INTERVENTIONAL MSK PROCEDURES SPECIAL FEATURE:

REVIEW ARTICLE

Ultrasound-guided intervention in the ankle and foot

1ELENI

DRAKONAKI, MD, PhD, 2GINA M ALLEN, MRCP, MRCGP, and 3ROLAND WATURA, MB BCh, MRCP
1Independent Practice, Heraklion, Greece 2Department of Radiology, Oxford University Hospitals NHS Trust and St Lukes Radiology, Oxford,

UK 3Department of Radiology, North Bristol NHS Trust, Bristol, UK

Address correspondence to: Dr Eleni E Drakonaki E-mail: drakonaki@yahoo.gr

ABSTRACT

In this comprehensive review, we discuss the main interventions performed in the foot and ankle for Achilles tendinopathy,
Mortons neuromas and Plantar fasciitis as well as techniques for intra-articular and peritendinous injections. We present the
different imaging techniques and injectable agents that can be used in clinical practice, trying to help the reader decide the
most appropriate way of managing the patient with a problem in the ankle and foot.

ULTRASOUND-GUIDED INJECTIONS AROUND TENDONS Tendinopathyandtenosynovitisarevery

commoninthefootandankle.Theycanbeassociatedwithmechanicfactors,chronicrepetitivestressoroveruse
injury,agerelateddegenerationorcanbesecondarytoinfammatoryarthritis.1,2Tendinopathycanbealso
associatedtoprevioussurgery,especiallyforanklefractures,resultingtotendonimpingementbyinternalfxation
devices.2
TheimaginginvestigationofatendonlesionintheankleandfootincludesMRIandultrasound.24MRIisusedfor
diagnosticpurposesbutisgenerallylessaccuratethanultrasound,asultrasoundhasbetterspatialresolution.2,3
Ultrasoundistheimagingtestofchoicetodiagnosethepresenceofacuteorchronictendinopathy,toassessits
activityandtoguideinterventionaroundtendons.3,4Normaltendonsappearashyperechoicbandsconsistingof
fneintrasubstancehyperandhypoechoicfbrils.Tendonsdisplayanisotropy,andtherefore,itisnecessaryto
alwayskeepthetransducerperpendiculartothetendontomaximizetendonechogenicityandavoid
misinterpretation.3,4Thetendonsheathcannotbediscriminatedwhennotdistendedwithfuid,andthereisno
detectablevascularityincolourDopplerimaging.3,4
Theultrasoundimagingfeaturesofacutetendinopathyoftheankleandfoottendonsincludefusiformhypoechoic
thickeningoftheaffectedtendonwithlossofnormalfascicularechostructure.3,4Therecanbehypoechoic
synovialthickeningsurroundingthetendonandareasofmicrofssuringandmucinousdegenerationintotheten
donsubstance(Figure1).EvaluationusingDopplerimagingmayrevealthepresenceofneovascularityinand
aroundthetendon,afeatureassociatedwithactiveinfammation.3,4Atamorechronicstage,therecanbethinning
ofthetendonalthoughitscontinuitycanbemaintained.Tenosynovitisischaracterizedbydistensionofthe
synovialtendonsheathbyfuid,whichmayormaynotbeaccompaniedbytheabnormalappearanceofthetendon
fbres.3,4
Besidesestablishingthediagnosisoftendinopathyortenosynovitis,ultrasoundcanalsobeusedtoguidethein
jectionofsteroidandlocalanaestheticintothetendonsheath.57Patientpositioningdependsontheanatomic
location,andalinearhighfrequencytransducer(718MHz)isusedtoidentifythepathologicaltendonandguide
theneedle.Ifpossible,ahockeysticktransducerisused,asitallowsmorespacetomanipulatetheneedle.Doppler
imagingpriortotheinjectionshouldbeusedtoidentifysurroundingvascularstructuresandtodetectareasof
increasedneovascularityastargetareas.57Theoptimalneedleentrypointandthecourseofneedlemustbe
assessedpriortoskinpreparation.Theinjectionisperformedundersterileconditionsusinga23Gneedle,and
theinjectioncanbecarriedoutwiththeneedleorientedaxiallyorlongitudinallytothenprobeunderdirectultra
soundguidance.57Ifthereisasignifcantsynovialsheatheffusion,thiscanbeaspiratedpriortoinjecting.Care
isBJR Drakonaki et al
Figure 1. (a) Axial ultrasound image of the tibialis posterior (TP) and fexor digitorum longus (FDL) tendons at the level of the
medial malleolus and (b) longitudinal ultrasound image of TP distally to the medial malleolus of a 32-year-old patient with
infammatory arthritis. There is effusion in the tendon sheath of both tendons together with an intratendinous hypoechoic area
in the FDL tendon, corresponding to an area of mucinous degeneration. FDL is also swollen and larger than TP, which is the
reverse of normal.

takentodeliverthesteroidinthesynovialsheatharoundthetendonandnotintothetendon,asintratendinous
injectionsareassociatedwithcollagenbreakdownandriskofrupture.8Incasesofdiffcultyindiscriminatingthe
synovialsheathfromthetendon(whennotdistendedwithfuid),apreliminaryinjectionoflocalanaestheticmay
beusefultodistendthecavitybeforeinjectingthesteroid.Carefulconsiderationanddiscussionwiththepatient
shouldbemadebeforesteroidinjectionaroundaweightbearingtendon(especiallytheposteriortibialtendon),as
theresultingreliefofpaincanleadtooverusebythepatient,whichcanworsenanatomiclesionsandpredisposeto
rupture.Inthesecases,thepatientmaybeneftfromtemporaryimmobilizationinaboot.Biomechanical
assessmentisalsoimportanttopreventrecurrenceoftendinopathy.
Peritendinoushyaluronicacidinjectionsarealsocommerciallyavailableforapplicationinimpingement
tendinopathiesandpostoperativeperitendinousadhesions.9,10However,thereisonlyscarceevidence,and
thereforetheuseofviscosupplementationaroundtendonsshouldbelimitedbeforefurtherinvestigationonsafety

andeffcacyisundertaken.Surgicaltreatmentoftendinopathyisindicatedafterfailureofconservativemeasures
orinrecalcitrantcases.11
INJECTABLE SUBSTANCES AND TECHNIQUES
Steroidinjectionsintosofttissues,bursae,tendonsheathsandjointsareverycommonlyusedinclinicalpractice
fortheir
antiinfammatoryproperties.12Inmostinstitutions,thetwocorticosteroidsusedmostroutinelyaretriamcinolone
acetonideandmethylprednisoloneacetate.Thesearegenerallymixedwithalocalanaesthetic,eitherlidocaine1%
oralonglastinganaestheticsuchasbupivacaineorropivacaine0.25%.Severalpotentialsideeffectsof
corticosteroidsareknown.1216Theseincludelocalsideeffects,includingskinatrophy,skindepigmentationand
fatnecrosis.Methylprednisoloneislesspronetocausingskinatrophythantriamcinoloneand,therefore,is
preferredwheninjectingsuperfciallesions.Moreover,intratendinoussteroidinjectionsincreasedirecttendon
damageandinanimalstudiesincreaseyourriskofrupture,1216astheyhavebeenshowntosuppresstenocyte
activityandcollagensynthesisandreducetendoncellviability.1315Therearealsoseveralsystemicsideeffects,
suchasfacialfushing,menstrualirregularityinfemalesandvividdreamsforseveraldaysafterwards.16Steroids
shouldalsobeusedwithcautioninpatientswithdiabetesandinpatientsusingtheantismokingdrugZyban,as
theycanincreasetheriskoffts.17Fortheabovereasons,theuseofsteroidsfortendinopathyisnotrecommended
bytheBritishNationalFormularyfordrugsandtheBritishSocietyofRheumatology,andtheyarebanned
substancesbytheWorldAntiDopingAgencyincompetition.
Autologousbloodtreatmentaroseover40yearsagointheequineworld.18Someoftheinitialstudieswere
performedonrabbittendonsshowinganincreaseincollagenType1andincreasedmaturityofrepairtissue.19
Theuseofautologousbloodanddryneedlinginpatellartendinosiswaspublishedin2007byJamesetal.20
Plateletrichplasmawasintroducedtoreducetheaftereffectoftheautologousblood,whichcanclotinthesyringe
andcausealotofsorenessbecauseoftheotherfactorswithinthebloodwhichareirritants.Anewproductwas
thereforedevelopedbycentrifugingthebloodandproducingbothproteinrichandproteinpoorplasma.The
proteinrichplasmaappearstoincreasetheamountofgrowthfactorsandenhancestheamountofcollagenType1
toaidincreasedhealing.2124This,however,madetheproceduremorecomplex,andaneedforsterilitybecame
importantasthebloodwasbeinghandledbeforebeingreinjectedintothepatient.Theautologousbloodorplatelet
richplasma(PRP)treatmenthasbeenusedextensivelyinconjunctionwithadryneedlingtechnique.