ANATOMY AND ULTRASOUND CORRELATION WITH
AN EMPHASIS ON NORMAL VARIATION
GIUSEPPE MONETTI
DIRETTORE DIPARTIMENTO DI DIAGNOSTICA PER IMMAGINI OSPEDALI RIUNITI NIGRISOLI
FACOLTA^ DI SCIENZE MOTORIE ED ISTITUTO DI MEDICINA DELLO SPORT
- UNIVERSITA^ DEGLI STUDI - BOLOGNA ITALY
INFO@MUSKULTRASOUND.IT
3
3
1
THE ANKLE AND FOOT ARE MADE UP OF ANCHOR AND
SLIDING TENDONS. THE ANCHOR ONES ARE PROVIDED
1
OF ONLY PERITENON , WHILE THOSE OF SLIDING ALSO
HAVE A SYNOVIAL SHEATH , NOT USUALLY
RECOGNIZABLE UNDER PHYSIOLOGICAL CONDITIONS.
4
4
2
3
AT
2
2
1
3
3
1
THE ACHILLES TENDON ,
WICH IS DISPLAIED IN
SAGITTAL SCAN , IS
EVIDENCED BY THE
CALCANEAL DISTAL
INSERTION TO THE
GASTROCNEMIUS AND
SOLEUS MUSCLES
JUNCTION. IT HAS THE
TYPICAL FIBRILLAR
STRUCTURE
UNIFORMLY
ECHOGENIC. BELOW
THE ACHILLES TENDON
IS RECOGNIZABLE THE
KAGER’S FAT PAD.
THE SAME TENDON , VIEWED WITH AXIAL
SCAN , PRESENTS OVAL HOMOGENEOUS ASPECT
1
, WITH ANTERO-POSTERIOR
DIAMETER OF
ABOUT 5-6 MM.
THE ACHILLES TENDON HAS
TWO BURSAE , THE FIRST ONE
ON THE SUB-CUTANEOUS
SURFACE, THE SECOND ONE
SEATED AT THE
RETROCALCANEAL DEEP
PLANE. THIS LAST BURSA ,
EVEN UNDER PHYSIOLOGICAL
CONDITIONS , OFTEN PRESENTS
A MODEST AMOUNT OF
SYNOVIAL FLUID THAT IS
BETTER VISIBLE.
2
2
3
1
1
4
4
THE ACHILLES TENDON , VIEWED WITH 3D RECONSTRUCTION IN CORONAL
PLANE, PRESENTS HOMOGENEOUS ISOECHOIC SIGNAL.
1
1
1
1
2
2
C
A
B
IN THE POSTEROMEDIAL
COMPARTMENT ,
BEHIND THE DISTAL
INSERTION OF THE
ACHILLE ‘S TENDON ,
WE VISUALIZE THE
PLANTAR GRACILIS
TENDON .
1
2
1
3
1
2
1
C
2
3
2
3
1
A
A DISCREETLY FREQUENT ANATOMICAL VARIATION IN THAT SEAT , IS
CONSTITUTED BY THE ACCESSORY SOLEUS MUSCLE , LOCATED
IMMEDIATELY BELOW THE ACHILLES TENDON WHERE THERE IS FOUND
MOST OF THE KAGER ‘S FAT PAD. THE DYNAMIC INVESTIGATION IS ABLE
TO HIGLIGHTS IN THE CONTRACTION PHASE , THE PHYSIOLOGICAL
MOVEMENT OF THIS MUSCLE .
B
3
2
3
2
1
1
3
A
C
THE ANTERIOR EXTENSOR TENDONS COMPARTMENT IS FORMED , FROM
MEDIAL TO LATERAL SIDE , BY THE TIBIALIS ANTERIOR TENDON , EXTENSOR
HALLUCIS LONGUS AND EXTENSOR DIGITORUM COMMUNIS TENDON.
3
ELD
1
2
C
EAL
TA
1
3
A
2
EAL
ELD
TA
2
1
1
2
1
C
B
B
1
1
1
D
1
AXIAL AND SAGITTAL SCANS DEMONSTRATING THE PRESENCE OF THE
TIBIALIS ANTERIOR TENDON , WITH ITS SYNOVIAL SHEATH. IT IS ALWAIS
USEFUL DURING THE EXAMINATION , TO PERFORM DYNAMIC FOOT FLEXIONA
EXTENSION , IN ORDER TO RECOGNIZE THE SLIDING PLANE OF THE TENDON.
1
2
1
2
3
3
1
C
B
1
1
1
D
1
THE EXTENSOR HALLUCIS LONGUS TENDON IS RECOGNIZABLE IN AXIAL
AND SAGITTAL MORE CENTRAL PLANE. IT HAS THE SAME SEMIOTICS OF
THE TIBIALIS ANTERIOR TENDON.
A
THE LATERAL COMPARTMENT IS MADE UP OF LONG AND SHORT
PERONEAL TENDONS.
2
1
1
2
2
3
1
1
3
2
1
2
4
C
D
E
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3
2
1
1
2
2
BY MAKING A SAGITTAL RETRO-MALLEOLAR SCAN , YOU SEE THE TWO
5
TENDONS
: THE SURFACE FORMED BY THE PERONEUS LONGUS AND DEEPEST
A
THE PERONEUS BREVIS TENDON.
4
1
2
D
3
2
1
2
1
B
THE PERONEUS BREVIS TENDON CAN EASILY BE STUDIED IN THE SAGITTAL
PLANE TO ITS INSERTION ON THE FIFTH METATARSAL BONE.
C
1
2
4
1
2
3
1
2
1
A
PERONEUS LONGUS AND BREVIS TENDONS VISUALIZED IN AXIAL SCAN
WITH ULTRASOUND AND MRI EXAMINATIONS.
3
1
4
2
4
5
1-2
A
B
3
1
6
2
5
3
1
2
ANB ANATOMICAL VARIATION
CERTAINLY MORE EASILY RECOGNIZED
A
C
THROUGH A SURVEY WITH MRI , CONSISTS OF THE PERONEUS QUARTUS
TENDON , LOCATED JUST INSIDE THE LONG AND SHORT PERONEAL TENDONS.
3
3
2
3
1
D
THE FLEXOR TENDONS OF THE MEDIAL COMPARTMENT ARE LOCATED
8
B
WITHIN THE MEDIAL
TARSAL TUNNEL D. WE RECOGNIZE THE POSTERIOR
1
TIBIAL TENDON , THE FLEXOR DIGITORUM TENDON , THE NERVOUS VASCULAR
1
1
BUNDLE CONSISTING OF THE POSTERIOR TIBIAL
NERVE AND THE MEDIAL
AND LATERAL
PLANTAR NERVES , AND FINALLY THE FLEXOR LONGUS 2
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2
10
HALLUCIS TENDON LOCATED DEEPER.
2
7
9
3-4-5-6
3
3-4-5-67
C
10
5
1
2
6
8
4
3
7
3
1
7
9
2
A
E
1
1
SAGITTAL
AND AXIAL SCAN ON MEDIAL MALLEOLUS , WICH RECOGNIZE THE
A
COURSE OF THE POSTERIOR TIBIAL TENDON . THE TENDON THAT IS VERY
IMPORTANT ASSOCIATED WITH THE PERONEAL TENDONS IN THE
1
STABILIZATION OF THE TALUS
, WICH HAS NO TENDON INSERTION .
1
1
1
D
B
C
A
B
2
1
1
2
1
C
3
3
3
4
1
1
4
1
4
THE POSTERIOR TIBIAL TENDON CAN BE RECOGNIZED IN THE SAGITTAL
PLANE UNTIL DISTAL INSERTION , MAINLY TO THE SCAPHOID AND PARTLY IN
THE FIRST CUNEIFORMIS BONE.
D
1
1
A
1
A SAGITTAL AND AXIAL
SLIGHTLY POSTERIOR SCAN ,
SHOWS THE PRESENCE OF
THE FLEXOR DIGITORUM
TENDON , BEHIND THE
POSTERIOR TIBIAL TENDON.
1
1
B
C
D
1-2-3
MOVING THE PROBE EVEN
MORE REAR , DISPLAYS THE
NERVOUS-VASCULAR
BUNDLE CONSISTING OF
TIBIAL ARTERY AND VEINS
A, THE POSTERIOR TIBIAL
NERVE AND THE MEDIAL
AND LATERAL PLANTAR
NERVES.
1
3
1
2
4
B
1
4
3
2
1
1-2-3
B
C
A
B
1
1
1
2
1
2
1
A SUBSEQUENT SCAN SHOWS IN
A MOST POSTERIOR SAGITTAL
PLANE THE FLEXOR HALLUCIS
LONGUS TENDON , THAT EVEN
UNDER PHYSIOLOGICAL
CONDITIONS HAS OFTEN A FAIR
AMOUNT OF SYNOVIAL FLUID.
3
3
2
1
1
2
THE EXTERNAL CAPSULAR LIGAMENT ARE THE ANTERIOR TALO-FIBULAR
LIGAMENT AND THE CALCANEO-FIBULAR LIGAMENT.
2
1
3
A
ORIENTING THE PROBE FROM THE FIBULAR MALLEOLUS , IT UNDERLINES
THE COURSE OF THE ANTERIOR TALO-FIBULAR LIGAMENT , WICH IS
CONSTITUTED BY THE CAPSULE IN ITS LOWER PART. PERFORMING A
DYNAMIC EXAMINATION , YOU GET A FUNCTIONAL ASSESSMENT OF THE
1
LIGAMENT PERFORMING INVERSION AND
EVERSION ANKLE MOVEMENTS.
3
C
3
1
2
1
1
2
B
D
A
B
C
1
2
2
1
1
1
3
COMPARISON VIEW OF THE
3 ANTERIOR TALO-FIBULAR LIGAMENT ALSO
PERFORMED WITH 3D
THE FUNCTIONAL EVALUATION OF THE ANKLE
LIGAMENTS FULLY ACHIEVED TROUGH THE USE OF THE
ELASTOSONOGRAPHY. THE SIGNAL AT THE LEVEL OF
THE ATFL HAS AN AVERAGE ELASTICITY , REFERRED TO
HIG CONTENT OF ELASTINA LIGAMENT ITSELF.
SAGITTAL SCAN MADE BRINGING THE PROBE FROM THE FIBULAR
MALLEOLUS IN A POSTERIOR DIRECTION , POSSIBLY WITH DORSI-FLEXION OF
THE FOOT , WICH SHOWS THE PRESENCE OF CALCANEO-FIBULAR LIGAMENT ,
WICH CONTRACTS ANATOMICAL INTIMACY WITH THE COMMON PERONEAL
TENDONS SHEATH.
LPC
PER
CALC
TPL
TPB
LPC
5
5
3-4
3-4
1-2
1-2
THE MEDIAL CAPSULAR-LIGAMENT COMPLEX CONSISTS OF THE DEEP AND
SUPERFICIAL TIBIO-TALAR LIGAMENT AND OF THE DEEP AND SUPERFICIAL
TIBIO-CALCANEAL SURFACE LIGAMENT , FORMING THE SO CALLED DELTOID
LIGAMENT.
1-2
3
1
2
4
3
1
4
2
THE ANTERIOR BUNDLE OF THE DELTOID
LIGAMENT CONSISTS OF THE SUPERFICIAL
AND DEEP TIBIO-TALAR LIGAMENTS , VIEWED
WITH SAGITTAL SCAN STARTING FROM THE
ANKLE ALONG THE COURSE OF THE
LIGAMENTS , WICH APPEAR IN A TRIANGULAR
B
SHAPE.
1
5
2
3
3
3-4
1
4
2
A
3
1
2
B
2
THE DISPLAY OF THE DEEP
SURFACE OF THE TIBIO-CALCANEAL LIGAMENT ,
IS POSSIBLE BY POSITIONING THE PROBE FROM THE MALLEOLUS WITH
POSTERIOR AND OBLIQUUE COURSE. THAT LIGAMENTS ARE HIGHLIGHTED
C
IMMEDIATELY BELOW THE TENDONS FORMING THE MEDIAL TARSAL
TUNNEL.
1
B
1
1
THE POSTERIOR TALO-FIBULAR LIGAMENT IS
WELL DETECTABLE BY MRI AND CT SCAN ,
BEING MODERATELY ARCUATE. THE
ULTRASOUND STUDY FIND DISCRETE
PROBLEMS TO DEPICT THE LIGAMENT
1
A
1
D
C
1
1
OTHER LIGAMENT OF GREAT IMPORTANCE IS
THE ANTERIOR INFERIOR TIBIO-FIBULAR
SYNDESMOSIS
THE DISPLAY OF THIS LIGAMENT IS DONE BY PLACING THE PROBE TURNED
UPWARDS BETWEEN TIBIA AND FIBULA TO ITS DISTAL SITE , WHERE THERE
IS A THICK AND ECHOGENIC BAND WICH CONSTITUTES THE ANTERIOR
SYNDESMOSIS LIGAMENT.
D
1
1
1
C
B
1
A
1
THE JOINT CAPSULE IS IDENTIFIED BY PLACING THE PROBE ON THE BACK
IN THE SAGITTAL SCAN , EXACTLY ABOVE THE ANTERIOR TIBIALIS TENDON ,
ADJACENT THE TIBIO-TALAR JOINT.
2
3
3
1
4
B
A
4
PLACING THE PROBE IN AXIAL SCAN , YOU GET THE DISPLAY TO THAT
LEVEL OF TALAR DOME , WITH HYPERECHOIC IMAGES CONSTITUTING THE
CORTICAL RIM , COVERED BY HYALINE CARTILAGE AND JOINT CAPSULE.
C
3
3
2
1
2
1
B
2
1
A
2
1
1
2
THE SINUS TARSI IS A FUNDAMENTAL STRUCTURE FOR THE PROPER
STABILIZATION OF THE ANKLE AND FOOT . IT IS CONSTITUTED BY
CERVICAL LIGAMENT AND RETINACULUM IN THE SAGITTAL PLANE ,
WHILE THE INTEROSSEUS LIGAMENT WITH CORONAL AND AXIAL SCAN .
THE METHOD OF CHOICE FOR THE STUDY OF LIGAMENTS FORMING THE
SINUS TARSI , IS PROVIDED BY MRI EXAM , DEMONSTRATING CERVICAL
LIGAMENT AND RETINACULUM IN THE SAGITTAL PLANE , WHILE THE
INTEROSSEUS LIGAMENT WITH CORONAL SCAN.
1
2
3
3
1
2
3
2
A
C
B
3
2
1
THE ULTRASOUND EXAMINATION IS ABLE OF HIGHLIGHT THE CERVICAL
LIGAMENT ONLY IN THREE-DIMENSIONAL RECONSTRUCTION , BY SCANNING
3D SAGITTAL PLANE .
3
3
2
2
1
1
B
A
2
1
1
1
3
C
B
IT’S THE SAME FOR THE INTEROSSEUS LIGAMENT , VIEWABLE ONLY BY
PERFORMING A CORONAL 3D ULTRASOUND RECONSTRUCTION .
4
4
1
1
2
2
D
A
AN ANATOMICAL REGION OF CONSIDERABLE
IMPORTANCE IS CONSTITUDED BY THE COXA PEDIS ,
WHERE IS PRESENT A LIGAMENT OF FUNDAMENTAL
IMPORTANCE FOR THE FOOT STABILITY : THE SPRINGLIGAMENT OR CALCANEO-NAVICULAR LIGAMENT .
2
1
3
4
4
1
3
1
2
A
3
THEC SPRING-LIGAMENT IS COMPOSED OF THREE LAYERS , THE
SUPERFICIAL ,
2
MEDIUM AND DEEP LAYERS . THE ULTRASOUND EXAMINATION , CARRIED
OUT ON CORONAL PLANES ON THE MEDIAL SIDE , IS ABLE TO HIGHLIGHT
2
3
AT LEAST THE MORE
SUPERFICIAL . THE METHOD OF CHOICE , HOWEVER , IS
THE MRI METHOD , PERFORMED ON SAGITTAL
SCAN .
1
1
1
3
3
1
2
2
B
1
C
1
2
3
THE DORSAL TALO-NAVICULAR LIGAMENT VISUALIZED WITH THE SAGITTAL
SCAN AND 3D RECONSTRUCTION.
B
3
1
1
3
2
2
A
THE SONOGRAPHIC STUDY OF THE FOOT IS MOSTLY CARRIED OUT ON THE
FLEXOR AND EXTENSOR TENDONS , ON THE PLANTAR FASCIA AND FINALLY
ON THE INTER-METATARSAL NEURO-VASCULAR STRUCTURES , MAINLY
INCLUDING THE MEDIAL AND LATERAL PLANTAR NERVES .
C
A
B
FOOT
C
THE
VISUALISATION OF THE PLANTAR FASCIA IS OBTAINED BY
PERFORMING A SAGITTAL SCAN AT THE LEVEL OF PLANTAR HEEL .
B
2
2
1
1
2
1
2
1
A
A
3
3
3
2
2
1
1
2
1
THE
REGION OF HENRY’S AKNOT IS COMPOSED BY THE INTERSECTION
B
C
FORMED BY THE FLEXOR HALLUCIS LONGUS AND FLEXOR COMMUNIS
TENDONS AND THE MEDIAL PLANTAR NERVE.
D
1
1
E
B
1
1
2
3
1
THE STUDY OF THE FLEXOR
HALLUCIS LONGUS TENDON IS MOSTLY
3
2
CARRIED OUT ON SAGITTAL SCAN WITH DYNAMIC FOOT PLANTAR FLEXIONC
F
A
EXTENSION , IN ORDER TO ASSESS PROPER 2 SLIDING OF THE TENDON .
OTHER SCAN THAT IS PERFORMED AT THE LEVEL OF THE FEXOR HALLUCIS
B
TENDON
, IS AT THE SESAMOID REGION , WHERE IT CAN PERFORM DYNAMIC
2
TESTS FOR THE STABILITY OF THESE STRUCTURES .
1
1
1
3
3
2
C
1
2
1
3
1
A
D
E
1
LIKE THE FLEXOR TENDONS STUDY , THE EXTENSOR TENDONS
EXAMINATION
A
IS PERFORMED MAINLY WITH SAGITTAL DYNAMIC ULTRASOUND SCANS .
C
1
1
B
THE STUDY OF THE COLLATERAL LIGAMENTS IS PERFORMED WITH
INTERDIGITAL CORONAL SCANS THAT SHOW THE CONNECTION TO THE
PROXIMAL AND DISTAL EMERGENCY OF THE SINGLE PHALANGES.
C
1
1
1
B
1
A
2
6
3
4
5
1
B
THE VASCULAR AND NERVOUS
INTERMETATARSAL BUNDLES
IS
1
CONSTITUTED BY THE MEDIAL AND
LATERAL PLANTAR NERVES , AND
INVESTIGATED BY AXIAL AND
1
SAGITTAL SCANS
PERFORMED AT
THE LEVEL OF THE METATARSAL
HEADS . IT IS EVIDENT THE
CENTRAL NERVOUS BUNDLE , QUITE
6
ISO-HYPOECHOIC
, WITH
THE
4
2
HOMONIMOUS VEIN AND ARTERY .
CAN BE USEFUL A DYNAMIC
COMPRESSION , IN ORDER
3 TO
EVALUATE POSSIBLE CAPSULAR
5
1
LIGAMENT INSTABILITY OF THE
METATARSAL HEADS .
THANK
YOU
3
2
C
A
2
6
4
3
1