Musculoskeletal Ultrasound of the
Foot And Ankle
Arthur Jason De Luigi, DO
Program Director, Sports Medicine Fellowship
Director of Sports Medicine
MedStar National Rehabilitation Hospital
MedStar Georgetown University Hospital
Disclosure
• Nothing to Disclose
OBJECTIVES
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General Survey
Anteromedial
Superior
Posterior
Pathology
Injections
TABLE OF CONTENTS
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General survey
Anterior
Lateral
Medial
Posterior
General survey
• Complex anatomy: > 26 bones,
33 joints
• Conceptual construct
– Hindfoot: tibia, fibula, talus,
calcaneus, ankle and subtalar
joint
– Midfoot: cuboid, navicular,
cuneiforms; arches of the foot
supported by static and dynamic
arch stabilizers
– Forefoot: metatarsals, phanges
Functional units
• Ankle
• Transverse tarsal joint
complex
– Calcaneocuboid
– Talocalcaneonavicular
• Tarsometatarsal joint
(Lisfranc)
TABLE OF CONTENT
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General survey
Anterior
Lateral
Medial
Posterior
Plantar
Dorsum
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Tibialis anterior
Extensor hallucis longus
Extensor digitorum longus
Deep peroneal nerve and dorsalis pedis artery
Anterior joint recess (effusion, loose bodies,
and synovial thickening)
• Anterior joint capsule
Extensors of ankle
• Crossing anterior to the ankle
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Tibialis anterior (TA)
Extensor hallucis longus (EHL)
Extensor digitorum longus
Dorsalis pedis artery and vein
Deep peroneal nerve
• Place probe in transverse axis to
the tibia on anterior ankle near the
joint line
Anterior ankle
• TA
– Most medial
• EHL
• Dorsalis Vasculature (a,v)
• EDL
– Most lateral
• Each tendon is enclosed
within its own tendon
sheath
• Deep peroneal nerve (s)
– Close proximity to the
vascular bundle
• The inferior extensor
retinaculum (6) lies
superficial
• Both EHL and EDL have low-lying
myotendinous junction.
• Muscle belly comes in view quickly as the
transducer is moved proximally
Tibialis anterior
• Turn transducer to long-axis to tibia and place over TA
at level of the ankle
• TA is superficial to the anterior ankle joint recess,
which is filled with fat (f).
• The cartilage (6) appears as hypo/anechoic layer
superficial to the talar dome (TD)
Tibialis insertion
• Trace probe along the TA tendon to see its
insertion on the inferior aspect of medial
cuneiform and the base of 1st metatarsal
Extensor Hallucis Longus (EHL)
• Origins at anterior surface of
the fibula and interosseous
membrane for about the
middle two-fourths of its
extent, passes under the
inferior extensor retinaculum
(cruciate crural ligament) and
inserts on base of great toe
distal phalanx
• Extends the great toe, invert
and dosiflex the foot
EHL
• Return to distal tibia over TA tendon in long-axis and
move laterally;
• EHL is the next tendon in view
• The body of EHL (**) can be seen in supramalleolar
region
EHL over dorsal midfoot
• Following the EHL over talar neck (T),
navicular (N) and medial cuneiform (MC)
EHL insertion
• Trace distally over the course of the great
toe
• EHL inserts at base of distal phalanx
– An anatomical variation of EDB may send a
tendon and insert on base of proximal
phalanx, known as extensor hallucis brevis,
or EHB (^)
Extensor Digitorum Longus (EDL)
• Originates from anterior lateral
condyle of tibia, anterior shaft of
fibula and superior ¾ of
interosseous membrane
• Tendons contained within single
tendon sheath until divide
superficial to EDB
• Inserts on dorsal surface of
middle, and distal phalanges of
lateral four toes
EDL
• Level of the ankle
joint recess. The
inferior extensor
retinaculum (h) is
superficial to the
tendon
• Joint recess is
visible superficial
to the talar dome
cartilage (6)
Lisfranc Joint
• Important for mid foot stability
• Skeletal elements:
tarsometatarsal, intertarsal,
and intermetatarsal articular
surfaces
• Non-skeletal elements:
articular capsules, the various
ligaments
Lisfranc ligament
• Complex of ligament which extends
from plantar-lateral aspect of medial
cuneiform, passes in front of the
intermediate cuneiform ligament, and
inserts into the plantar-medial of
second metatarsal
• Oblique band connecting 2nd
metatarsals (M2) and intermediate
cuneiform (C2) to the medial
cuneiform (C1) most important
• Reinforces bony stability of base of the
2nd metatarsal between medial and
lateral cuneiforms
Dorsal Lisfranc ligament
• Place transducer in
transverse axis over
dorsal medial foot over
first and second
metatarsal (M1, M2)
Dorsal Lisfranc ligament
• Move proximally until medial cuneiform (C1) is seen, which
appears angular instead of round compared to metatarsals
• Lisfranc ligament (arrow) appears hyperechoic and fibrillar,
with a characteristic notch in C1 at its attachment
• C1 and M2 distance (arrowhead) should be minimal to
none
TABLE OF CONTENT
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General survey
Anterior
Lateral
Medial
Posterior
Plantar
Lateral
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Peroneus brevis
Peroneus longus
Superior peroneal retinaculum
Anterior TaloFibular Ligament (ATFL)
Calcaneo-Fibular Ligatment (CFL)
Peroneus groups
• Peroneus longus (PL)
– Originates at head of fibula, wraps
around cuboid laterally and enter
deep space of foot, inserting on
medial cuneiform and 1st metatarsal
• Peroneus brevis (PB)
– Originates at proximal 1/3 of fibula,
inserts on base of 5th metatarsal
• Both tendon wraps around
posterior lateral malleolus before
parting ways at peroneal tubercle
(aka trochlear process) on lateral
aspect of calcaneus
Lateral ankle ligaments
• Anterior talofibular ligament (ATFL)
– Most frequently injured structure in
lateral ankle sprain
– Generally two separate bands
– Loose during foot neutral and taut
when foot plantarflexed and inverted,
subject to injury
• Calcaneofibular ligament (CFL)
– The only ligament bridging both the
talocrural joint and subtalar joint
– Remain taut throughout entire ROM
• Posterior talofibular ligament (PTFL)
– Difficult to visualize on US
– Relaxed in neutral and plantar flexion,
taut in dorsiflexion
1 Tip of the lateral malleolus
2 Tibia
3 Anterior tibiofibular ligament
4 Distal fascicle of the anterior tibiofibular
ligament
5 Superior band of the anterior talofibular
ligament
6 Inferior band of the anterior talofibular
ligament
7 Lateral articular surface of the talus
8 Neck of the talus
9 Head of the talus
10 Calcaneofibular ligament
11 Talocalcaneal interosseous ligament
12 Cervical ligament
13 Talonavicular ligament
14 Navicular
Peroneus group, supramalleolar
• Place transducer on
transverse axis over
lateral ankle just
proximal to lateral
malleolus
• Peroneus longus (PL) is
superficial to the body
of peroneus brevis (PB),
with the PB tendon (^)
forming just deep to PL
tendon
Peroneus group, retromalleolar
• PB
– Condensed into mostly
tendon, and stays deep to
PL as the tendons course
around the malleolus
• Superior peroneal
retinaculum (^)
– connects calcaneus to
fibula (F) and may be
visible
• PTFL (↓) is deep to the
peroneal tendons
Peroneus group, inframalleolar
• Place transducer over
tip of fibula
• Deep to the inferior
peroneal retinaculum
(^), PL and PB may
appear oblique as they
diverge toward
peroneal tubercle
• The calcaneofibular
ligament (6) connects
fibula and calcaneus
Peroneal tubercle
• Move transducer slightly
caudal and locate the
• Peroneal tubercle (*)
– which appears like a peak
on the surface of calcaneus
• Deep to the inferior
peroneal retinaculum (^),
PL (g) and PB (a)
• Generally divides around
PT with PB maintains
superior and PL dives
inferior, as seen in the top
sonogram
Peroneus brevis insertion
• Place transducer
over lateral aspect
of base of 5th
metatarsal (5MT) in
longitudinal axis, PB
can be seen
inserting onto the
base
Peroneus Longus (PL)
• PL (s) tendon dives around cuboid (Cu) and travels deep until reaching 1MT
base, together with TP forming a tendinous stirrup
– Start at the lateral border of foot at cuboid, scan in longitudinal axis with PL
toward 1MT
• Plantar aponeurosis (^) is seen superficial to FDB
• FHL tendon appears hypoechoic given its oblique course in this view
Anterior TaloFibular Ligament (ATFL)
• Place transducer in
transverse axis over
anterior surface of
fibula parallel to
the plantar surface
of the foot
• ATFL (*) connects
between fibula (F)
and talus (T), deep
to the superior
extensor
retinaculum (^)
Anterior tibiofibular ligament
• Move transducer
cephalad until tibia
(T) comes in view
in close proximity
to the fibula
• Anterior
tibiofibular
ligament (*) is flat
and broad,
inserting slightly
obliquely from tibia
onto fibula
TABLE OF CONTENT
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General survey
Anterior
Lateral
Medial
Posterior
Plantar
Medial
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Posterior tibialis
Flexor digitorum longus
Posterior tibial nerve
Tibial artery and veins
Flexor hallucis longus
Tarsal tunnel
• Roof: flexor
retinaculum
• Floor: tibia and talus
and more inferiorly
the medial aspects
of the navicular and
calcaneus
• Content: tibialis
posterior (TP), flexor
digitorum longus
(FDL), tibial
vasculature, tibial
nerve, flexor hallucis
longus (FHL)
Tarsal tunnel, proximal ankle
• Transducer in transverse axis posterior to medial malleolus
• From anterior to posterior, TP is followed by FDL, the tibial veins
(v) and artery (a), tibial nerve, then finally FHL
• (Tom, Dick and A Very Nervous Harry).
• Achilles tendon (A) is barely visible at the edge of field
• At this level, most of FHL is hypoechoic muscle belly (dotted
line); the hyperechoic tendon can be difficult to distinguish
Tibialis posterior
• Place transducer in longitudinal axis with TP tendon
• The tendon sheath for TP is clearly visible
• At this level, TP travels with FDL; FHL is lateral to TP
and FDL
Tibialis posterior insertion
• Tracing TP pass the sustentaculum tali (ST) toward
its insertion at navicular (N); note the tendon
appears hypoechoic
• The hyaline cartilage (6) of talar head (Tal) appears
as a hypoechoic layer
Flexor Digitorum Longus (FDL)
• Tracing the FDL distally, the tendon crosses the
joint between talus and sustentaculum tali of
calcaneus before curving and diving deep into
the plantar surface
Flexor Hallucis Longus (FHL)
• Turning the transducer to longitudinal axis in retromalleolar
region, then short-axis slide posteriorly around the TP and FDL
tendons to reveal the FHL tendon
• FHL tendon is surrounded by fat pads (*), and its tendon
sheath appears hyperechoic
TABLE OF CONTENT
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General survey
Anterior
Lateral
Medial
Posterior
Plantar
Posterior
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Achilles tendon and paratenon
Plantaris tendon (as indicated)
Retrocalcaneal bursa
Retro-Achilles/Superficial Achilles bursa
Dynamic scanning in of Achilles (as indicated
to assist with tear evaluation)
Achilles tendon
• Confluence of gastrocnemius and
soleus, and inserts on calcaneus
• Also accepts plantaris tendon
• Strongest tendon in the body, and
frequently injured
• Surrounded by paratenon, a thin
layer of vascular tissue, without
tendon sheath—always abnormal
if surrounded by fluid
Gastrocnemius-Soleus longitudinal
• Start with proximal calf in longitudinal axis & scan distally
• Achilles tendon (A) can be seem forming as the
gastrocnemius (G) and soleus (S) converge into tendons
• Traumatic tear of the gastroc may be a source of calf pain
Gastrocnemius-Soleus transverse distal
• Sliding distally, the Achilles tendon (A) starts to converge
superficial to gastroc, and lateral gastroc bulk gives away to
mostly medial gastroc (MG)
• The transverse intermuscular septum (^) separates soleus (S)
from deep posterior compartment muscles (FDL, FHL, TP)
Achilles, longitudinal
• Place transducer in longitudinal axis over Achilles tendon
• Achilles (A) is thick, fibrillar and hyperechoic, inserting on
calcaneus. Hyperechoic paratenon (^) can be observed
• Anterior to the Achilles is Kager’s fat pad (K)
• Retrocalcaneal bursa may exist posterior to Achilles tendon
Achilles, horizontal
• Stand-off gel can help to reduce artifact
• Achilles tendon (A) should be fairly homogeneously
hyperechoic, superficial to the Kager’s fat pad.
Plantaris tendon (*) maybe visible as its distinct entity
TABLE OF CONTENT
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General survey
Anterior
Lateral
Medial
Posterior
Plantar
Plantar surface
• Plantar Fascia
• Dynamic scanning
• Applying pressure for Morton’s neuroma,
and/or ultrasonographic Mulder’s click (as
indicated)
Plantar aponeurosis
• Strong fascia, connecting from calcaneus to
plantar plantar plant of metatarsal heads
• Three distinct bands
– Central: thickest, attached to calcaneal tuberosity,
divides into fascicles for each toes distally insert into
MTP and flexor tendons
– Lateral: attaches to medial process of the calcaneus
– Medial: thinnest, covers AbH
• Contribute to maintenance of both longitudinal
and horizontal arches
Plantar aponeurosis, PQ
• Place transducer in long axis over calcaneal
tubercle
• Plantar aponeurosis (s) is robust, superficial
to FDB and PQ
SUMMARY
• Complex anatomy, complicated by the depth
and the crossing of tissue planes
• Dynamic examination of tendons helpful
• Proper selection of transducer to maximize
resolution at depth and maneuverability in
exam
• Practice makes perfect
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Thank You