Ultrasound of the Ankle

Indications
Tendinitis and tenosynovitis
Ligament tears
Joint synovitis
Masses
Tarsal tunnel syndrome

Gross Anatomy (Figure 1)

Lateral posterior peri-articular structures
(anterior to posterior)
Peroneus brevis tendon (PB)
Peroneus longus tendon (PL)
Anterior peri-articular structures superficial to
the anterior joint capsule (medial to lateral)
Tibialis anterior tendon (TA)

Lateral ligament complex: Tri-radiate ligament

Anterior fibula-talar ligament (AFTL)
(anterior horizontal oblique)
Calcaneo-fibular ligament (CFL)
(posterior vertical oblique)
Posterior fibula-talar ligament (PFTL)
(posterior horizontal oblique)
Anterior tibio-fibular ligament (ATFL)
(anterior horizontal)
Medial ligament complex
Superficial deltoid ligament (SDL)
Deep deltoid ligament (DDL)
Extensor halucius longus
Extensor digitorum longus
Tibialis anterior

Extensor hallucis tendon (EH)

Dorsalis pedis artery
Medial melleolus

Extensor digitorum tendons (ED)

Peroneus tertius tendon (PT)
Medial posterior peri-articular structures
(anterior to posterior)
Tibialis posterior tendon (TP)
Flexor digitorum longus tendons (FDL)
Tibialis posterior artery
(with venae commitantes on either side)
Tibial nerve
Flexor hallucis longus tendon (FHL)

Talus
Lateral malleolus

Tibialis posterior
Flexor digitorum
longus

Peroneus brevis
Peroneus longus

Flexor hallucis longus

Achilles tendon

Figure 1.. Transverse section at level of ankle joint.

Probe Placement/Alignment/Movement
The scan is best performed with a small footprint high
resolution linear array transducer. The small transducer
allows maintenance of good transducer-to-skin contact
over the irregular surface contours of the ankle region.
Most of the relevant anatomical structures are within
1-2 cm of the skin surface and therefore good near-field
focusing is essential.
The anterior peri-articular structures and the anterior
ankle joint capsule are best examined with the patient
lying in the supine position. The ipsilateral knee is flexed
so that the plantar surface of the foot is able to lie flat
on the examination couch. The structures are initially
scanned in the sagittal plane passing from medial to
lateral anterior to the ankle joint. These structures
are then individually examined in the transverse plane
sweeping from approximately 5 cm above to 5 cm below
the ankle joint.
The posterior structures are best examined with the
patient lying supine with the foot initially in comfortable
equinus or with the patient lying prone with their ankle
and foot overhanging the end of the examination couch.
The postero-medial structures, i.e. all of the posterior
peri-articular structures except for the PL and PB
tendons, are first examined in a longitudinal plane.
The tendons arc around the malleoli and therefore
the transducer angle must be continually altered to
maintain a perpendicular incident beam. The FHL and
FDL tendons (also PB tendon laterally) after rounding
the malleoli pass plantarward so as to continue towards
the midfoot, and great care is again required in order
to avoid anisotropy (beam obliquity artifact). The
tibialis posterior tendon in particular is then scanned
transversely along its length initially with the foot
plantarflexed. It is then scanned posterior to the
medial malleolus with the foot dorsiflexed and inverted
so as to assess possible anterior tendon subluxation
or dislocation.
The peroneal tendons are examined in a similar way to
the postero-medial peri-articular tendons except that
anterior subluxation due to retinacular tear is assessed
with the foot dorsiflexed and everted. The lateral
ankle ligaments are well defined as discrete structures
and lie in the planes described above in the section on
gross anatomy. Those should be individually examined
using the tip of the lateral malleolus of fibula as the
initial landmark. The ATFL lies more proximally and is
located just above the level of the anterior tibial plafond/
articular margin.
The anterior joint capsule lies deep to the anterior
peri-articular tendons and may be examined at the same
time as these structures. The posterior joint capsule
should be examined in a posterior sagittal plane (deep to
the FHL).

The medial ligaments consist of fan-shaped deep

and superficial layers and merge anteriorly and
posteriorly with the anterior and posterior joint
capsules respectively.
The anterior joint capsule attaches distally on the dorsal
surface of the neck of talus. It attaches proximal to
another well defined ligament, i.e. the dorsal
talo-navicular ligament.

Sonographic Anatomy

Usual regions of
degeneration or tear

Common site of tendon injury (lateral aspect).

The ligaments of the lateral ligament complex

sonographically appear in normal individuals as discrete
echogenic bands very similar in appearance to tendons.
The ligaments of the superficial ligament complex are
thinner and less well defined than those seen on the
lateral side. The deep layer, due to its short length,
oblique downward orientation and overhanging bony
attachments, may be difficult to demonstrate as an
echogenic structure proximally due to anisotropy and
access problems. The anterior joint capsule is also seen
as a thin echogenic band. The thin hypoechoic layer of
articular cartilage over the dome of talus is best seen
anteriorly (Figures 2 and 3) and is usually more clearly
defined in the presence of a small ankle joint effusion
(where a thin echogenic interface line is also present
between its surface and the overlying fluid).

Imaging Protocol/Sequence of Views

The lateral ankle is usually examined first, starting
with the lateral ligament complex structures in their
longitudinal axis scanning from anterior to posterior,
followed by the lateral ankle tendons scanned in both
longitudinal and transverse axes, again scanning from
anterior to posterior. A dynamic study of the peroneal
tendons is then performed. Next, the anterior ankle
structures are examined in both longitudinal and
transverse planes. The medial ligaments and periarticular structures are then examined in a similar
manner to the lateral ankle structures. Finally, the
posterior joint capsule may be scanned in a posterior
sagittal plane, either with the patient prone or supine,
with the limb raised off the examination couch (this
latter position will accentuate any joint effusion in the
posterior recess and is especially recommended if
posterior intra-articular loose bodies are suspected).

TA

T
D

Figure 2a. Longitudinal section of the anterior

ankle through the tibialis anterior tendon (TA),
showing thin hypoechoic layer of articular
cartilage (arrows) overlying the talar dome (D).
The articular cartilage of the tibial plafond (T)
cannot usually be demonstrated on ultrasound.

Figure 3. Coronal section of the medial

ankle in a 1-year-old child. The ossified distal
tibial metaphysis (M) and adjacent secondary
ossification center (S) are clearly identified,
as well as the echogenic interface (arrows)
between non-ossified structural cartilage of
distal tibial epiphysis and talus (T).

TA
TP
M
T

Figure 2b. Similar image plane in a patient with

a florid synovitis of the tibialis anterior tendon
sheath with marked hyperemia of supplying
vessels (arrows), but with a normal tibialis
anterior tendon (TA) and without an interface
sign to suggest an ankle joint effusion.

Figure 4a. Coronal section of the medial ankle

showing an echogenic medial collateral ligament
extending between the tip of medial malleolus
(M) and adjacent talus (T), with the tibialis
posterior tendon (TP) being seen in crosssection overlying the ligament (arrows).

TP
M

Figure 4b. Similar image in a footballer, with

an acute ligament tear demonstrating a central
heterogenous hypoechoic band of edema/
hemorrhage and bone irregularity on the
talar surface (arrow), consistent with distal
attachment avulsion injury.

TP
TP

Figure 5a. Transverse section through the

anterior aspect of the distal tibio-fibular joint.
An echogenic band representing the anterior
tibio-fibular ligament (arrow heads) is seen
bridging the gap between the anterior aspects
of tibia (T) and fibula (F).

Figure 6a. Split screen longitudinal image

through the tibialis posterior tendons (TP),
showing a normal tendon on the right and a
tendon exhibiting a florid tenosynovitis and
longitudinal tear (arrow) on the left.

T
F
M

Figure 5b. Similar image in another footballer,

showing a discrete tear within the central
ligament (curved arrow) and malalignment/
redundancy of the ligament remnants.

Figure 6b. Transverse section image through

the left tendon at level of the tip of medial
malleolus (M) again shows the longitudinal split
within the tendon (arrow).

L
M

F
F

PI

DE

Figure 7. Split screen image transverse

section through the lateral malleolus. With
the foot in plantarflexion-inversion (P-I), the
peroneus longus tendon (L) lies superficial and
posterior to the peroneus brevis tendon (B).
In a dorsiflexed-everted (D-E) position, the
peroneus longus tendon now lies anterior to
the peroneus brevis tendon due to peroneal
tendon subluxation.

Figure 9. Oblique transverse section through

the tibialis posterior tendon at the level of
the tip of medial malleolus showing thickening
and edema of the flexor retinaculum (arrows)
and avulsion of a small bone fragment (curved
arrow) from its posterior attachment.

TP
S
N

B
C

Figure 8. Oblique transverse section through

the peroneal tendons in the recess between
fibula (F) and calcaneum (C). The peroneus
longus tendon (L) is impinging onto the
peroneus brevis tendon (B), producing in this
latter tendon a longitudinal tear (arrow).

Figure 10. Longitudinal section through the

distal tibialis posterior tendon (TP) close to
its insertion into the medial border of navicula
(N). The calcified area within the distal tendon
(S) reflects a normal sessamoid bone, i.e. the os
tibiale externa.

Findings

Pitfalls

Ligament tears are usually seen as focal or diffuse areas

of hypoechoic/thickened ligament which may have
associated calcific foci at their proximal or distal ends if
avulsion of their osseous attachments has occurred. In
acute injuries there may be profound superficial softtissue edema and a hemarthrosis deep to the ligament
(Figures 4). In chronic tears there may be a discrete
ligament interruption or redundancy (Figures 5).

A small or even moderate amount of fluid in the

posterior peri-articular tendons may be a normal
finding or may reflect fluid communicating from an
ankle joint effusion.

Peroneal and TP tendon tears are usually orientated

along the long axis of the tendons as they change from
a vertical to a horizontal orientation, i.e. as they round
the malleoli (Figures 6).
Peroneus longus may be demonstrated to override
peroneus brevis on dorsi-flexion and eversion
(Figure 7). The longus tendon may also herniate into
a defect in the brevis tendon causing the latter to
split or become V shaped on transverse scans
(Figure 8). The peroneal and TP tendons may also
sublux secondary to retinacular tear or avulsion
(Figure 9).

The distal end of the tibialis posterior tendon usually

becomes thickened as it nears its attachment to the
medial border of navicular bone and may also appear
hypoechoic due to anisotropy.
Sessamoid bones and accessory ossicles are common
in the ankle region and should not be confused with
tendon or tendon sheath calcification. Also a smooth
margin and an absence of surrounding edema should
help distinguish them from an acute tendon or
ligamentous avulsion injury (Figure 10).
Acute hemorrhage may be echogenic and therefore
less well seen within the substance of ligaments. Tears
may therefore be better seen on delayed scanning, i.e.
after 2 - 3 days where edema dissecting between tissue
planes also improves tissue contrast.

In a tenosynovitis, especially at an early stage in its

development, there may be profound tendon sheath
synovitis in the presence of an otherwise normal
tendon (Figure 2b).

REFERENCES
1. Fessell DP, Vanderschueren GM, Jacobson JA, Ceulemans RY,
Prasad A, Craig JG, Bouffard JA, Shirazi KK, van Holsbeeck MT. US of
the ankle: technique, anatomy, and diagnosis of pathologic conditions.
Radiographics. 18(2):325 - 40, 1998.
2. Miller SD, Van Holsbeeck M, Boruta PM, Wu KK, Katcherian DA.
Ultrasound in the diagnosis of posterior tibial tendon pathology.
Foot & Ankle International. 17(9):555 - 8, 1996 Sep.
CLINICAL SOURCE
Prof. Wayne W. Gibbon, MD
Consultant Musculoskeletal Radiologist, UK

Philips Medical
Systems is part
of Royal Philips
Electronics
www.medical.philips.com/
ultrasound

North America
Tel: 800 229 6417
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Tel: 852 2821 5888
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Tel: 49 40 5078 4532
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