Subtalar Joint Injection

- [Voiceover] A linear array transducer
with a musculoskeletal exam type
is used to perform an ultrasound examination
of the metatarsal phalangeal joint in the foot.
The patient is placed in a supine position,
with the knee flexed and the foot on the bed.
The transducer is placed over the dorsal surface
of the metatarsal phalangeal joint
in a longitudinal fashion,
with the orientation marker directed
toward the patient's head.
The metatarsal head is seen
as a bright, hyperechoic rounded structure.
The proximal phalanx can be seen
as a hyperechoic linear structure,
just distal to the metatarsal.
The extensor tendon lies above the bony structures,
and appears as a hyperechoic fibrillar structure.
The metatarsal phalangeal joint can be seen
as a dark hypoechoic region between the metatarsal head
and the first phalanx.
The transducer should be slowly moved
along the medial surface of the metatarsal phalangeal joint
to evaluate the joint space.
The transducer is rotated 90 degrees counterclockwise
to obtain a transverse view.
The extensor tendon appears as an elliptical structure
above the metatarsal head.
The transducer should be slowly moved
to allow a full view of the metatarsal phalangeal joint.

Brightcove ID

5751488312001

https://youtube.com/watch?v=Wb6gFe_TZZw

How To: Foot Injection

Read more about How To: Foot Injection

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Dr. Scott Pollock demonstrates how to perform an ultrasound guided foot injection.

Clinical Specialties

Physical Med & Rehab

Media Library Type

How To Videos

Media Library Tag

Msk Ultrasound

Musculoskeletal Ultrasound

Subtalar Joint Injection

Podiatry

Subtitles

- Injection or aspiration of fluid from the ankle
is best obtained most of the time anteriorly.
But it really depends on where the fluid
is most easily visible
where the blood vessels are and what the best approach is
for the angle of the needle.
This is the joint that we would be aiming for
right at the base of that v.
And if there were fluid there
we would see it as a black area
filling in the base of the v.
This can approached then with a needle and syringe
using sterile technique
and obviously here do not have sterile gel
or sterile preparation
it's just for demonstration purposes.
The needle can be placed in this way.
Sometimes this is very easy to do
especially when a person has full mobility of the ankle
and the ankle can be
kept in this orientation.
Sometimes it's necessary to visualize the effusion this way
holding the transducer transversely.
And then injecting or aspirating
with the needle parallel to the transducer
with the approach this way.
It's very important to watch for arteries
and you can see the artery pulsating
in the center of the field.
When the tranducer's in the longitudinal plane
it's important to look for blood vessels
and this large vessel that's most likely
the dorsalis pedis artery is right superficial
to that structure.
It would be very important for me to move either
medially or laterally to avoid that artery.
This can also be checked by switching on the color
and seeing the artery pulsating right there.
So I would move this over a little medially
and then enter here
relatively close to the transducer edge
and going in at an angle sufficient
to get down to the depths where the effusion is.
This joint is approximately
one and a half centimeters deep
and so I'm gonna to have to angle this syringe
such that the tip of the needle
goes to the depth of two centimeters.
So here is an image of
taken of a person with an ankle effusion.
This is a transverse image.
So we don't really see the tibiotalar joint
with that classic v presentation
but we see the bone here
and we see an artery probably
the dorsalis pedis artery here
and this hypoechoic and anechoic black area
is all joint effusion
with synovial proliferation.
In this still image you can see the needle coming down
and as I turn on the video
you'll see the needle advanced in injected material
which you can see circulating around.
You can see the artery pulsating.
In this image
this is a person with acute gout.
We have a transverse image of the left first
metatarsal phalangeal joint
and this is the bone surface.
This is the distal end of the metatarsal
and this area of hypoechoic and anechoic
black appearance is fluid in that joint.
There's a digital artery over here
and the needle can be seen coming down
from the left side of the screen.
You can see the bevel on the needle.
Right now the end of the needle is caught
in a small amount of synovial tissue
and there is steroid injected in.

Brightcove ID

5751505197001

https://youtube.com/watch?v=MkEuZklbJ9I

How To: Foot Exam

Read more about How To: Foot Exam

/sites/default/files/Coach_pollock_foot_exam_thumb.jpg

Dr. Scott Pollock demonstrates how to perform a foot exam.

Clinical Specialties

Physical Med & Rehab

Media Library Type

How To Videos

Media Library Tag

Msk Ultrasound

Musculoskeletal Ultrasound

Subtalar Joint Injection

Podiatry

Subtitles

- We're going to exam the ankle.
She's lying down on her back with her knee flexed
and ankle in approximately this position.
I've selected an L25 transducer
because it has a small footprint.
It's easy to get around the curves in the ankle.
On the Sonosite M-Turbo,
I've set for its factory preset for Msk.
For orientation, this mark on the transducer
corresponds to the turquoise dot
on the upper left portion of the screen.
And I'll examine the anterior portion
of the true ankle joint first.
And on the left side of the screen is the tibia.
And in this view, you see the tibiotalar joint.
There is a hypoechoic, or anechoic, stripe
over the talus, which is cartilage.
And there are vessels and tendons superficially.
This would be one of the best views
for a rheumatologist to find an ankle effusion.
And that can be seen as an anechoic area in that V
between the two bones.
The lateral aspect of the ankle joint can also be examined.
The fibula is the bony structure underneath the marker.
And the talus is to the right.
You can see an effusion again, between those bones as well.
Transverse images are very good
for looking at extensor tendons,
and for tendon abnormalities.
You might see anechoic fluid around the tendon
or synovitis.
And also see in the middle of the screen,
the dorsalis pedis artery pulsating.
It's very important to identify the position
of the arteries so that when you do injections,
so you'll be able to avoid them.
Next I'm going to examine the medial aspect of the ankle.
The medial tendons, three of them,
run just inside, or just posterior,
to that medial malleolus.
It's best to examine these initially
in the transverse plane.
And we can see two of those tendons very clearly,
right superficial to the tibial bone.
As a rheumatologist, you can see peritendinous processes
with fluid and synovial proliferation.
You can also find large tears or tendinopathy.
A longitudinal image of those tendons is also very easy
to obtain because they're so superficial.
We can look at the lateral aspect of the ankle.
The peroneus tendons are present here.
And just posterior
to the lateral malleolus are the peroneus tendons.
You can see them on the screen just
to the right of the bone.
There are two tendons there.
For examination of the Achilles tendon,
it's best to have the patient in the prone position,
and have the Achilles tendon lined up.
The image that you see on the screen,
the bony structure is the calcaneus.
The Achilles tendon is inserting
into the calcaneus distally.
This is a frequent zone of calcification.
And then going proximally,
you can get a very nice view both medially and laterally
of this Achilles tendon.
The structures deeper to the tendon include a bursa
and some fatty tissue.
This is the area where many tendon tears occur.
We also should then
examine the Achilles tendon transversely.
And this can be done all the way distal,
to the point where this Achilles tendon
gets smaller and smaller,
and inserts on the bone.
Or as we move proximally,
you might be able to see areas of tendinosis,
or tendonitis, or rupture here.
There are a number of appropriate measurements
that are frequently taken for the size,
accessing the size of the Achilles tendon.
These can be done
both in the transverse and longitudinal plane.
And usually we go just to the border
where the calcaneus ends,
and freeze the image.
And then using the calipers,
and place
one on this side
and one on this side for getting a measurement
from medial to lateral.
You can then get another measurement of thickness
from the superficial to the deep.
You can also measure an area.
Probably the best way to do it is manual.
And so then this gives us an area of the tendon,
in a cross section,
and that area is .85 centimeters squared.
You can also take measurements of the Achilles tendon
in the longitudinal plane.
And measure the thickness
at the edge of the calcaneus.

Brightcove ID

5751496699001

https://youtube.com/watch?v=CKcM5zFZk_g

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