Step-By-Step Ultrasound Assessment of
the Ankle
CAITLIN GARDINER
Presentation

25 year old male

Referral: US assessment of the RIGHT ankle ?ATAF rupture

Patient indicates falling off a skateboard 3 weeks ago

Lateral ankle pain and swelling

Reduction in symptoms

Reserved movement
Ultrasound Examination

Explained examination to the patient to gain informed consent

Patient was positioned supine on the bed with right knee bent

A 5-13MHz linear array transducer

MSK General preset
Anterior Ankle
Lateral Ankle
Findings

Rupture of the ATAF ligament

Anterior Joint Effusion

A 12*7*3mm ganglion cyst arising from the medial talo-navicular
joint

Mild tenosynovitis of the peroneal tendons

Strain of the calcaneo-fibular ligament
The Anterior Talo-Fibular Ligament

Most commonly injurered ligament of the ankle

Typically occurs in individuals under 35 years of age, mostly 15-19
years and is sports-related in around 50% of cases (van den Bekerom
et al, 2012)

Important role in limiting anterior diaplacement of the talus and
plantar flexion of the ankle

Typically damaged by an inversion injury (Golano et al, 2010)

Clinical Presentation

Ankle diability

Pain and swelling

‘Giving way’ or instability (Golano et al, 2010)
The Anterior Talo-Fibular Ligament

The anterior talofibular ligament is composed of two bands,
separated by vascular branches of the perforating peroneal artery
and lateral malleolar artery

The upper band is taut on plantar flexion

The inferior band is taut on dorsiflexion

Originates at the anterior malleolus and attaches around 10mm
proximal to the fibula

Overall width of 6-10mm (Golano et al, 2010)
The Anterior Talo-Fibular Ligament

Ultrasound Findings

Distruption/discontinuation of ligament pattern/hyperechoic bundlesTorn

Hypechoic lesion- strain

Can be classified as

Attachment to fibula

Mid-substance

Attachment to the talus

Relevant as a 5mm margin of remnant from the attachment is
required to suture the ligament (Oae et al, 2010).

Around 60% of acute ATAF rupture cases showing a tibiotalar
effusion (McCarthy et al, 2008)
The Anterior Talo-Fibular Ligament


Treatment is typically conservative measure

Rest, Ice, Non-steroidal anti-inflammatories

Support bandages and immobilisation

Physical therapy

Interventional is typically only required in profession sports players (van
den Bekerom et al, 2012)
Imaging Modalities

Arthroscopy- Gold Standard

MR (93% when compared with Arthoscpy in the ATAF injury)

US- easily available, economical and portable. Less reliable (63% when
compared to Arthroscopy) (Oae et al, 2010).
Reflection

Also use a hockey-stick probe


Comparison picture of the calcaneo-fibular ligament


Unfortunately only one hockey-stick probe at the practice and was
unavailable at the time of examination
To highlight the strain of the ligament
Assess the type of tear of the ATAF

Prior to this assignment I was unaware this is something that can and
should be assessed
References

Galano P, Vega J, de Leeuw PAJ et al, 2010. Anatomy of the Ankle
Ligaments: A pictorial essay. Knee Surg Sports Traumatol Arthesc; 18:
557-569

McCarthy CL, Wilson DJ, Coltman TP, 2008. Anterolateral ankle
inmpingement; findings and diagnostic accuracy with ultrasound
imaging; 37(209-216).

Oae K, Takao M, Uchio Y and Ochi M, 2010. Evaluation of Anterior
Talofibular Ligament with stress radiography, ultrasonography and
MR imaging. Skeletal Radiol; 39:41-47.

Van den Bekerom MPJ, Kerkhoffs GM, McCullum GA et al, 2012.
Management of Acute Lateral Ankle Injury in the Atheltete. Knee
Surg Sports Traumatol Arthosc; 21(6): 1390-1395