.
Ankle and Foot 151
Medial Ligaments
The plantar calcaneonavicular ligament or spring ligament complex includes 3 parts: supero-
medial, medioplantar oblique, and inferoplantar longitudinal (see Figure 5-23).
1. Patient position: Foot in neutral to slight dorsiflexion
2. Probe/transducer position: The superomedial portion is scanned by placing one end of the
probe on the sustentaculum tali and the other end on the superomedial aspect of the navicular
bone (Figure 5-51).
A
B
C
Figure 5-51. Spring ligament, or plantar calcaneonavicular ligament. (A)
Probe placement between the sustentaculum tali and the superomedial
aspect of the navicular bone. (B) Plantar calcaneonavicular ligament (white
arrows) between the sustentaculum tali (ST) and the navicular bone (N).
(C) Relevant anatomy and probe placement.
The medioplantar oblique and inferoplantar longitudinal components of the spring ligament complex are deep and therefore difficult to visualize. Dynamic evaluation with valgus
stress may be used to check the medioplantar and inferoplantar portions for their intactness.
3. Relevant anatomy: The superomedial portion of the spring ligament appears as a hyperechoic
band. The overlying posterior tibialis tendon can be visualized.
2
4. Points to remember: The spring ligament complex is a major stabilizer of the plantar arch. Due
to its close proximity to the posterior tibialis tendon, injury or dysfunction is closely related to
posterior tibialis tendon dysfunction, and vice versa.
2
152 Chapter 5
FOREFOOT
Metatarsophalangeal Joint and Plantar Plate
Relevant anatomy is shown in Figure 5-52.
Figure 5-52. Relevant anatomy of the metatarsophalangeal (MTP) joint and plantar plate region.
Ankle and Foot 153
1. Patient position: Supine with the foot in neutral position
2. Probe/transducer position:
a. Plantar aspect: The probe is placed in the LX along the plantar aspect of the MTP joint. The
probe is placed transversely for the SX view (Figures 5-53 through 5-55).
A B
Figure 5-53. LX view of the first MTP joint on the plantar aspect. (A) Probe placement. (B) FHL tendon (white arrows)
and hyperechoic plantar plate (yellow arrow) overlying the MTP region.
A
Figure 5-54. SX view of the first MTP joint on the plantar aspect. (A) Probe placement. (B) FHL tendon (white arrow)
between 2 sesamoid bones (SB). Also shown is the intersesamoid ligament (blue arrow).
B
154 Chapter 5
A
B
Figure 5-55. LX view of the second MTP joint on the plantar aspect. (A) Probe placement. (B) Flexor tendons (white
arrows) and hyperechoic plantar plate (between the yellow arrows) overlying the MTP region.
b. Dorsal aspect: The probe is placed in the LX along the dorsal aspect of the MTP joint
(Figure 5-56). The probe is placed transversely for the SX view.
A
B
Figure 5-56. LX view of the first MTP joint on the dorsal aspect. (A) Probe placement. (B) MTP joint and overlying
extensor tendon (white arrows).
Ankle and Foot 155
3. Relevant anatomy:
a. First MTP: There are 2 sesamoid bones present on the plantar aspect of the first MTP joint
held together by ligaments. Between the 2 sesamoid bones is the small window to visualize
the plantar plate region, which lies deep to the intersesamoid ligament and just above the
MTP joint articulation. The FHL runs above the intersesamoid ligament to insert distally
at the base of the distal phalanx.
14,15
b. Lesser MTP joints: In the lesser MTP joints, 2 tendons overlie the plantar plate region: the
FDL and the flexor digitorum brevis (FDB). The FDB divides into 2 slips distally to attach
on either side of the proximal phalanx. The FDL attaches distally at the base of the distal
phalanx (see Figure 5-55).
15,16
4. Points to remember: The plantar plates act as a primary stabilizer of the MTP joint and are
formed by the fiber contribution from multiple structures blending together, such as the flexor
hallucis tendon, deep intermetatarsal ligament, distal margin of the intersesamoid ligament,
plantar fascia, and aponeurotic fibers of the extensor hood. In the lesser MTP joints, the plantar plate consists of fibrocartilage and type I collagen.
16,17
Intermetatarsal Space
Relevant anatomy is shown in Figure 5-57.
Figure 5-57. Relevant anatomy of the intermetatarsal space. (EDB = extensor digitorum brevis; M = metatarsal.)
156 Chapter 5
1. Patient position: Supine with the foot in neutral position
2. Probe/transducer position: The probe is placed transversely at the level of the metatarsal heads
on the plantar aspect for plantar examination or the dorsal aspect for dorsal examination
(Figures 5-58 and 5-59).
A
Figure 5-58. Intermetatarsal space
on the plantar aspect. (A) Probe
placement with relevant anatomy. (B)
Intermetatarsal space on the plantar
aspect showing the FHL (yellow arrow),
FDB (white arrow), FDL (red arrow),
artery (red triangle), digital nerve
(yellow triangle), and sesamoid bone
(SB). (M = metatarsal.) (C) Color Doppler
image showing an artery (red triangle)
and nerve (yellow triangle).
B
C
Ankle and Foot 157
A
B
Figure 5-59. Intermetatarsal space
on the dorsal aspect. (A) Probe
placement with relevant anatomy.
(B) Intermetatarsal space on the
dorsal aspect showing the extensor
digitorum brevis (blue arrow), EDL
(red arrow), EHL (white arrow), digital
nerve (yellow arrow), artery (white A),
and dorsal interosseous muscle (DI).
(M = metatarsal.)
3. Relevant anatomy: The intermetatarsal space on the dorsal aspect contains the neurovascular
bundle, dorsal interosseous muscle, plantar interosseous muscle, and intermetatarsal bursa. On
the plantar space, the neurovascular bundle and lumbrical muscle occupy the intermetatarsal
space.18
4. Points to remember: Intermetatarsal bursal effusion and bursitis can present similar to Morton
neuroma. Evaluation of the intermetatarsal space can be performed by placing the probe on
the dorsal or plantar aspect with one of the examiner’s fingers providing counterpressure
toward the probe from the opposite aspect of the metatarsal space. This procedure will help
differentiate fluid (bursal effusion) from a solid mass, as in neuroma.
19
158 Chapter 5
REFERENCES
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extensor compartment of the ank le. Radiographics. 2013;33(7):2047-2064.
2. Sconfienza LM, Orlandi D, Lacelli F, Serafini G, Silvestri E. Dynamic high-resolution US of ankle and midfoot
ligaments: normal anatomic structure and imaging technique. Radiographics. 2015;35(1):164-178.
3. Hermans JJ, Beumer A, de Jong TA, Kleinrensink GJ. Anatomy of the distal tibiofibular syndesmosis in adults:
a pictorial essay with a multimodality approach. J Anat. 2010;217(6):633-645.
4. Golano P, Vega J, de Leeuw PA, et al. Anatomy of the ankle ligaments: a pictorial essay. Knee Surg Sports
Tra u mato l Arth r osc. 2010;18(5):557-569.
5. Bilgili MG, Kaynak G, Botanlioglu H, et al. Peroneus quartus: prevalence and clinical importance. Arch Orthop
Tra u ma S u r g. 2014;134(4):481-487.
6. Ballal MS, Walker CR, Molloy AP. The anatomical footprint of the Achilles tendon: a cadaveric study. Bone
Joint J. 2014;96-B(10):1344-1348.
7. Theobald P, Bydder G, Dent C, Nokes L, Pugh N, Benjamin M. The functional anatomy of Kager’s fat pad in
relation to retrocalcaneal problems and other hindfoot disorders. J Anat. 2006;208(1):91-97.
8. Stecco C, Corradin M, Macchi V, et al. Plantar fascia anatomy and its relationship with Achilles tendon and
paratenon. J Anat. 2013;223(6):665-676.
9. Dalmau-Pastor M, Fargues-Polo B Jr, Casanova-Martinez D Jr, Vega J, Golanó P. Anatomy of the triceps surae:
a pictorial essay. Foot Ankle Clin. 2014;19(4):603-635.
10. Olewnik L, Wysiadecki G, Polguj M, Topol M. Anatomic study suggests that the morphology of the plantaris
tendon may be related to Achilles tendonitis. Surg Radiol Anat. 2017;39(1):69-75.
11. Mandl P, Bong D, Balint PV, et al. Sonographic and anatomic description of the subtalar joint. Ultrasound Med
Biol. 2018;44(1):119-123.
12. Hoffman DF, Nazarian LN, Smith J. Enthesopathy of the lateral cord of the plantar fascia. J Ultrasound Med.
2014;33(9):1711-1716.
13. 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;37(10):929-935.
14. Nery C, Fonseca LF, Gonçalves JP, et al. First MTP joint instability—expanding the concept of “turf-toe” injuries. Foot Ankle Surg. 2020;26(1):47-53.
15. Nery C, Baumfeld D, Umans H, Yamada AF. MR imaging of the plantar plate: normal anatomy, turf toe, and
other injuries. Magn Reson Imaging Clin N Am. 2017;25(1):127-144.
16. Finney FT, Cata E, Holmes JR, Talusan PG. Anatomy and physiology of the lesser metatarsophalangeal joints.
Foot Ankle Clin. 2018;23(1):1-7.
17. Stone M, Eyler W, Rhodenizer J, van Holsbeeck M. Accuracy of sonography in plantar plate tears in cadavers.
J Ultrasound Med. 2017;36(7):1355-1361.
18. Theumann NH, Pfirrmann CW, Chung CB, et al. Intermetatarsal spaces: analysis with MR bursography, anatomic correlation, and histopatholog y in cadavers. Radiology. 2001;221(2):478-484.
19. Bianchi S. Practical US of the forefoot. J Ultrasound. 2014;17(2):151-164.
Knee
Mohini Rawat, DPT, MS, ECS, OCS, RMSK
Contents
• Anterior Knee
Suprapatellar Region
º
Quadriceps Tendon
º
Femoral Trochlear Cartilage
º
Patellar Tendon
º
Anterior Bursae
º
Medial and Lateral Patellar Retinaculum
º
• Medial Knee
Medial Joint and Meniscus
º
Medial Collateral Ligament, Posterior Oblique Ligament, Adductor Magnus Tendon, and
º
Medial Patellofemoral Ligament
Pes Anserine Tendons
º
• Lateral Knee
Lateral Joint and Meniscus
º
Popliteus Tendon
º
Lateral Collateral Ligament
º
Iliotibial Band
º
Biceps Femoris Tendon
º
Common Fibular Nerve
º
• Posterior Knee
Joint Anatomy
º
Semimembranosus Muscle-Tendon Complex
º
Tibial Nerve and Blood Vessels
º
- 159 -
Atlas of Musculoskeletal Ultrasound of the E xtremities (pp 159-199).
6
Rawat M.
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