Johannes Roth, MD PhD FRCPC RhMSUS

The Foot and Ankle –

sonoanatomy, relevant pathology & needle approach

Nothing to disclose

Illustrations have been adapted from C Martinoli

Thank you to the sponsors of this courseAbbvie, BMS, and Johnson& Johnson

Objectives

• Review the sonoanatomy of the foot and ankle

• Discuss relevant pathology

• Describe ultrasound guided interventions

Planning of Joint InjectionAnkle second most frequently affected joint in JIA (knee most common)

RR of Relapse following ankle injection double compared to knee (Zulian 2003)

Rooney et al, J Rheumatol 2009, “Ultrasound findings in clinically swollen ankles”

34 JIA Patients with swollen ankles

Sonoanatomy

Talus

Capsule

Tibiotalar long

Anterior (Tibiotalar) transverse

Talus with cartilage on top

Tib ant Ext Hall. Ext Dig.

Hoffa

Perimalleolarmedial transverse

Lateral Ankle

PL PBMalleolus Peroneus

tendons

Subtalar Joint

A = Anterior Facet

B= Medial Facet

A+B = Anterior Subtalar Joint

C = Posterior Facet = PSTJ

D = Sinus Canal

Talus Navic.

Talonavicular

Tib post Flex Dig

Talus Sustentaculum Flex hall

Subtalar Joint medial

Sinus Tarsi Slide –Subtalar Joint from lateral

Tib Talus Calcaneus

Posterior Subtalar (and Tibiotalar)

PlantarFascia

Midfoot longitudinal scan

Dorsal Longitudinal & Transverse Scan

IP

Pathology

Pathology Anterior

Injection avoid the artery

Talonavicular

Talonavicular

Move across !

Talonavicular – move the joint !

?

Synovitis Subtalar medial (ASTJ)

Talus Calcaneus

** = Effusion

Synovitis Subtalar lateral (PSTJ)

Tenosynovitis Peroneal

Plantar Fasciitis

Bursitis

Synovitis IP joint

Patient 1:13 year old, JIA, national cheerleading champion

• Treated with DMARD

• Presenting with recurrence of right ankle pain

• On exam mild swelling, mild restriction in range of motionof tibiotalar and subtalar joint, pain on medial aspect ankle

• ? Overuse with training, ? flare of JIA

• ? Joint injection, ? Change of systemic medication

A thirteen year old with JIA and ankle pain

Tib post

Sustentaculum talli

Tib post

TalusTibia Talus

Sinus tarsi talonavicular

Injection

13 year old national cheerleading champion

• Targeted injection tibialis post tendon sheath

• Lateral subtalar joint

• Outcome complete remission for now 2 years

Patient 2:

• 4 year old girl presenting with likely longstanding JIA, polyarticular

• Leg length discrepancies• Growth delay• Excellent response to MTX, full resolution of

polyarthritis but persistent morning stiffness, limp, points to her knees

Visualization of synovitis (movement)

Injection

Injection

Injection

Posterior Subtalar Joint Sinus Tarsi approachSmith J et al J Ultrasound Med 2015; 34:83–93

Patient 3:Relapse in a 16 year old poly JIA

Calcaneus Cuboid

Calcaneocuboid

Patient 4: a colleague

healthy

pathologic

• Peritendinous vs intratendinous vs entheseal injection

• Which agent ? Steroid, PRP, Sclerosing Agent, Glucose

• Rupture ? Only in steroids but may be because of lack of training

• (Reversible) sc atrophy•

Duration of effect (Cochrane limited, but might need to be repeated)

Fredberg U Scand J Rheumatol 2004;33:94–101Kearney RS Cochrane Database of Systematic Reviews 2015 Srivastava P, Indian Journal of Rheumatology 9 · November 2014

Various presentations may require various approaches

Patient 5: 17 year old with enthesitis related arthritis

Patient 6: 10 year old with sJIA

Outcome: Complete resolution of findings and symptoms

10 year old sJIA patient coming in for routine Tocilizumab treatment.Noticed area of swelling of midfoot and forefoot, painful.

Patient 7: Monarthritis of the toe

Patient 8: Keloid in a 9 year old with EF and LS

And now try it yourself !!!