ankle normal
lateral ankle
- peroneus longus and brevis tendons
- calcaneo-fibula ligament
- anterior talofibula ligament
- tibio-fibula ligament
- subtalar joint
peroneus longus & brevis tendons
peroneus longus wraps under the lateral foot to insert medially onto the 1st cuniform and proximal end of 1st metatarsal. approximately 20% of patients have an os peroneum (accessory ossicle) at the insertion
peroneus brevis inserts to the base of the 5th metatarsal.
to scan the peroneus tendons:
- you need access to the lateral ankle and foot in a position to invert/evert the foot.
- patient supine or with their foot off the side of the bed is best.
to identify the peroneus tendons:
- place the probe transversely, posterior to the lateral malleolus (proximal to the malleolar tip)
- ensure the fibula is visible on the image.
- the pb and pl will be in the centre of your image. pb will be deepest and against the bone with pl ontop of it.
- slide proximally to the musculo-tendinous junction.
- now slide distally following the tendons until they separate.
normal appearance:
- proximal to the malleolus:
transverse: peroneus longus tendon is formed. peroneus brevis musculo-tendinous junction is still visible
- at the level of the malleolus:
transverse: both tendons echogenic and homogeneous. peroneus brevis against the fibula. peroneus longus on top.
longitudinal: echogenic and fibrillar tendons.
- distal to the malleouls:
the tendons move apart. the tendon sheaths terminate approximately 3cm from the malleolus.
tips:
brevis-bone-base. peroneus brevis is closer to the bone and then inserts onto the base of the 5th metatarsal.
once you identify the 2 tendons:
- are they fibrillar and homogeneous
- is there any fluid in the sheath (there should not be any visible fluid)
- do the tendons glide freely when mobilized (invert/evert the forefoot)
- does the brevis underlie longus at the malleolus
- are they both intact at their insertions
tip: peroneus brevis may split at the malleolus with peroneus longus laying partially or entirely within the division.
peroneus longus and brevis tendon scan plane (transverse).
peroneus longus and brevis tendons.
transverse plane at the lateral malleolus.
scan plane for ultrasound of the peroneus brevis tendon insertion to the base of the 5th metatarsal.
ultrasound of the peroneus brevis tendon insertion to the base of the 5th metatarsal.
scan plane for ultrasound assessment of the peroneus longus tendon insertion.
to the base of the 1st metatarsal and the medial cuneiform.
ultrasound of the peroneus longus tendon insertion.
calcaneo-fibula ligament (cfl)
- the cfl runs from the distal fibula to a tubercle on the calcaneum.
- it stabilises the subtalar joint and limits inversion.
- the fibula origin is difficult to assess with ultrasound.
to scan the calcaneo-fibular ligament:
- you need access to the lateral ankle and foot in a position to dorsiflex the foot.
- patient supine or with their foot off the side of the bed is best.
to identify the cfl:
.place the tip of the probe against the underside of the fibula anteriorly.
the heel of the probe directed towards the apex of the heel curve.
tip: dorsiflex the ankle
normal appearance:
the cfl has:
- an echogenic, fibrillar echotexture.
- a thin tapering calcaneal insertion
- a broader curved, fibula insertion.
- the peroneus tendons should lie immediatly on top of the cfl.
tip: the fibres at the fibular origin overlie the distal component of the anterior talo fibula ligament (atfl).
once you identify the cfl:
- is it fibrillar, echogenic and homogeneous
- is there any fluid deep to the ligament in the subtalar joint (there should not be any visible fluid)
- is the ligament intact.
ultrasound scan plane for the calcaneo-fubula ligament.
dorsiflex the foot.
probe position from the anterior lateral malleolus towards the tip of the heel.
ultrasound of the calcaneo fibula ligament.
the peroneus tendons are seen in short axis overlying the ligament.
anterior talo-fibula ligament (atfl)
- the atfl runs from the distal fibula to the neck of the talus.
- it is continuous with the joint capsule.
- the atfl helps stabilise the talus and limits inversion.
- it is the weakest of the lateral ankle ligament complex.
- there are 2 bands of the atfl.
to scan the anterior talo fibula ligament:
- you need access to the lateral ankle and foot in a position to plantar flex and evert the foot.
- patient supine or with their foot off the side of the bed is best.
to identify the atfl:
.place the heel of the probe against the underside of the fibula anteriorly.
the probe in a transverse plane, tip anteriorly.
rotate the tip of the probe distally until you visualise the ligament.
tip: plantar-flex and invert the ankle.
normal appearance:
the atfl has:
- an echogenic, fibrillar echotexture.
- parallel flat deep and superficial contours
tip: it is common to see a small amount of joint fluid deep to the ligament.
once you identify the atfl:
- is it fibrillar, echogenic and homogeneous?
- it may be slightly hypoechoic due to it's oblique angle to the probe (anisotrophy)
- is the ligament intact.
- any bony irregularity? particularly at the fibular end.
anatomy of the anterior talofibular ligament.
note that there is a lesser, secondary band inferior to the primary band of the ligament. this has a common origin with the calcaneofibular ligament.
- the atfl runs from the anterior distal fibula to the talus.
- it is the weakest of the lateral ankle ligament complex
tip: plantar-flex and invert the ankle.
ultrasound scan plane for the anterior talofibular ligament (atfl)
important to note there are 2 parallel bands to assess.
ultrasound of the anterior talofibular ligament (atfl)
anterior tibiofibular ligament (tfl)
- the anterior tfl runs from the distal fibula to the distal tibia.
- it is continuous with the syndesmosis (inter-osseous border) between the tibia and fibula.
to scan the tfl (tibio fibula ligament):
- you need access to the lateral ankle and foot in a position to plantar flex and evert the foot.
- patient supine or with their foot off the side of the bed is best.
to identify the tfl:
from the atfl, fix the probe on the fibula and rotate the other end of the probe towards the horizontal.
talus will leave the image and tibia will appear. this is when you will visualise the tibio-fibula ligament.
normal appearance:
the tfl has:
- an echogenic, fibrillar echotexture.
- parallel flat deep and superficial contours
- approximately 1.5mm thick
once you identify the atfl:
- is it fibrillar, echogenic and homogeneous?
- is the ligament intact.
- any bony irregularity?
tip: assess dynamically by squeezing the proximal tibia and fibula head together. there should be minimal movement at the tfl site. if the tibia and fibula move apart, suspect disruption of the ligament.
scan plane for ultrasound of the tibiofibular ligament.
from the atfl, fix the probe on the fibula and rotate the other end of the probe towards the horizontal.
talus will leave the image and tibia will appear. this is when you will visualise the tibiofibular ligament.
ultrasound of the tibiofibular ligament.
the tibia and fibula should be seen as 2 similar ‘hills’.
superficial peroneal nerve
- the superficial peroneal nerve exits the muscle fascia on the lateral lower leg, approximately 10cm proximal to the lateral malleolus. this is a potential area for entrapment.
- it then descends superficially along the fascia to provide branches to the anter-lateral foot and ankle.
to scan the tfl (tibio fibula ligament):
- you need access to the lateral ankle and foot in a position to plantar flex and evert the foot.
- patient supine or with their foot off the side of the bed is best.
to identify the superficial peroneal nerve:
place the probe in a transverse plane on the mid lateral lower leg.
slowly slide distally towards the malleolus.
- you will see the neurovascular bundle exit the fascia in a transverse slice.
- follow the nerve distally in transverse.
- rotate into longitudinal at the point it exited the fascia.
normal appearance:
the superficial peroneal nerve:
transverse:
- ovoid hypoechoic.
longitudinal
- parallel, slightly fibrillar (stripey) appearance
- approximately 1.5mm thick
once you identify the superficial peroneal nerve:
- is it uniform in size?
- are there any masses, collections, varices or scars that may cause entrapment.
the superficial peroneal nerve (spn) exits the fascia leading to the median and intermediate dorsal cutaneous nerves.
ref: k paraskevas, george & natsis, konstantinos & tzika, maria & ioannidis, orestis. (2013). potential entrapment of an accessory superficial peroneal sensory nerve at the lateral malleolar area: a cadaveric case report and review of the literature.. the journal of foot and ankle surgery : official publication of the american college of foot and ankle surgeons. 53. 10.1053/j.jfas.2013.06.012.
- the superficial peroneal nerve exits the muscle fascia on the lateral lower leg, approximately 10cm proximal to the lateral malleolus. this is a potential area for entrapment.
- it then descends superficially along the fascia to provide branches to the anter-lateral foot and ankle.
ultrasound of the superficial peroneal nerve in the transverse plane.
highlighted ultrasound of the superficial peroneal nerve. a longitudinal plane as it exits the fascia.
anterior ankle
the primary structures to assess anteriorly are:
- tibialis anterior tendon
- extensor digitorum longus tendon
- extensor hallucis longus tendon
- extensor retinaculum
- ankle joint(s)
- deep peroneal nerve
extensor retinaculae
there are 2 extensor retinaculae of the anterior ankle/foot
both overly the extensor tendons acting as pulleys/fulcrum points.
- superior extensor retinaculum: a single broad anchoring band at the level of the distal tibia.
- inferior extensor retinaculum: a slightly y-shaped band. single laterally, dividing into 2 bands laterally. the more proximal inserts onto the tibia, the more distal wraps around to insert onto the planta aponeurosis.
ultrasound appearance:
- hypoechoic 1mm layer overlying the extensor tendons in a transverse plane.
- easily identifiable as you slide down in transverse from the distal tibia.
- the superior will appear, then fade, followed by the inferior retinaculum.
what to look for:
- thickening with or without hyperaemia.
- intact? (complete tears are uncommon)
mechanism of injury:
- hyperextension/plantar flexion injuries
ultrasound scan plane to assess the ankle extensor retinaculum and tendons.
there is a thicker superior retinaculum at the level of the distal tibia and an inferior retinaculum below the ankle crease.
ultrasound of the extensor digitorum tendon and the retinaculum reflecting around it.
tibialis anterior tendon
- the tibialis anterior tendon inserts onto the plantar surface on base of first metatarsal and medial plantar surface of 1st cuneiform.
- the tendon sheath runs from the musculotendinous junction to the medial arch.
- dorsiflexes and inverts foot at the ankle.
ref: anatomylearning.com
ref: anatomylearning.com
to ultrasound the tibialis anterior tendon
- you need access to the antero-medial ankle with gentle eversion.
- patient supine or with their foot off the side of the bed is best.
to identify the tibialis anterior tendon:
this is an easy tendon to palpate with dorsiflexion (pull the toes up)
- place the probe in a transverse plane across the distal tibia (on the tendon you palpated).
slowly slide distally keeping the tendon in the center of your image.
- as you approach the insertion on the medial arch the tendon will become thinner.
- rotate into longitudinal to assess the insertion.
- follow the tendon back up in longitudinal and assess sliding with passive inversion/eversion of the forefoot.
normal ultrasound appearance of the tibialis anterior tendon:
the largest of the 3 anterior ankle tendons.
transverse:
- ovoid echogenic (very subject to anisotropy with probe angulation).
longitudinal
- parallel, echogenic fibrillar appearance
insertion
- a thin tapering insertion curving slightly around to the 1st metatarsal and cuneiform.
once you identify the tibialis anterior tendon
- is it uniform in size?
- is it homogenous (echogenic and fibrillar)
- is it intact at the insertion/
- is there any fluid in the sheath? (there should be no visible fluid)
- is there any vascularity of the tendon or paratendon on colour doppler (there should be no discernable vascularity)
scan plane to assess the tibialis anterior tendon from the proximal musculo-tendinous junction to the distal insertion.
transverse view of the tibialis anterior tendon at the level of the superior extensor retinaculum.
ultrasound scan plane to assess the tibialis anterior tendon longitudinally.
ultrasound of a normal tibialis anterior tendon – longitudinal plane at the distal tibia.
ultrasound scan plane to assess the tibialis anterior tendon insertion to the base of the 1st metatarsal (and cuneiform).
the distal tibialis anterior tendon curves around the medial arch to it’s insertion.
it is important to follow all the way, particularly patients with a background of degenerative oa.
extensor digitorum and hallucis tendons
the extensor hallucis tendon:
- lies lateral to the tibialis anterior tendon.
- the musculo-tendinous junction is more distal than either the tibialis anterior or the extensor digitorum tendons.
- the tendon sheath runs from the musculotendinous junction to the distal foot.
- inserts on the base of the distal phalanx of the 1st toe.
the extensor digitorum tendons:
- lies lateral to the extensor hallucis tendon.
- a common tendon at the anterior ankle crease dividing into 4 at the level of the talus.
- a common tendon sheath from the musculo-tendinous junction to the mid-foot.
- inserts on the base of the distal phalanx of each toe.
ref: anatomylearning.com
to ultrasound the extensor tendons
- you need access to the antero-medial ankle with gentle eversion.
- patient supine with the sole of their foot flat on the bed in slight dorsiflexion.
to identify the tibialis anterior tendon:
- place the probe in a transverse plane across the distal tibia.
- identify the 2 tendons (ehl and ed)
- slowly slide distally keeping the tendon you are evaluating in the center of your image.
- follow the tendon in transverse to the level of the metatarsals
- in longitudinal at the ankle crease, mobilise (flex) each toe 1 at a time, ensuring smooth tendon sliding.
normal ultrasound appearance of the ankle extensor tendons:
- ovoid echogenic (very subject to anisotropy with probe angulation).
longitudinal
- parallel, echogenic fibrillar appearance
tip:
extensor hallucis musculo-tendinous junction is more distal than the other tendons and can easily be mistaken for complex sheath fluid.
once you identify the extensor tendons:
- are they homogenous (echogenic and fibrillar)
- are they intact? did they glide freely with independent toe flexion?
- is there any fluid in the sheaths? (there should be no visible fluid)
- is there any vascularity of the tendon or paratendon on colour doppler (there should be no discernable vascularity)
deep peroneal nerve
- the deep peroneal nerve accompanies the anterior tibial artery at the distal tibia. as you scan distally in the transverse plane, the nerve is seen to switch from medial to lateral to the artery.
to scan the deep peroneal nerve at the ankle:
- patient supine or seated on the bed.
- foot flat with some plantar flexion.
to identify the deep peroneal nerve:
place the probe in a transverse plane on the mid lateral lower leg.
slowly slide distally towards the malleolus.
- you will see the nerve adjacent to the anterior tibial artery.
- follow the nerve distally in transverse.
normal appearance:
the deep peroneal nerve:
transverse:
- ovoid hypoechoic.
longitudinal
- parallel, slightly fibrillar (stripey) appearance
- approximately 1.5mm thick
once you identify the deep peroneal nerve:
- is it uniform in size?
- are there any masses, collections, varices or scars that may cause entrapment.
ultrasound scan plane to find the deep peroneal nerve at the anterior ankle.
scan proximally and distally to assess the nerve in transverse.
the nerve accompanies the anterior tibial artery at the distal tibia. as you scan distally in the transverse plane, the nerve is seen to switch from medial to lateral to the artery.
to read a helpful resource for the deep peroneal nerve.
medial ankle
- tibialis posterior tendon
- flexor digitorum tendon
- flexor hallucis longus tendon
- deltoid ligament
- spring ligament
- tibial nerve (and branches)
- deep peroneal nerve.
scan plane to see tibialis posterior, flexor digitorum and flexor hallucis longus tendons (you may need to adjust the probe posteriorly to view the deeper fhl).
ultrasound of tibialis posterior, flexor digitorum and flexor hallucis longus tendons (known as “tom, dick & harry”). if including the neurovascular bundle – tom dick and very nervous harry.
tibialis posterior tendon
- the tibialis posterior tendon inserts onto multiple bones. the primary insertion is to the navicular. however there are slips to the cuneiforms and the metatarsals.
- the tendon sheath runs from the musculotendinous junction to the medial arch.
- plantar-flexes and inverts the foot at the ankle.
to ultrasound the tibialis posterior tendon
- you need access to the medial ankle with gentle eversion.
- patient supine or with their foot off the side of the bed is best.
to identify the tibialis posterior tendon:
place the probe in a transverse plane on the posterior aspect of the ankle approximately 2cm above the medial malleolar tip.
- the tibialis posterior tendon should be visible in a transverse plane agains the tibia. (flexor digitorum tendon lying on top).
- slowly slide distally keeping the tendon in the center of your image.
- as you round the malleolus, you will need to rotate the probe to maintain a transverse plane.
- as you approach the insertion, the tendon will become broader and more heterogeneous (due to it's splayed insertion).
- rotate into longitudinal to assess the insertion.
- follow the tendon back up in longitudinal and assess sliding with passive inversion/eversion of the forefoot.
normal ultrasound appearance of the tibialis posterior tendon:
the largest of the 3 medial ankle tendons.
transverse:
- ovoid echogenic (very subject to anisotropy with probe angulation).
- normal to see a trace of fluid in the tendon sheath just distal to the medial malleolus.
longitudinal
- parallel, echogenic fibrillar appearance
insertion
- a broad complex insertion.
the collagen fibrillar architecture of the tendon becomes speckled by fibro-cartilage as the tendon fibres spread to the various insertional points.
a small accessory ossicle is visible in many patients.(type i accessory navicular bone).
once you identify the tibialis anterior tendon
- is it uniform in size?
- is it homogenous? (echogenic and fibrillar)
- is it intact at the insertion?
- is there any significant fluid in the sheath?
- is there any vascularity of the tendon or paratendon on colour doppler (there should be no discernable vascularity)
ultrasound of the tibialis posterior tendon insertion.
the collagen fibrillar architecture of the tendon becomes speckled by fibro-cartilage as the tendon fibres spread to the various insertional points.
a small accessory ossicle is visible in many patients.(type i accessory navicular bone).
this rounded, embedded ossicle should not be confused with an avulsion
flexor digitorum longus (fdl)and flexor hallucis longus (fhl) tendons
the ‘knot of henry’ where the fhl and fdl tendons cross at the plantar aspect of the posterior arch.
a trace of fluid may normally accumulate here in the fhl sheath. a small percentage of patients may have a communication between the fhl sheath and the ankle joint.
deltoid ligament
the deltoid liagment is a complex piece of anatomy stabilizing the medial ankle joint. due to it’s complexity and oblique fibres, ultrasound cannot entirely exclude pathology, however it is a good positive predictor. (ie ultrasound cannot exclude pathology).
the deltoid ligament is comprised of 4 inter-related ligamentous components.
- posterior tibiotalar ligament.
- tibiocalcaneal ligament
- tibionavicular ligament.
- anterior tibiotalar ligament.
to examine the deltoid ligament with ultrasound, you need to evert and flex the foot to stretch each component individually.
the posterior tibio-talar ligament ultrasound scan plane.
dorsiflex and evert the foot.
deltoid ligament ultrasound.
- the posterior tibio-talar ligament component.
tibio-calcaneal ligament ultrasound scan plane.
dorsiflex and evert the foot.
deltoid ligament ultrasound.
2. the tibio-calcaneal ligament component.
the tibio-navicular ligament ultrasound scan plane.
plantar-flex and evert the foot.
deltoid ligament ultrasound.
3. the tibio-navicular ligament component.
the anterior tibio-talar ligament ultrasound scan plane.
also plantar flex and evert the foot.
deltoid ligament
4.the anterior tibio-talar ligament component
spring ligament (calcaneo-navicular ligament)
this is a technically challenging ligamentous complex to examine with ultrasound.
the spring ligament is comprised of 3 bands which are indistinguishable from one another on ultrasound. posteriorly, the fibres blend with the deltoid ligament.
it runs from sustentaculum talus on the calcaneum to the navicula where it has 3 attachment points.
tibial nerve
distal to the medial malleolus, the tibial nerve divides into the medial and lateral plantar nerves.
a slightly more proximal branch, the medial calcaneal nerve, innervates the superficial area of the heel.
baxters nerve (inferior calcaneal nerve) is the 1st branch off the lateral plantar nerve. entrapment of this nerve may simulate plantar fascitis.
anatomy of the medial ankle, heel and arch nerves.
the tibial nerve bifurcates into the medial calcaneal nerve (posterior) and plantar nerve(anterior).
the plantar nerve then bifurcates into the lateral and medial plantar nerves.
the lateral plantar nerve gives rise to the inferior calcaneal nerve at the posterior arch (this is also called baxter’s nerve).
transverse image posterior and slightly superior to the medial malleolus. this is where the medial calcaneal nerve arises posteriorly from the tibial nerve.
ultrasound scan plane for the tibial and plantar nerves.
tibial nerve bifurcation ultrasound.
transverse image at the infero-posterior arch of the foot showing the subtle bifurcation of the tibial nerve into the plantar nerves.
the medial plantar nerve is anterior.
the lateral plantar nerve is more posterior and then gives rise to the inferior calcaneal nerve (baxter’s nerve)
longitudinal ultrasound of baxter’s (inferior calcaneal) nerve.
this is immediately inferior to the bifurcation of the tibial nerve into the plantar nerves shown in the previous image.
to read a description of baxters nerve pathology on radsource.
scan protocol
role of ultrasound
ultrasound is essentially used for the external structures of the ankle. ultrasound is a valuable diagnostic tool in assessing the following indications; muscular, tendinous and ligamentous damage (chronic and acute) bursitis joint effusion vascular pathology haematomas soft tissue masses such as ganglia, lipomas classification of a mass eg solid, cystic, mixed post surgical complications eg abscess, oedema guidance of injection, aspiration or biopsy relationship of normal anatomy and pathology to each other some bony pathology.
limitations
it is recognised that ultrasound cannot adequately assess the deltoid ligament, the ankle mortice and some inter-tarsal ligments.
patient preparation
- position the patient comfortably where you can readily access the ankle to scan and manipulate.
- this may be supine or seated on the examination bed with feet on the bed.
- alternatively seated on the side of the bed, you seated in front of the ultrasound machine with their foot on your knee.
equipment setup
use of a high resolution, (>10mhz), small footprint probe is essential when assessing the superficial structures of the ankle. careful scanning technique to avoid anisotropy (and possible misdiagnosis). beam steering or compounding can help to overcome anisotropy in linear structures such as tendons. good colour / power / doppler capabilities when assessing vessels or vascularity of a structure. be prepared to change frequency output of the probe (or probes) to adequately assess both superficial and deeper structures.
any assessment of vascularity, the tissue should not be undertension as this may compress the micro-vasculature. ensure light probe pressure and tendons relaxed.
common pathology
- joint effusions.
- tendinopathy and tendon tears
- ligamentosis and ligament tears
- foreign bodies
- oedema
- haematomas
- collections / abscess’
- arthroses / arthritis
scanning technique
lateral ankle
patient sits on the side of a raised bed with foot resting on the sonographers knee for support. alternatively, the patient may sit or lie supine on bed with their foot flat.
peroneus longus and brevis tendons: begin in transverse, posterior to the lateral malleolus. the two tendons are easily seen with the peroneus brevis closest to the bone. 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.
calcaneo-fibular ligament: with the probe diagonally under the malleolus, angled from the fibula to the heel, you will see the peroneus tendons in transverse and the calcaneo-fibula ligament underlying them.
anterior ankle
patient positioned as above.
anterior talo-fibula ligament (atfl): place the heel of the probe on the anterior aspect of the distal fibula and rotate the toe of the probe towards the 2nd toe. the ligament should be readily visible as a 2cm long, 3mm thick tight fibrillar structure.
tibio-fibula ligament (tfl): from the ataf, further rotate the toe of the probe until just above the horizontal. the tfl has a similar appearance to the ataf.
extensor tendons: in transverse across the anterior ankle crease, you will see, from lateral to medial, the extensor digitorum, extensor hallucis and tibialis anterior tendons. by independently mobilising each of the toes and watching the tendons glide, you can identify which is which and exclude tendon rupture the overlying extensor retinaculum should also be observed.
medial ankle
patient positioned as above.
tibialis posterior, flexor digitorum and flexor hallucis longus tendons: 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. begin diagonally under the medial malleolus with the toe of the probe on the malleolus. you will see the tibialis posterior and flexor digitorum tendons in transverse. slide the probe postero-inferiorly and you will see the flexor hallucis longus tendon deeper against the calcaneum.
the deltoid ligament: is poorly assessed with ultrasound.
posterior tibial nerve: the neurovascular bundle is easily seen posterior to the medial malleolus
posterior ankle
patient positioned prone with the feet off the end of the bed.
achilles tendon: perform a survey scan ,in transverse, from the calcaneum up to the musculo-tendinous junction (of both medial and lateral gastrocnemii). rotate into longitudinal and examine for thickening and integrity. at the same time assess the retrocalcaneal (kager’s) fat pad.
the calf muscles and plantaris tendon should also be assessed as clinically indicated.
basic hardcopy imaging
- if undertaking a targeted examination, saved imaging of normal and pathology in 2 planes should be performed.
a comprehensive ankle series should include the following minimum images:
- peroneus tendons – long, trans + peroneus brevis insertion
- calcaneo-fibular ligament
- anterior talo-fibula ligament
- tibio-fibula ligament
- extensor digitorum tendon
- extensor hallucis longus tendon
- tibialis anterior tendon
- tibialis posterior tendon
- flexor digitorum tendon
- flexor hallucis longus
- achilles tendon and retro calcaneal bursa
- document the normal anatomy. any pathology found in 2 planes(ligament tears or thickening, synovial bulging/cysts, joint effusion, gross bony changes), including measurements and any vascularity.