使用超声波评估外侧踝关节

- Okay, now welcome to the Sono site behind the scan webinar called Using Ultrasound to evaluate the lateral ankle. Now this is the last known four part series about ankle ultrasound and if you'd like to check out the previous webinars in this series, you can visit our webinars page on sono site.com. With that out the way, we can get up today's presentation started. My name is Chris Pennell and I'll be moderating today's webinar. Before we begin, please be advised all attendees are muted and you can type your questions into the q and a box in the toolbar located at the bottom or the side of your screen. We conduct that q and a session at the end of the presentation and demonstration, and this webinar will be recorded and archived for future reference on our webinars page. Here with us today we have Daniel Shelton. Daniel is the director of musculoskeletal market development for Fujifilm SonoSite. Daniel has spent 18 years as a dedicated musculoskeletal sonographer and 12 of those years have been here at SonoSite. He now leads musculoskeletal mark market development where he works to spread the word about the benefits of point-of-care ultrasound. Today's webinar is going to be a very thorough examination of the lateral ankle, so I'll turn it over to Daniel to get started. - Very excited to give these slides and wrap up the ankle series and add it to the collection of the other joints that we've concluded. Again, here's our indications for ankle, foot and ankle ultrasound by the A IUM. You can check those out on their excellent website and on the lateral structures. Today we're gonna be focusing on these bulleted structures. Now I'll say the A TFL was covered in depth on the, the front of the ankle on the anterior presentation, so we won't belabor that one too much today, but we do have a few slides on it. But primarily we're gonna be covering the P perus brevis Pius longus tendons, the anterior talo fibular ligament, the posterior talo fibular ligament, and the calcan fibular ligament. But let's, let's first start with the bony anatomy like we always do, we start at the bones and work our way up. And today's no different. We're gonna start with the fibula laterally. It hangs down much lower than the tibia, so it makes it an excellent landmark. It articulates with the alis and we also have, sorry, it articulates with the tibia and creates this tibial fibular joint, but it's our main lighthouse of a landmark here. We've already covered the articulations of the Alis and calcaneus, so I won't read these bullets, they're in previous presentations, but let's get to the live demonstration, just cover our bony anatomy, that way we, we have a base to kind of get started on here. Alright, so now we'll get started on the live scan. I do want to introduce the transducers that we'll be using today. Today we'll be scanning on the sono site PX ultrasound system and we're gonna be using linear 15 to four megaherz transducer pri, or not necessarily primarily, but we'll be going back and forth and showing the benefits between the larger linear on the lateral ankle and the smaller L 19 to five transducers. So 19 megahertz, smaller footprint fits in those tight spaces, a lot nicer. So we'll go ahead and get started with the larger linear, the 15 four just to go do the anatomy survey of our bony ankle features. So lemme get that set scan. I use a lot of gel on the lateral ankle, so you're gonna notice a, a large bead of gel here. And I'll probably go ahead and just start with a large bead of gel, just right where I'm gonna be scanning. So I start and cross-section right here on the posterior lateral malleolar area. And we're gonna look at the fibula, the posterior tibia, talus and calcaneus, a big bee to gel to fill that air gap that typically occurs when we're scanning the lateral ankle. And I like to put the cord around my wrist and the left side of the screen. Okay, I'm gonna keep the left side of the screen towards the Ellis, which is pretty, pretty typical. It's a great landmark. So we're gonna float that right through there. And I'm just hanging my finger right underneath the gel surface as a standoff kind of stabilizer to keep my hand from floating so much. I rest all the weight of the transducer onto my finger first and then down to the, in this case the calcaneus. But I'm just gonna slowly lower that transducer footprint in the gel, just like that. So here we have the arrow. So here's the fibula. Okay. And you can see that retro malleolar groove. We can actually see the, the, the retina AUM going over the, the perineals there. But let's focus on the bones. If I stay up high in posterior deep, we have the tibia here. I'm gonna drop my frequency by hitting gin there. And so here we have the posterior tibia, the posterior fibula, okay, and then I'm just gonna swing the distal part of my probe or the posterior side of the probe, which is on the achilles side, which we can see the Achilles back here just as a FYI where we are on the anatomy. Here's the Achilles CRE fat pad. So way up here is posterior tibia and then I'm gonna swing and keep this part pivoted the distal or posterior side of the probe planted. So here's the ali. So we saw a big jump in where the bone is, right, there's a big jump, there's nothing there. And then we see the tibia alis. So it's just a windshield wiper maneuver of pivoting between tibia and Alis. And that's gonna come really important when it comes time to scan these ligaments Further posterior, we're gonna plant fibular side of the transducer and keep windshield wiping down to the calcaneus. And you can see that long neck of the calcaneus. That'll be a huge landmark for us as we continue to scan. And then if I translate the entire probe distally, now we should hit the posterior lateral subtalar joint. So this is talus calcaneus. And then if I keep going posterior, or sorry, not posterior, inferior and lateral, we've fallen onto the cuboid bone, which houses this, this nice little tubercle here. And then we'll go long axis on these structures here. And then another structure that'll come in later with the tendon exam is the base of the fifth metatarsal. And I just tell people to go ahead and feel for the, the shaft of that base of the fifth metatarsal and work your way approximately until it falls off. When it falls off, bring that to the side of your screen and then pivot the transducer, the rest of the transducer up to the malleolus. And that'll, that'll help us get these two bones in the same shot with the larger linear array transducer. That about does it for the bony survey. We'll go ahead and get started on the slides for our ankle ligaments. All right, ligaments of the ankle, A TFL, which we did cover in the first anterior ankle presentation. It does articulate what the distal or originates at the distal fibula and inserts on the distal als right here at this little tubercle, I don't know the name of that tubercle, but it's very prominent on ultrasound. And basically we just fan the ultrasound beam over the cartilage until we see that pronounced tubercle. And that is just about a hundred percent of the time where you find it. Here's that little tubercle, here's what it's gonna look like. And this nice little bridge of connective tissue makes up the ligament. And our probe orientation here is slightly oblique and it's pretty, pretty easy to find once you just plant the probe on the fibula and pivot or a windshield wiper, the distal portion of the probe. Then posteriorly it's counterpart is the PTFL. It's origin is the lateral malar fossa. The insertion is a lateral talor tubercle. It is the strongest of these. So also similar scanning orientation. It's relatively horizontal and slightly oblique when you're scanning relative to the anatomy model that you see here. It's, it's harder to visualize. It shows up as this prominent shadow underneath the fibula. So we'll see this an isotropic shadow here attaching to the alis. Then you're just gonna want a windshield wiper, the finger side of the probe here, the achilles side of the probe and catch all of its insertions across the alis. But it's original. Its origin is the lateral malleolar fossa. Its insertion is the lateral lar tubercle. This one's a little bit more fun to look at the calcaneal fibular ligament, I think of the ligaments of the lateral ankle. It's the most practical and it's right there in our lighthouse view once we get to the perennial tendons tube. Its origin is a lateral malar tip, the insertions of calcaneal tr trochlear imminence. It does traverse under the perennial tendons and it does provide lateral support of the subtaler joint. Incidentally, it often tears with the A TFL tears too. But this is the illustration that I've got here and what you'll notice is a lot of the fibers are very anterior on the fib end. We'll we'll check that out in the life scan probe orientation. You can see how oblique we are slightly on the superior surface of the calcaneus. We should see the really nice ligament here supporting the pros, brevis and longus tendons right over the posterior lateral subtalar joint. Alright, let's get to the live demonstration of these ligaments and share some scanning tips and tricks. Alright, let's get to those ligaments here. We've got the same plant that we did earlier. Lots of gel back here. Now let's focus on what those shadows were. All right, so how do I know if this is a tibia or alis? We just need to exhaust all of our options. So it's that windshield wiper sweep up. I see a tibia back there on a ligament we're not gonna focus on. And then down we see this, this oblique shadow. So this oblique shadow right here is that posterior talo fibular ligament. All right? And it is a challenge to see. So you have to kind of bury the Achilles side of the transducer in because we have this huge gap here where it, it is hard to dig in. So I do have part of the transducer making it hard to see because of the achilles being in the way. And then the other part of the transducer hard to manipulate because the fibula is in the way. So we have to rely on not only sweeping our transducer up and down and here's that nice ligament, maybe try a little bit of dorsiflexion and plantar flexion and let's get that tailless to move, do some aversion maneuvers. And I think we catch a little bit nicer ligament that way. So I'm inverting the foot, maybe even catching some old scar tissue right there in the middle of that ligament. That's kind of cool right in there where it looks irregular stays hyper coic no matter which way in a, in a very an isotropic environment, typically scar. All right, so that does it for that ligament. Now let's keep windshield wiping posteriorly. This where it might be a bit of a challenge. There we go. That's really nice. Bring our depth up more shallow, double tap our a, b, C key to get the arrow back up. But one scanning tip for the fibula calcaneal ligament or calcaneal fibular ligament is fall off of the fibula right here. So here's fibula, here's calcaneus, here's the perineal tendons that we'll we'll get to, but I'm gonna fall off the fibula. So my thumb side on the scanning there. And then you already see this horizontal band and those are the, the ligament fibers that now it's just a, it's just a twisting of the transducer clockwise and counterclockwise until you elongate this band here. But that is our calcan fibular ligament right there. And then you can see the perennial tendon sitting on top of it like a hammock. Pretty easy to get to. So only scanning pearl there is to fall off the fibula. If you feel frustrated, like if you get this image here, we have some ligament here and don't stop there because we need to see a little bit more of the origin and all the anatomy diagrams that you'll see, they really do show this ligament starting on the edge of the fibula. But if you'll notice on ultrasound, we can see with, with even more accuracy, this ligament wraps around of the anterior fibula a bit right there. So we're off the tip of the mauss here and we can see the fibers are still continuing to the front side of that lateral fibular mauss right there. So don't forget to check the origin of that ligament, get that nice bridge all the way across there, planter and dorsiflexion. We will stress these fibers and you can see that ligament bouncing up and down. You can also do inversion maneuvers, but planter and dorsiflexion is really gonna get that thing to bounce. So dynamic maneuvers, this is ultrasound. Do everything you can to make it move. Alright, now finally a little bit of a redundant review on the anterior talo fibular ligament, which we did cover in the first webinar. But I do wanna kind of go over that is find our anterior fibula and we're gonna windshield wiper maneuver. Here we go, anterior fibula talus, and then that little dark shadow right there. That stripe is our A TFL. If you want a more in-depth review of that ligament, which we have already covered on the anterior ankle webinar, I suggest that you go back to that and catch where we did kind of a deep dive on that ligament. But that covers the ligaments for the lateral ankle and we'll get into those tendons. All right, let's start the tendons of the lateral ankle. Not too many to cover. There's just two that we're gonna focus on today. First is the p perus brevis tendon. Its origin is the distal two thirds of the lateral fibula. Its insertions the base of the fifth metatarsal. It's responsible for aversion of the foot and it limits inversion. But one thing of note is this large muscle distal musculo tendonous junction, which does get right up to the retina AUM that we're gonna be imaging here. Peel that away. And you can see the P perus longest tendon, which its origin is the proximal two thirds of the lateral fibular head or the lateral fibula and fibular head. Its insertions on the plantar base of the first metatarsal and the medial QA form. It does plant or flex the ankle and is responsible for foot aversion and it supports the arch. As you can see, they do kind of create a little crisscross. Once we're in the live scanning, you'll notice that a little bit more than we're seeing here in the model. But it does have a really nice synovial tendon sheath. It's very easy to scan and you're gonna wanna use the gel standoff to make that more pronounced. But scanning these, we typically start in a transverse orientation right at the lateral maus cutting posteriorly. And we're just gonna stay on the fibula and pivot the distal into the probe or the posterior end of the probe towards the calcaneus in a windshield wiper like fashion. And there's also dynamic maneuvers that we'll do in the live scan, but we're gonna be focusing on the P pros, longus and brevis. Brevis is on the bottom, longus is on the top and it stays that way all the way to the fibula calcan ligament or calcan fibular ligament, sorry. And then we want to take note of this perennial Retin alum that straps these tendons down to the fibula at the retro malar groove as we go. Long axis, the brevis in longest or kind of blended in. Take note of the transducer angle that we have here. We're not scanning just straight into the coronal plane of the ankle, we're, we're scanning posteriorly but sagittal in in the overall ankle. And it gives a nice bony backboard and we'll cover that in the scanning tips in the live scan of that as well. But all these tendons run the same direction at the malleolar level, much like I've discussed in the previous webinars. But, but keep in mind, once we leave that fibula, once we leave the malleolar level, these tendons tend to go off in all kinds of various different directions. And that's something that will also be covering in the live scan a little bit more as we go distal to the fibula. These, these tendons jump over the calcan fibular ligament. As we previously discussed. The superficial most one of these, at least at this point is the prunus longus. And then the deeper one is the prunus brevis. At this point they make that crisscross that I had mentioned where the brevis will then start to shoot more superficially and ride its way to the base of the fifth metatarsal. And the PS longest is gonna be the one that dies really deep. It's very anti isotropic. And if symptoms weren't for you to scan to the base of the first metatarsal, then then we can go to the bottom of the foot. But typically after the perennial tubercle, we really don't have to scan much further unless the symptoms warrant that you chase it down to the, to the arch of the foot. We do need to cover the base of the fifth metatarsal for this examination. The PS brevis does insert on the base of the fifth metatarsal typically fine if you just palpate your finger on the base of the fifth metatarsal and run your transducer towards the malleolus that you catch a very nice long axis of this tendon. Let's get to the live demo where, where all the scanning is and, and it's easier to teach these tricky tendons as they traverse these different directions. All right, let's scan these tendons. So again, more gel makes everything in the ankle look better. Big beta gel posterior fibula. We're gonna go right back into that retromalleolar groove. We're gonna cut the ankle into a axial slice again hanging a finger down to stabilize our gel heap. And we see a really nice fibula. Again, we're at the level of the Retin aum and you can just windshield wiper across until you elongate the ulu down to the calcaneus if you feel the need to. But right here at that posterior malleolus is where we're gonna do a dynamic maneuver. So what I'm gonna do is lift up the ankle, we're gonna have our model just do some ankle rolls. So we're just gonna, yep, go into a rolling motion. And this is where it's really important to use that finger as a stabilizer so that we know we're not pushing the tendons down and keeping them from subluxing, but those tendons are just rolling in that retromolar groove. They're not perching or subluxing on top of the groove. Another great dynamic exam. So go and relax. But yeah, we just wanna make sure that these are not crisscrossing, that I'm not getting the P pres longest herniating through the P pres brevis. And that the integrity of this Retin aum, this wedge up here maintains intact. That's a good time to switch over to the 19 megahertz transducer, which is a little easier to do that dynamic maneuver 'cause we had so much transducer having to be bridged by all that gel. It made it a little tough. So we're gonna be looking with 19 megahertz now. And this transducer starts with the depth zoomed out quite a bit for perspective. So it's not like you're putting your nose right on the glass, but I'm gonna bring up the depth just a bit there. And now we can see more detail in the tendons even maybe more importantly on this exam, more detail on that retina ulu to make sure that we don't have any tears in the retina ulu. And then I'm just gonna raise her ankle up again and we're gonna do slow rolls. There we go. And let's just watch that Retin ulu edge. I'm gonna put my thumb on the front side of the malleolus to help kind of stabilize the transducer while we do this roll. So my thumbs on the front of the malleolus transferring the weight of the transducer from the probe to my thumb and then my thumb to the front side of the malleolus. And that keeps the probe from pushing down so much. So give that a try when you get in front of your machine and maybe it'll improve your dynamic lateral ankle exam. But everything stays right where it's supposed to be. So we're gonna relax very nice. And let's keep following these tendons distally now. So now we're at 19 megahertz. There should be no question which tendon is which. So we have B for bone. Brevis for bone is the lowest one here, right here. Actually P pres longest has this muscle belly coming off of it. So if you're ever confused, which is which P pres longest has the muscle belly with a more distal, there we go. We're gonna just keep following the superficial guy. Actually that was brevis. Yeah. Wow. I got, I got turned around. But that's the beauty of ultrasound. We get to trace these things out. So brevis here, this little thin slip, that makes a lot more sense actually because this tendon, which is still tendon, is gonna go all the way up to the proximal fibular neck. So that would be prunus longus superficially p preis brevis deep. And I should have just remembered what I was taught. B for bone. Brevis for bone is the one on the bottom here. All right, so now we have the, the p PRUs brevis sitting on top of that fibular calcaneal ligament. Look how nice that ligament looks with 19 megahertz, we can actually trace that ligament back here posteriorly to the calcaneus very nicely. P perus brevis is the one that we're gonna focus on here. So it's this oval here. All right, so now it's, it's on the more dorsal aspect of that p perennial tubercle. All right, and this is where we see the two prunus longest prunus brevis take a different direction. So prunus brevis will stay centered in the screen and remain shallow. Pius longest will dive through that cuboid groove to the base of the first metatarsal. But here we are at the base of the fifth metatarsal and cross-sectionally evaluating that PS brev is really, really nice. Let's go long axis and just kind of confirm our work. Okay, so screen left base of the fifth. And then here we have really, really nicely perus brevis tendon. Let's chase it proximally or at the perennial tubercle level 'cause I can feel it under the transducer. And then we're gonna see this oval right here, this crisscrossing shadow. And that's res longest coming into view. And now they're gonna, they're gonna pair up and run in tandem up to the mall Ellis. And that's where we see these two guys there. So superficially, if we trace this shadow here, proximal to the perennial tubercle, the superficial guy is the prunus longest, the deep one that was sitting on top of that calcan fibular ligament, which is this and cross-section. You guys remember that ligament that we were looking at right here that looked like a hammock for these tendons that's providing kind of this inflection point for the tendons to take a, a little bit of a different turn also. But here's calcan fibular ligament and cross-section, beautiful 19 megahertz image. And let's just keep following each of these. So now let's follow the shallow or the superficial guy here. So this will be P longest. It's gonna take a turn and wrap around the cuboid groove. And I'm gonna have to dig for angle here into the foot, but it's, it's trying to dive into the deeper soft tissues. And on this 19 megahertz transducer, if you feel like you've lost penetration at about a centimeter and a half, I will say it's worth going over here to your, to your menus on more controls, toggle down to THI and turn that THI off and we'll get a little bit more penetration outta this transducer. Turn our gain up a little bit and I'll just toggle on off and I'm gonna point out the PS longest as it jumps that gap. So here's prunus longest long axis and then I'll toggle off the THI. Just so you know, from a scanning standpoint, we're we're looking for lower frequency echoes in the far field of the image. When we're shallow at 19 megahertz, A THI makes a lot more sense, but when we're deep and we're trying to, trying to reach these tissues with the probe that we have, toggling that on off just to, just to see what you can see. Now if pathology, if symptoms warrant scanning any further distal, go ahead and chase it to the base of the fifth metatarsal or to the base of the first, I should say, on the far reach of the arch of the foot. And we can do that real quick. I'm gonna switch back over to my L 15. It's a great place to show the differences in why it's, why it's nice to have both. We're gonna go over here to the arch left side of the screen will be towards the base of the first and let's find those structures. There we go. So we can see the base of the base of the first right here. Kinda hard to see camera wise just how far over I am. There we are right where the arrow is base of the, and it's just neat to see how long that tendon really is. And I'm obliquely orienting the transducer all the way to the malleolus basically. But that's it right there. This is it. This is the pretty longest exiting that cuboid groove coming out. Fanning out just a bit. And it will insert on the base of the first and some fibers to the medial mosts under surface of the the medial uniform. All right, so one scanning tip also while we're back here on the posterior mallis, don't scan these perennial tendons straight up and down like this. When you're doing your long axis shot, you will catch the tendons, okay? And they do look like tendons up here. But to get a good image in reference to where we need to be scanning, I want you to pin the tendons between their bony backboard, which is this retromolar groove of the fibula by laying the transducer relatively towards the achilles right here. And then pinching those tendons between the, the fibula and your transducer. So you end up with this really, really nice picture just like that. So here's the two tendons stacked on top of each other. It's kind of hard to see the difference between the two two tendons except when we leave, yeah, once I start fanning more, more posteriorly, we see the difference between the two tendons. But once you're right up here on the retro malar groove, it is a little bit more difficult. But that is a big scanning pearl for catching a really nice clean image of these perennial tendons. And long axis at the proximal part of the exam, once you go distal to the fibula, you're just gonna plant the probe on that, on that fibula and use it as a pivot point right there. So screen right is our fibula screen left is the pivoting portion of the exam. And there we have our tendons taking their two different angles right there. Cross-sectional fibula, calcan, calcan, fibular ligament, sorry, CFL is right here. So you don't wanna call that scar tissue or anything like that. That's just a cross-sectional ligament. We can, we can show that by doing a, a split screen. Take that shot right there and go long axis. Same, same zone. There we are. So you can see that ligament and long axis really nicely here. Short axis here. So don't call that an area of pathology that is just a ligament and it's normal to see that amount of fluid. What we shouldn't see is fluid that is circumferential around the tendons. So you wanna float the gel distal to the malleolus and cross-section to the tendons and look for those tendon sheaths to be full of effusion right around that perennial tubercle here, perennial tubercle, see a little ret aum wrapping around it, little shadow from that reticulum and then chase those tendons distal, you can see one already trying to go superficial. So that's perus brevis and Perus longest takes the deeper dive at that point. So that's it for well lateral ankle exam and we'll go ahead and let you guys queue up those questions in the chat portal. So go to the q and a type your questions. This is a live webinar and you, this is your chance to go ahead and ask those questions in the recording. We typically don't post the questions, so don't feel pressured that, that you shouldn't type in any questions because of getting in the way of the webinar or anything like that. This is a great time to go ahead and ask those questions. I'm gonna keep scanning 19 megahertz just to really show off these tendons and ligaments really nicely. While we wait for those questions to come in and we'll have Chris close us out. I thank you for joining us. - As Daniel said, now you can go ahead and put questions in the QA box. Now it should be at the bottom or the side of your screen, so we'll wait just a little bit for those to come in. Daniel, is there anything else that you kind of wanted to show everybody? - You know, we, we covered a lot. This of course was the final of the ankle series, so your q and a could pertain to really any, any part of the ankle and we'll go ahead and cover it. So just to kind of close the series out, I do want you guys to be sending us feedback. You can, you can do that through this q and a portal or email me at daniel.Shelton@fujifilm.com about the content you'd like in future webinars. So we've concluded the diagnostic session, which we did the shoulder, elbow, hand and wrist. And then we've done the hip knee and then we've just concluded with the ankle, I would anticipate that we'll still have some to look at on the foot. We would like to explore a series on nerves and then we'll be doing a procedural series that will be basically moderated by myself, but having guest physicians on showing their pearls and how they do procedures. So that's the next, I would say calendar year, maybe even year and a half on the menu for, for these webinar topics, they'll be interactive or you can ask these questions through the q and a portal. They are all have live demonstrations and many of them are gonna have guest guest physicians. So we look forward to having you guys come on and ask those questions. But for today, you know, ask those questions, go ahead and ask us to review anything, we'll go over it. I have the slides still pulled up if you total all these slides up. Let me, let me cruise back to the slide deck here. You'll see that - It does look like we have a question in here. - Alright, go ahead. - They'd like to know, please show what is the easiest and most direct site for lateral ankle injections. - Oh, all right, so that, that answers my suspicion that we do need an injection series. Okay, so from a injection approach, I'm okay showing how to access a joint intraarticular or peri tendinous sheath injections or bursal injections from a, from localizing anatomy. Where I'm going to reach my limit is what to inject, why, what to expect out of it. The mixtures, you know, I can speak a little bit to what fits in a needle selection and what's appropriate for certain sites, but that I, I think just with this being our first question right outta the gates, confirms my suspicion. Chris, we need an ankle or not an ankle, we need a procedures webinar. But to access the ankle joint proper, I just show people anywhere you see cartilage around the tails, you're gonna catch yourself in the joint. So here we are with the lateral fibula view right here. Here's the ALIS with the cartilage, here's the A TFL. So we see that ligament really nicely stretching across the screen. Underneath that ligament is the ankle joint. You have the cartilage of the alis. If we just climb a little bit further anterior, you don't have to pop through the ligament and you don't want to trickle any steroids into the connective tissue. But this is fat. So this is just a wedge of fat that borders the joint. You can make the fat move with your finger and decide where the articular surface is. And I see people either coming in from this side where the perennial tendons end from the mallis side, you can just go right over that little fat wedge into the joint where that, where that fat is. I think the most common sense approach is to do a, a center line, which is where you activate that feature on your machine, avoid hitting vessels or anything like that. And then you would just drop the needle out a plane right under the arrow into that same space of the ankle joint. You can inject anteriorly. So we're gonna roll our model's foot face u you just end up with other, you know, big reds in, in view like the dorsalis pitus artery. But I, I would say that's a pretty common approach is to come anterior. You see the cartilage of the tails anywhere you see the cartilage of the tails is intraarticular and you can drop your needle. I would advise you go off to the side of the extensor digitorum up here and not to the side of the dorsal pitus. So you wanna stay maybe a little bit more lateral. So if you're a little bit more lateral, you can go from distal to proximal if you're pretty obsessed about seeing your needle the entire way. Or I still find people that will just find the, I think we're right at the extensor digitorum here. And then if you go off to the side of the tendon, you catch just muscle belly and that won't, that won't drag your needle so bad and you can just slip the needle out a plane right down into the ankle joint there. But anywhere you see the tus and the tailless cartilage ordering the tibia, you're gonna access the intraarticular space of the, of the proper ankle joint. Good question. Hopefully it's an icebreaker. Hopefully we get more people asking questions on. - We've got one more here. Acute injury with lots of swelling. What are the best strategies to view partial versus complete rupture of A TFL - Compared to the other side? So if you're looking at an athlete, pretty often they have trashed ankles. So don't get too excited when you see disruptions in the A TFL or swelling in the A TFL. It's not always because of that particular day, but I think of swelling being like a loaded paintbrush. Like our, our ligament on the screen right now is very thin and parallel. And it's by parallel, I mean it's superficial border is parallel with its deep border. Now when you see one side or the other or the middle loaded up like a paint brush full of fluid where it shouldn't be and it's asymmetrical. If you see all the fibers, you've got an acute inflammation. If you don't see the fibers and you see homogeneous basically echoes instead of linear longitudinal striations. When they become homogeneous and non fibrillar, you're looking at a degenerative condition, typically you wanna throw your color power doppler on at that point and see if you have chronic inflammation that has set into those degenerated fibers. When you have an acute tear that just occurred hours prior, it shouldn't light up with all the doppler crazy inflammation that you would expect. You would expect it to light up and just be all kinds of angry and upset. But in, in reality, it takes a little while for all that to set in. And sometimes the edema around it can kind of distort the image a little. Sometimes it can help the image a little in an area that needs a little acoustic enhancement. But great question. So in short, if it's an acute injury, I see fibers, but they're swollen away from each other. If it's chronic, I, I don't see fibers with the swelling and I typically see lots of hyperemia colored off activity like this little group of vessels I would put that on as a, as a baseline. Basically throw your color on, see if you can dial your machine into a surrounding small vessel. Like I think I should get more flow than I am. So I'm just gonna go down on my color scale a bit and make the color doppler a little bit more sensitive. I'm gonna turn my gain up a little bit until I see noise underneath the bone. So bring your doppler box down underneath the cortex and when you see all that noise, you just wanna reduce your gain and then take that same color parameter over the injured site or over the chronic inflammation site and see if you have signs of tendinosis with hyperemia. But it takes a couple of days, if not, yeah, I'd say a couple of days before you start seeing the inflammation really angry in a tear site where, where it's sending those little healing vessels, those neo vessels into the area. Excellent question. All - Right, - Well on a light, on a lighter note, this is hilarious. You know, since we probably won't record the webinar or the, the questions on the webinar, I was looking at the sal nerve of a few months ago on this particular model, right? But here's the sal nerve just to have fun with it. So here's Achilles CAGR fat pad and then here's the sal nerve and then look at these little veins, top and bottom. And then I had a little bit of fun if I caught it at the right slice, we caught a big smiley face across the screen and this guy started blinking at us. That was funny. There's, you know, gotta gotta find humor in what you're doing. Live webinar. Gotta have a little fun with it and we'll probably clip this off the recording. But yeah, this a happy little sterile nerve. So we've got the two eyes and here's the nerve right there. Happy Tuesday, right? - That's right. All right, well it looks like there's no more questions coming in. So everybody, just a reminder, this was the last now four part series about ankle ultrasound. So if you'd like to catch up on the previous three, you can go to our webinars page on sono site.com and we'll also be announcing some more webinars soon. So keep an eye on that webpage for more details. So thank you so much Daniel, for taking the time to put together this presentation. We appreciate you sharing your expertise with the audience. And thank you everybody so much for joining us today. We appreciate it. We'll see you at the next one. - Thank you everybody. , plain_text