MSK- foot and ankle protocol

Question 1

anterior ankle structures of interest (3)?

Answer 1

Anterior joint space
Anterior extensor tendons(anterior tibial, EHL,EDL)
Anterior inferior tibiofibular ligament

Question 2

Anterior tibial margin meets?

Answer 2

cartilage dome of talus

Question 3

normal amount of fluid in anterior ankle?

Answer 3

Normal = 3mm fluid

Question 4

Anterior talo-fibula ligament (ATFL) scan?

Answer 4

• heel of the probe on the anterior aspect of the distal fibula
• rotate the toe of the probe towards the 2nd toe

Question 5

Anterior talo-fibula ligament (ATFL) size?

• length
• thickness

Answer 5

• 2cm long

- 3mm thick

Question 6

Tibio-Fibula ligament (TFL) scan?

Answer 6

• from the ATAF, further rotate the toe of the probe until just above the horizontal
• TFL has a similar appearance to the ATAF

Question 7

How to examine the Extensor tendons?

Answer 7

seen by independently mobilising each of the toes and watching the tendons glide, you can identify which is which and exclude tendon rupture

Question 8

what should be seen in extensor tendons scan?

Answer 8

in transverse across the anterior ankle crease, you will see from lateral to medial:

• theextensor digitorum
• extensor hallucis
• tibialis anteriortendons
• overlying extensor retinaculum should also be observed

Question 9

Lateral ankle structues of interest? (3)

Answer 9

Peroneus longus and brevis tendons.
Calcaneo-fibula ligament.
Anterior Talo-Fibula ligament

Question 10

whats more common a ankle ligament or tendon injury?

Answer 10

ligament

Question 11

most commonly injured ankle ligament?

Answer 11

Anterior talofibular ligament

Question 12

most commonly dislocated?

Answer 12

Peroneal tendons

Question 13

Peroneus longus and brevis tendons easily seen how?

Answer 13

the two tendons are easily seen with the peroneusbrevis closest to thebone

Question 14

how to scan Peroneus longus and brevis tendons?

Answer 14

• begin in transverse, posterior to the lateral malleolus
• follow them proximally to the muscle and distally with particular attention to the insertion of the peroneus brevis tendon onto the base of the 5th metatarsal

Question 15

how to scan Calcaneo-fibular ligament?

Answer 15

with probe diagonally under the malleolus, angled from the fibula to the heel=peroneus tendons in transverse , calcaneo-fibula ligament underlying them

Question 16

medial anke- structures of interest? (5)

Answer 16

Tibialis Posterior tendon
Flexor Digitorum tendon
Flexor Hallucis Longus tendon
Deltoid ligament
Posterior tibial nerve

Question 17

How to scan Tibialis posterior, flexor digitorum and flexor hallucis longus tendons?

Answer 17

• Assess the tendons along their length in longitudinal and transverse
• Pay particular attention to the insertion of the Tibialis Posterior tendon with caution not to mistake the often present accessory ossicle, for an avulsed fragment

Question 18

what ligament in the medial ankle is poorly assessed with ultrasound?

Answer 18

deltoid ligament

Question 19

where is the posterior tibial nerve easily seen?

Answer 19

neurovascular bundle easily seen posterior to the medial malleolus

Question 20

Posterior ankle structures of intrest?

Answer 20

Achilles tendon
Retrocalcaneal (Kager’s) fat-pad
Retrocalcaneal bursa
Plantar fascia

Question 21

achilles tendon normal thickness?

Answer 21

5-6 mm thick

Question 22

most frequently injured ankle tendon?

Answer 22

achilles tendon

Question 23

achilles tendon most common site of injury?

Answer 23

2-6 cm proximal to calcaneal insertion (area relative avascularity)

Question 24

what is the only ankle tendon that does not have a synovial sheath?

Answer 24

achilles tendon

Question 25

what is the only ankle tendon that does not have a synovial sheath?

Answer 25

achilles tendon

Question 26

Retrocalacaneal bursa normal fluid?

Answer 26

2-3mm

Question 27

Plantar fascia thickness and echotexture?

Answer 27

3-4 mm thick, uniform echotexture

Question 28

how to assess Plantar Fascia?

Answer 28

• Patient prone on bed, foot flexed with toes on the bed for support
• Place the probe over the midline of the heel on the plantar aspect
• The toe of the probe towards the heel

Question 29

sono apperance of plantar fascia?

Answer 29

• fibrillar structure inserting onto the calcaneum

- It should be flat and homogenous

Question 30

assessment of Plantar Fibromatosis?

Answer 30

• Follow the plantar fascia into the arch and look for fusiform, nodular thickenings
• They may be subtle and more numerous than can be palpated.

Question 31

how does plantar fibromatosis present?

Answer 31

one or more palpable thickenings in the arch of their foot

Question 32

sono apperance of plantar plates?

Answer 32

a homogeneous elongated wedge arising from the base of the proximal phalanx extending under the head of the metatarsal

Question 33

sono apperance of mortons neroma?

Answer 33

compressible, hypoechoic rounded mass at the metatarsal head interspace

Question 34

sono apperance of intermetatarsal bursa?

Answer 34

• hypoechoic area between the metatarsal heads but will be compressible and avascular
• seen to bulge out the plantar aspect

Question 35

3 Joint effusions?

Answer 35

1, gout
2, osteoarthritis
3. rheumatois arthritis

Question 36

gout?

Answer 36

Abnormal uric acid metabolism resulting in joint inflammation

May see tophaceous gout as a complex echogenic mass (tophus) in the soft tissue of the big toe

Question 37

Osteoarthritis?

Answer 37

Bony irregularity at the bone ends with joint effusion. When acute the joint will be hyperaemic

Question 38

Rheumatoid arthritis?

Answer 38

Thickened synovium with a complex ‘thick’ joint effusion, pannus & associated boney iregularity