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Musculoskeletal system
226
LOWER LIMB: ANKLE
Anterior, medial, and lateral tendons
PREPARATION
None.
POSITION
Supine.
TRANSDUCER
10.0–15.0 MHz linear transducer.
METHOD
With the patient supine, the transducer is placed longitudinally across
the tibiotalar joint to assess for uid in the anterior recess.
APPEARANCE
Probe position Appearance
Medial
Transverse image at
the medial ankle.
Each tendon assessed
in transverse and
longitudinal section.
Tibialis posterior is identied just
behind the malleolus, and exor
digitorum longus lies just
posterior to this. Flexor hallucis
longus lies deep and may be more
readily identied by a posterior
approach.
Anterior
Lateral
Anterior to the
tibiotalar joint
Transverse behind the
lateral malleolus
Tibialis anterior, extensor hallucis
longus, and extensor digitorum
longus (medial to lateral).
Peroneus brevis and longus
tendons. Peroneus brevis lies
anteromedially to longus and can
be followed to its insertion at the
base of the 5th metatarsal, while
peroneus longus crosses the sole
to insert at the base of the 1
metatarsal and the medial
cuneiform.
st
Anterior, medial, and lateral tendons
Longitudinal view through the anterior joint space of the ankle (TIB, tibia; TAL, talus). The
arrow points to the anterior synovial recess, where the joint may be evaluated for the
presence of an effusion.
227
Transverse view of the medial ankle tendons behind the medial malleolus (MM). (TP, tibialis
posterior; FDL, exor digitorum longus; FHL, exor hallucis longus.) Posterior tibial artery
(A), veins (V), and posterior tibial nerve (arrow) are also demonstrated.
MEASUREMENTS
The anterior recess of the tibiotalar joint may normally contain up to
3 mm depth of uid. Fluid may normally be identied in the tibialis
posterior tendon sheath at, or below, the malleolar level, within the
peroneal tendons below the malleolar level, and may be asymmetric.
The exor digitorum longus and exor hallucis longus may also normally show a small amount of surrounding uid, unlike the anterior
tendons, which normally do not.
Musculoskeletal system
228
Transverse view of the lateral ankle tendons behind the lateral malleolus (LM). (PB,
peroneus brevis tendon; PBM peroneus brevis muscle; PL, peroneus longus tendon.)
The tibialis posterior is the largest of the medial tendons, measuring
4–6 mm in diameter. It may be followed to its insertion into the navicular where the bers normally fan out.
FURTHER READING
Bianchi S, Martinoli C, Gaignot C, De Gautard R, Meyer JM.
Ultrasound of the ankle: Anatomy of the tendons, bursae, and
ligaments. Semin Musculoskelet Radiol. 2005; 9:243–259.
Nazarian LN, Nandkumar MR, Martin CE, Schweitzer ME.
Synovial uid in the hindfoot and ankle: Detection of amount
and distribution with US. Radiology. 1995; 197:275–278.
Schmidt WA, Schmidt H, Schicke B, Gromnica-Ihle E. Standard
reference values for musculoskeletal ultrasonography. Ann
Rheum Dis. 2004; 63:988–994.
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Musculoskeletal system
230
Achilles tendon
PREPARATION
None.
POSITION
The patient is prone with feet hanging over the edge of the examination couch or supine with hip exed and externally rotated and the
knee exed.
TRANSDUCER
10.0–15.0 MHz linear transducer.
METHOD
The transducer is placed over the Achilles tendon longitudinally and
transversely to assess the full length of the tendon from the musculotendinous junction to calcaneal insertion. Movement of the ankle is
helpful to fully evaluate tears.
APPEARANCE
The Achilles tendon has an ovoid shape in transverse section. The calcaneal insertion of the tendon may appear of low reectivity due to
anisotropy or the presence of cartilage at the enthesis. The plantaris
tendon should be separately identied as it runs from the posterolateral
knee to insert on the posteromedial calcaneus/Achilles. The retrocalcaneal bursa lies between the Achilles tendon and the calcaneus.
Longitudinal view of the distal Achilles tendon (A) attaching onto the calcaneum (CAL). The
hypoechoic retrocalcaneal bursa (arrows) lies between the Achilles tendon and calcaneum.
Achilles tendon
Achilles tendon (arrows) in transverse view at the level of the medial malleolus where its
thickness can be measured.
MEASUREMENTS
231
Retrocalcaneal bursa
Achilles tendon thickness at the level of
Up to 3 mm depth of uid
5.3 mm (range 4–6 mm)
the medial malleolus in transverse section
FURTHER READING
Fornage BD. Achilles tendon: US examination. Radiology. 1986;
159:759–764.
Nazarian LN, Nandkumar MR, Martin CE, Schweitzer ME.
Synovial uid in the hindfoot and ankle: Detection of amount
and distribution with US. Radiology. 1995; 197:275–278.
Schmidt WA, Schmidt H, Schicke B, Gromnica-Ihle E. Standard
reference values for musculoskeletal ultrasonography. Ann
Rheum Dis. 2004; 63:988–994.
Musculoskeletal system
232
LOWER LIMB: FOOT
Plantar fascia
PREPARATION
None.
POSITION
Prone with feet hanging over the edge of the examination couch or
supine with the hip exed and externally rotated and the knee exed.
TRANSDUCER
7.0–10.0 MHz linear array transducer.
METHOD
The transducer is placed longitudinally and transversely across the
plantar fascia. The origin of the central portion of the fascia is at
the calcaneal tuberosity, and the fascia is traced to the mid-arch but
becomes supercial and thin in the forefoot. Look for evidence of a
subcalcaneal spur.
APPEARANCE
The plantar fascia is well dened and of moderately high reectivity
with a uniform brillary pattern, but may show low reectivity at the
calcaneal tuberosity due to anisotropy.
Longitudinal view of the plantar fascia (arrows) across the sole of the foot (CAL, calcaneal
tuberosity).
Plantar fascia
MEASUREMENTS
Thicknesses of the proximal plantar fascia measurements are taken
in the longitudinal plane close to the calcaneal attachment. A plantar
fascia thickness of up to 4 mm is considered within normal limits.
FURTHER READING
McMillan AM, Landorf KB, Barrett JT, Menz HB, Bird AR.
Diagnostic imaging for chronic plantar heel pain: A systematic
review and meta-analysis. J Foot Ankle Res. 2009; 2:32.
233
Musculoskeletal system
234
INTERDIGITAL WEB SPACES
PREPARATION
None.
POSITION
Supine.
TRANSDUCER
7.0–10.0 MHz linear array transducer.
METHOD
The transducer is placed transversely across the dorsum of the foot to
examine the spaces between the metatarsal heads. At the same time
nger pressure is applied to the plantar surface of web space under
examination. Alternatively, forced exion of the toes or squeezing of
the metatarsal heads together by pressure from the examiner’s hand
may displace a neuroma for improved visualization. The process is
repeated with the probe on the plantar surface and nger pressure on
the dorsum of the foot. The interdigital space is also examined in longitudinal section by aligning the probe within the web space.
APPEARANCE
The normal interspace appears as high-reective fat bounded by the
high-reective metatarsal cortex on each side. A Morton’s neuroma
appears as a noncompressible low-reective mass, while a bursa
appears as a compressible low-reective mass.
FURTHER READING
Redd RA, Peters VJ, Emery SF, Branch HM, Rifkin MD.
Morton neuroma: Sonographic evaluation. Radiology. 1989;
171:415– 417.
Pediatric and
Neonatal