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Posterior Compartment
129
Fig. 8.22a Probe position to evaluate the
posterior tibio-talar recess
Fig. 8.22b *, posterior tibio-talar recess; arrowheads, flexor hallucis longus tendon;
Ti, tibia; T, talus
8.3.2 Posterior Tibio-Talar Recess
The posterior tibio-talar recess can be assessed
using coronal oblique scans on the medial side
of the Achilles tendon (Figs. 8.22a-b).
Fig. 8.23 Anatomical scheme of the anterior compart-
ment: 1, tibialis anterior tendon; 2, extensor hallucis
longus tendon; *, deep peroneal nerve; 3, extensor digi-
torumlongus tendon
8.4 Anterior Compartment
The foot must placed in the same position used
to assess the lateral compartment. Anatomical
scheme of the anterior compartment of the
ankle is shown in Fig. 8.23.
8.4.1 Anterior Tendons and Deep
Peroneal Nerve
Ankle position for anterior compartment evalu-
ation is shown in Fig. 8.24. The probe must be
placed on an axial plane on the anterior side of
the ankle. There, the tibialis anterior tendon,
the extensor hallucis longus tendon,andthe
extensor digitorum longus tendon can be
seen. The tendons must be followed distally up
to their insertion on the first cuneiform and on
the fingers, respectively (Figs. 8.25a, b).
In 5% of cases, an accessory tendon (per-
oneus tertius) can be seen laterally to the
extensor digitorum longus tendon.
The deep peroneal neurovascular bundle
can be seen deeply between the extensor hallu-
cis longus and the extensor digitorum longus
tendons (Fig. 8.25c).
The peroneus tertius muscle lies laterally to
the extensor digitorum longus. It arises from
the medial aspect of the fibula and from the
interosseous membrane. Its tendon enters the
extensor retinaculum of the ankle and inserts
on the fifth metatarsal bone.
The deep peroneal nerve is one of the termi-
nal branches of the common peroneal nerve.
At the level of the fibular neck, it pierces the
anterior intermuscular septum reaching the
anterior compartment of the leg. Here, it runs
parallel to the anterior tibial artery, between
the extensor hallucis longus and the tibialis
anterior tendons. Distally, it crosses posterior-
ly the extensor hallucis longus tendon and
enters the anterior retinaculum between the
extensor hallucis longus and the extensor dig-
itorum longus, ending in the subcutaneous tis-
sues, innervating the skin of the first and the
second fingers.
8 Ankle
130
Fig. 8.24 Ankle position to evaluate the anterior compart-
ment
Anterior Compartment
131
Fig. 8.25a Probe position to evaluate the anteri-
or compartment of the ankle
Fig. 8.25c The anterior compartment
on a longitudinal scan. Void arrow-
heads indicate the extensor
hallucis longus tendon; white arrow-
heads indicate the deep peroneal
nerve. Ti, tibia; T, talus
Fig. 8.25b The anterior compartment on an axial scan. EDL, extensor digitorum longus
tendon; A, tibial artery; EHL, extensor hallucis longus tendon; TA, tibialis anterior tendon;
arrowheads, deep peroneal nerve
Fig. 8.26a Probe position to evalu-
ate the anterior tibio-talar recess
Fig. 8.26b Longitudinal scan of the anterior tibio-talar recess (*). Ti, tibia; T, talus; c, cartilage
8.4.2 Anterior Tibio-Talar Recess
The anterior tibio-talar recess can be assessed
performing a longitudinal scan on the anterior
aspect of the ankle, between the extensor ten-
dons.
The anterior tibio-talar recess appears like a
triangular hyperechoic area, when not distended
by fluid. A thin layer of cartilage of the talus can
be also seen (Figs. 8.26a-b).
8 Ankle
132
The exam can be started either from the dorsal or
from the plantar side of the foot.
9.1 Hindfoot
The patient lies supine or prone with the foot
hanging out of the bed.
9.1.1 Plantar Aponeurosis
The foot must be dorsally flexed with the first toe
extended (Fig. 9.1a).
The probe must be placed longitudinally over
the heel to evaluate the insertional region of
plantar aponeurosis on a longitudinal scan (Fig.
9.1b).
Foot
9
Content s
9.1 Hindfoot
• Plantar Aponeurosis
9.2 Forefoot
• Plantar Side
• Dorsal Side
133
E. Silvestri, A. Muda, L. M. Sconfienza, Normal Ultrasound Anatomy of the Musculoskeletal System,
© Springer-Verlag Italia 2012
Fig. 9.1a Position of foot for evaluation of the plantar
aponeurosis
Fig. 9.1b Insertional region of the plantar aponeurosis on
a longitudinal scan (arrowheads). C, calcaneus
9.2 Forefoot
9.2.1 Plantar Side
The probe must be oriented on an axial plane
over the metatarsal heads (Figs. 9.2, 9.3a-c). At
this level, the intermetatarsal spaces and flexor
digitorum tendons can be seen.
Soft tissues within the intermetatarsal spaces
must be evaluated displacing them from their
natural position. This can be done either by
pressing the skin on the dorsal side of the foot or
by lateral compression of the whole forefoot
(Mulder’s maneuver). These maneuvers allow
for an improved detection of intermetatarsal bur-
sitis or Morton’s neuroma.
Flexor tendons and metatarsophalangeal
joints can be assessed using longitudinal scans
and passive mobilization of toes (Figs. 9.4a-c).
Dynamic scans allow also for detecting the
integrity of plantar plates.
9 Foot
134
Fig. 9.2 Anatomical scheme of a flexor digitorum tendon. P1, P2, P3, proximal, middle and distal phalanx; M, metatarsal
bone; FDS, flexor digitorum superficialis tendon; FDP, flexor digitorum profundus tendon; PP, plantar plate
Forefoot
135
Fig. 9.3a Probe position to evaluate the intermetatarsal spaces and flexor
digitorum tendons
Fig. 9.3b Axial scan of the plantar aspect of the foot. Arrowheads, flexor digitorum tendons;
II, III, second and third metatarsal bone; *, intermetatarsal space
Fig. 9.3c Axial scan at the level of the
sesamoid bones. MS, medial sesamoid bone;
LS, lateral sesamoid bone; *, flexor hallucis
longus tendon; M, first metatarsal head
9 Foot
136
Fig. 9.4a Probe position to evaluate flexor tendons on
the longitudinal axis
Fig. 9.4b Longitudinal
scan on the second
metatarsal-phalangeal
joint. M,
metatarsal
head; P1,proximal
phalanx; arrowheads,
flexor tendon course;
*, plantar plate
Fig. 9.4c Longitudinal scan on the second flexor digitorum tendons (arrowheads) at its insertion
on the distal phalanx. P2, P3, middle and distal phalanxes; *, plantar plate
9.2.2 Dorsal Side
The patient lies supine on the bed with the knee
flexed and the plantar side flat on the bed. The
probe must be oriented on an axial plane over the
metatarsal heads (Figs. 9.5a, b). The presence of
intermetatarsal bursitis and Morton’s neuroma
can also be detected from this position, perform-
ing the same maneuvers described for plantar
scans.
Short and long axis scans must be performed
to evaluate extensor tendons and laminae.
Forefoot
137
Fig. 9.5a Probe position to evaluate the intermetatarsal
spaces from the dorsal side
Fig. 9.5b Axial scan over the intermetatarsal spaces with a dorsal approach. *, intermetatarsal space; II, III, second
and third metatarsal bones; arrowheads, extensor tendons
Textbooks
Bianchi S, Martinoli C (2007) Ultrasound of the Muscu-
loskeletal System. Springer, Milan
Martino F, Silvestri E, Grassi W, Garaschi G (2006) Mus-
culoskeletal Sonography. Springer, Milan
McNally EG (2005) Practical Musculoskeletal Ultrasound.
Elsevier/Churchill Livingstone, Philadelphia
Papers
Bancroft LW, Merinbaum DJ, Zaleski CG, Peterson JJ,
Kransdorf MJ, Berquist TH (2007) Hip ultrasound.
Semin Musculoskelet Radiol 11:126-136
Beggs I (2011) Shoulder ultrasound. Semin Ultrasound
CT MR 32:101-113
Fessell DP, Jacobson JA (2008) Ultrasound of the hindfoot
and midfoot. Radiol Clin North Am 46:1027-1043
Khoury V, Guillin R, Dhanju J, Cardinal E (2007) Ultra-
sound of ankle and foot: overuse and sports injuries.
Semin Musculoskelet Radiol 11:149-161
Lee KS, Rosas HG, Craig JG (2010) Musculoskeletal ul-
trasound: elbow imaging and procedures. Semin Mus-
culoskelet Radiol. 14:449-460
Paczesny Ł, Kruczy ski J (2011) Ultrasound of the knee.
Semin Ultrasound CT MR. 32:114-124
Tagliafico A, Rubino M, Autuori A, Bianchi S, Martinoli
C (2007) Wrist and hand ultrasound. Semin Muscu-
loskelet Radiol 11:95-104
Recommended Reading
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