Foot and Ankle

Dorn Spinal Therapy

Spine Healing Therapy

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The most commonly requested peritendinous injections in the foot and ankle, in our experience, are in patients with chronic achillodynia, or those with medial or lateral ankle pain due to posterior tibial or peroneal tendinosis/tenosynovitis, respectively. The large majority of patients

A FH

FIGURE 2 Iliopsoas tendon sheath injection. (A) Transverse sonogram obtained over the anterior capsule (c) of the hip in a patient with a "snapping iliopsoas tendon." A small bursal fluid collection (*) is seen immediately superficial to the tendon. The iliopsoas tendon (arrow) is inhomogeneous-containing intrasubstance clefts. "fh" and "p" denote the femoral head and pubis, respectively. (B) Using a curved linear transducer and lateral approach, a 22-gauge spinal needle is advanced toward the deep surface of the iliopsoas tendon (t). (C) Improved visualization of the needle tip along the deep surface of the tendon is achieved by test injection of a small amount of local anesthetic. The presence of echogenic microbubbles along the deep surface of the tendon confirms needle position. (D) and (E) Longitudinal sonograms over the iliopsoas tendon before (D) and following (E) administration of anesthetic and corticosteroid. In (E), echogenic microbubbles (arrow) are seen to distribute along the deep surface of the tendon. "A" and "FH" denote acetabulum and femoral head, respectively. Source: From Ref. 7.

with achillodynia have pain referable to the enthesis, with associated retrocalcaneal bursitis and achilles tendinosis (2,16). When the pathology in this location is confirmed on gray-scale imaging, retrocalcaneal bursal injection may help alleviate local pain and inflammation (2). We scan the patient in a prone position with the ankle in mild dorsiflexion, using a 7.5 MHz or higher-frequency linear transducer. A short 1.5 in needle usually suffices in these situations, with placement of the needle using a lateral approach. The deep retrocalcaneal bursa is usually

FIGURE 3 Bicipital tenosynovitis. Transverse gray scale (A) and power Doppler (B) sonograms of the long head of the biceps tendon shows it to be inhomogeneous and surrounded by soft tissue and/or fluid. Increased peritendinous blood flow seen on power Doppler imaging (B) is indicative of an associated tenosynovitis. (C) Using a lateral approach, the tip of a 22-gauge spinal needle (N) is seen within the superficial aspect of the distended tendon sheath. (D) Following injection and needle removal, the sheath is distended about the abnormal-appearing biceps tendon. The mixture appears echogenic, likely due to small scatterers produced within the steroid-anesthetic mixture.

FIGURE 3 Bicipital tenosynovitis. Transverse gray scale (A) and power Doppler (B) sonograms of the long head of the biceps tendon shows it to be inhomogeneous and surrounded by soft tissue and/or fluid. Increased peritendinous blood flow seen on power Doppler imaging (B) is indicative of an associated tenosynovitis. (C) Using a lateral approach, the tip of a 22-gauge spinal needle (N) is seen within the superficial aspect of the distended tendon sheath. (D) Following injection and needle removal, the sheath is distended about the abnormal-appearing biceps tendon. The mixture appears echogenic, likely due to small scatterers produced within the steroid-anesthetic mixture.

FIGURE 4 Patient with retrocalcaneal pain. (A) Extended field of view longitudinal sonogram obtained over the Achilles tendon (T ), showing it to be fusiformly enlarged, inhomogeneous and containing a longitudinal split (arrow). (C ) denotes the calcaneus. (B and C) Transverse sonograms obtained over the Achilles tendon (T ) at the level of the retrocalcaneal bursa. The needle (N) is seen within the bursa and deep into the tendon before (B) and during (C) injection of anesthetic and corticosteroid. The immiscible nature of these two components can produce small scatterers, which are readily seen during real-time injection. The intrabursal injection of material is confirmed during real-time observation.

FIGURE 4 Patient with retrocalcaneal pain. (A) Extended field of view longitudinal sonogram obtained over the Achilles tendon (T ), showing it to be fusiformly enlarged, inhomogeneous and containing a longitudinal split (arrow). (C ) denotes the calcaneus. (B and C) Transverse sonograms obtained over the Achilles tendon (T ) at the level of the retrocalcaneal bursa. The needle (N) is seen within the bursa and deep into the tendon before (B) and during (C) injection of anesthetic and corticosteroid. The immiscible nature of these two components can produce small scatterers, which are readily seen during real-time injection. The intrabursal injection of material is confirmed during real-time observation.

well seen. A small amount of anesthetic will help confirm position by active distension of the bursa in real time (Fig. 4).

We similarly approach posterior tibial or peroneal tendons in short axis. Patients with pain in this distribution have been shown to benefit from local tendon sheath injections (2,17). The presence of preexisting tendon sheath fluid can facilitate needle visualization. However, careful scanning prior to the procedure to assess the needle trajectory relative to adjacent neurovascular structures should be undertaken. Use of color or power Doppler imaging can facilitate visualization of the neurovascular bundle. The posterior tibial nerve is closely related to adjacent vascular structures and is usually well seen prior to bifurcating into medial and lateral planter branches. In our experience, fluid is frequently seen in relation to the posterior tibial tendon, in the submalleolar region. The peroneal tendons are less predictable (19). Use of power Doppler imaging in conjunction with real-time guidance can be beneficial in localizing areas of inflammation for directed injection (20,21). In the case of stenosing tenosynovitis, the tendons may only be surrounded by proliferative synovium or scar tissue (Fig. 5) (17). In this latter case, the use of a test injection of local anesthesia to confirm the distribution of the therapeutic agent within the tendon sheath in real time can be invaluable (Fig. 6).

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