Musculoskeletal Ultrasound of the Knee, Foot and Ankle

Home , Lateral meniscus, Medial meniscus, Quadriceps tendon

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Musculoskeletal Ultrasound of Learning objecves:

the Knee, Foot and ankle • Understand the basics of knee, foot and ankle MSK ultrasound scanning protocols ADVANCED TEAM PHYSICIAN COURSE SAN DIEGO, CALIFORNIA DECEMBER 11TH 2016 • Demonstrate the normal ultrasound echotexture of the tendons and ligaments in the knee, foot and ankle

• Recognize the important neurovascular structures in the knee, foot and ankle regions Jonathan S. Halperin MD • Be able to posion the ultrasound transducer to demonstrate the bone acousc landmarks in knee, Foot and ankle region

ULTRASOUND OF THE LOWER LIMB FOCUSED EXAM OF THE KNEE • Focused or target exam • Anterior: Quadriceps tendon, Patella, Patellar tendon, Patellar renaculum, Suprapatellar recess, Pre-patellar bursa • Transducers: Use 10-18 Mhz for the foot and ankle, and an 8-13 Mhz transducer for the knee joint • Medial: Medial collateral ligament, Medial meniscus, Pes Anserine tendons and bursa • Assume a comfortable scanning posion and then move the joint to assess ligament and joint laxity • Lateral: Iliobial tract, Lateral collateral ligament, Biceps • Follow tendons from myotendinous juncon to bone inseron Femoris tendon, Common peroneal nerve, Popliteus, Lateral Meniscus • Know your bone/osseous acousc landmarks • Posterior: Baker cyst, Neurovascular structures

ANTERIOR KNEE EXAM FOCUSED EXAM OF THE ANKLE • Paent supine, knee flexed to thirty degrees, pillow under • ANTERIOR: Anterior biotalar joint recess, TA, EHL, and knee EDL tendons, Dorsalis pedis artery, Superficial peroneal nerve • In this posion, the following structures can be assessed • LATERAL: Peroneus longus and brevis tendons, Superfical a. Quadriceps tendon Renaculum, AITF, ATF , CF and PTF ligaments b. Suprapatellar recess c. Pre-patellar bursa • MEDIAL: Posterior bialis, Flexor digitorum longus, and Flexor d. Patellar renaculum Hallicus longus tendons, Tibial artery, Tibial vein Posterior bial e. Patella nerve, and Deltoid ligament f. Patellar tendon

• POSTERIOR: Achilles tendon, Retrocalcaneal and superﬁcial Achilles bursa, and Plantaris tendon

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EXTENSOR MECHANISM OF THE KNEE ANATOMIC RELATIONSHIPS: ANTERIOR KNEE

proximal distal

PROC EFOV PATELLAR TENDON

Quadriceps tendon and suprapatellar recess Patellar tendon region

• Scan in short and long axis • Bone acoutsic landmarks: distal patella and proximal bia • Use doppler to ID inﬂammatory tendinopathy

• Scan in short and long axis • Gentle squeeze of mid thigh can bring out ﬂuid in suprapatellar recess • Idenfy bone landmarks of proximal patella and distal femur

MEDIAL KNEE: Medial knee: anatomic relaonships

• Bring hip into external rotaon with knee ﬂexed To thirty degrees

• Scan the following structures: a. Medial collateral ligament b. Body of medial meniscus c. Pes anserine tendons and bursa

• Note the relaonship of distal MCL inseron to pes anserine tendons

• Note the superﬁcal and deep layers of MCL

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LATERAL KNEE Medial collateral ligament and medial meniscus • Paent lying on side and knee ﬂexed to thirty degrees • Following structures assessed: a. Lateral ( bial) collateral ligament b. Iliobial tract c. Biceps femoris inseron on ﬁbula d. Popliteus tendon e. Lateral meniscus f. Peroneal nerve

Note: trilaminar appearance of MCL.

Anatomic relaonships: Lateral knee LATERAL KNEE: Lateral collateral ligament and Lateral meniscus

• Note relaonships of Lateral collateral ligament and biceps femoris tendon as they insert on ﬁbular head

• Use bone acousc window of popliteal groove and ﬁbular head to ID relevant Use bone acousc landmarks ( ﬁbula, Gerdy’s tubercle, bia and femur) to help structures Idenfy structures

LATERAL KNEE: LCL, ITB and popliteus tendon POSTERIOR KNEE:

• Paent is in prone posion with pillow under patella

• Following assessment is done a. Asses for semimembrinosis/ medial gastrocnemius bursa ( Baker cyst) b. Neurovascular structures c. Posterior horn medial and lateral meniscus d. PCL inseron • Look for groove in distal femur to ID politeus tendon • Depending on orientaon of transducer the Iliobial tract or LCL seen superﬁcial to popliteus tendon

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Anatomic relaonships: Posterior knee • Note relaonship of MHG to SM and POSTERIOR KNEE: Evaluaon for Baker cyst the other pes anserine tendons • Note posion of neurovascular bundle • Note that popliteus muscle at anterior aspect of posterior fossa

Key bone landmarks: bia plateau and MFC

Key muscle tendon structures: Medial gastrocnemius muscle and semimembranosis tendon

Posterior lateral knee: Biceps femoris tendon and peroneal FOOT AND ANKLE EXAM nerve

ESSR MSK Ultrasound Technical Guidelines

ANTERIOR ANKLE: Anterior ankle SAX • Paent sing or supine with knee ﬂexed

• Asses the following structures: a. Anterior joint space b. Tibialis anterior, Extensor Hallicus Longus and Extensor digitorum tendons MD c. Neurovascular structures a Nelson Hager MD with permission

LAX

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LATERAL ANKLE LATERAL ANKLE: PERONEAL TENDONS • Paent side lying with knee ﬂexed to ninety degrees and ankle joint in neutral

• Asses the following structures: a. Peroneus longus and brevis tendons b. Anterior talo-ﬁbular ligament c. Calcaneo-ﬁbular ligament d. Anterior inferior talo-bial ligament

• Scan in short and long axis • Scan along course of distal ﬁbula • Asses PB inseron into 5th MT

LATERAL LIGAMENTS ANKLE LATERAL ANKLE LIGAMENTS : AITF

Anterior Talo-ﬁbular ligament (ATF)

Anterior Inferior Tibio-Fibular ligament AITFL

Nelson Hager MD with permission Pictures obtained from ESSR Musculoskeletal Technical Guidelines VI Ankle

LATERAL ANKLE LIGAMENTS: CALCANEO-FIBULAR MEDIAL ANKLE

• Paent supine with knee ﬂexed and leg in external Rotaon ( Frog leg posion)

• Asses the following structures: a. Posterior bialis tendon b. Flexor digitorum tendon c. Tibial artery and vein d. Tibial nerve e. Flexor hallicus longus tendon f. Medial ankle ligaments

ESSR MSK Ultrasound Technical Guidelines

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POSTERIOR ANKLE: POSTERIOR ANKLE: Achilles tendon

• Paent prone with leg over the edge of the table

• Asses the following structures: a. Achilles tendon b. Gastrocnemius/ soleus muscle complex c. Flexor hallicus longus tendon d. Plantaris tendon/muscle e. Bursal structures and fat pad

•Scan achilles tendon carefully in short and long axis • Measure thickness 5cm from inseron on calcaneus • Pay aenon to bone inseron on calcaneus • Use doppler to look for tendon inﬂammaon

POSTERIOR ANKLE: Flexor Hallicus longus TAKE HOME POINTS

• The MSK Ultrasound exam of knee, foot and ankle is a regional exam. The areas scanned are determined by history and physical ﬁndings Paent Prone Look for FHL in LAX medial to Achilles • Key components of knee exam: Asterick is posterior fat pad a. Extensor mechanism ( Quadriceps and patellar tendon) b. Ability to ID ﬂuid in suprapatellar recess and posterior knee joint c. Use bone landmarks to asses tendinopathy and ligament injury • Key components of ankle exam: a. Carefully scan achilles tendon to look for acute or chronic tendinopathy b. Use bone landmarks to idenfy and scan tendon and ligament structures c. Areas lateral and median tendon pathology are best seen In short axis ( peroneal tendons, bialis posterior tendon) •Key components of foot exam: a. Plantar fascia is best seen in long axis. Pay aenon to medial band b. First MTP is a common source of pathology c. Corcal defects seen in long axis view metatarsals may indicate early stress fracture ESSR MSK Ultrasound Technical Guidelines

Thanks for your attention!!!