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- Well hello everyone and welcome to the Sono site behind the scan webinar called Extend the Physical Examination of the Anterior Ankle with Ultrasound. This is the first no four-part series about ankle ultrasound and we'd love it if you could join us on Tuesday, September 13th for save time and cost using ultrasound to evaluate the posterior ankle on Tuesday, September 27th for time and cost saving tips for using ultrasound to evaluate the medial ankle and on Tuesday October 11th for efficient and cost saving ultrasound evaluation of the lateral ankle. With that out of the way, we can get 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. You can type your questions into the q and a box in the toolbar located at the bottom or the side of your screen and we'll conduct that q and a session at the end of the presentation and demonstration. This webinar will be recorded and archived for future reference on our webinars page. And here today with us we have Daniel Shelton. Daniel is the director of musculoskeletal market development for Fujifilm Sono site. Daniel has spent 18 years as a dedicated musculoskeletal sonographer and 12 of those years have been here at Sono site. He now leads musculoskeletal market development where he works to spread the word about the benefits of point of care ultrasound. Daniel has a lot of great info to show you today, so I'll go ahead and hand it over to him. - Alright, thank you Chris for that introduction. Hello everybody. We'll go ahead and get started on the anterior ankle first. These slides are pretty much just going to follow the A IUM guidelines and you can check those out and download them. It's a great file straight off the A IUM website. But here's what we're looking for when it comes to ultrasound of the ankle indicated uses of ultrasound are plantar fasciitis, plantar fibromatosis, Morton neuroma ganglion cyst, tenino tenino synovial giant cell tumor. We're gonna be focusing more on some of the falling today ligament rupture or tear tendinosis, tenino synovitis, joint effusion and nerve pathology. So I would say a lot of the other focal abnormal or abnormalities we typically would see around, you know, the, the bottom of the heel, bottom of the foot when it comes to Morton neuroma, for example. We won't be covering those today. Today we're pretty much gonna be following these tendons on the anterior ankle. Today we're gonna cover this anterior protocol, the following webinars. Don't forget to catch, we're gonna be covering the posterior webinar next then medial and lateral. And I think the medial and lateral have a lot of value with those ligaments and definitely the most common ankle injuries occurring on the medial and the lateral side. So going over a bit of anatomy, bones are our roadmap, especially in the foot and ankle. It gets very complicated when all these bones kind of jumble together and you might lose your place on where a tendon or a ligament is. So it's very important to know where to count, where to start. I always have everybody start with the tibia and then go find the fibula here. So here we have a, a lateral view, a medial to later aspect of the ankle. We have an oblique shot here, this is all 3D CT rotated. And then here's the AP or the anterior to posterior view. So we're gonna focus on that today. And then in the future we'll go over the lateral anatomy, the posterior anatomy and the inferior anatomy. But for today we're gonna be focusing on what can be seen pretty much here at this oblique angle and a little bit of the medial side. So we're gonna, we're gonna focus on the tibia fibula and the Alis today. A few other landmarks that will be helpful are the navicular medially and the cuboid laterally. We won't be going over any of the cums, but you should just know that they're there. And then the calcaneus may pop into view here and there just for this articulation while we do a live scan, but pretty much we're gonna focus on this joint. So let's dissect that joint a little bit following the tibia down until the tibia ends. Then we'll see another cortical landmark, but there's some soft tissue above that. As we pan the transducer across here, we should expect to see some of this fat pad, the articular lene cartilage and the joint capsule. So we're gonna focus on that first and, and then we'll work our way through the layers of anatomy. But we're gonna start here on the bone level and let's identify the joint. So here's the joint capsule. We're on that medial to later view. We've rotated the ankle and this is about where your transducer should be positioned to keep the proximal edge of the probe on the tibia, the distal edge of the probe you should windshield wiper over until you catch a good view of the tali with some articular lene cartilage. This is an inflated joint from a cadaver lab. So we went ahead and added an A effusion here and, and just to delineate the joint capsule. So here's the joint capsule, what it would look like within a effusion. And then here's a articular hy cartilage surface, which would be a cartilage interface sign of fluid. On top of this, this shiny prominence of cartilage. So tibia, tibia terminates. Here's Alis, that round Taylor dome just starts before it dives underneath the tail, the tibia, and we won't be able to see that. Here's the neck of the talis as we get to the next articular surfaces that we won't be covering here today, but not covering the soft tissues above. Right now we're just gonna focus on what is the joint capsule, where do we find it, and what's it look like on ultrasound. So we should be able to move on to the live demo next, and we'll do this kind of as a C one, do one, and we'll, we will keep going back - And forth with bite-sized chunks. All right, so to get - Started here, we're gonna begin by using the larger linear array transducer. This is a L 15 to four, and today we're scanning on the sono cyte PX ultrasound system and we'll have the ability later to show the difference between the transducers, but we've also got the chance to image with a 19 megaherz transducer, which I think is very beneficial on the foot and ankle. So we will also be using the L 19 to five linear array transducer as we start chasing down these smaller tendons and, and even some of the nerves. But we're gonna begin with the larger footprint, kind of the bread and butter of musculoskeletal ultrasound here, the 15 to four megahertz transducer. To get started, we're gonna begin with some gel and I use a lot of gel on ultrasound of the ankle, mainly around the, the lateral and medial sides. We, we have just these gaps, you know, where, where the malleoli are and, and some bony anatomy depending on who you're scanning. So lots of gel really, really helps. And hitting the unfreeze button also helps. So we're gonna start just by identifying the tibia as we mentioned, and we'll identify the, the fibula and the, but for this, for this view, we're gonna, we're gonna stick with that long axis view. I like to hang a finger underneath the transducer while I scan, and that helps me palpate a little bit and pivot. Sometimes I'll even, depending on the structure I'm scanning, I'll, I'll hang a, a finger right underneath the bottom of the probe and that helps me palpate and pivot, which we're gonna do on the lateral ankle here in a minute when we check out the ligaments. But you see I've got plenty of gel there. And first let's just locate the, the biggest bone that we can for our roadmap, and that's gonna be the tibia. So looking for a a, a high echogenic structure with posterior acoustic shadowing. Get my arrow up here and that would be this guy here. This is the tibia and it's, it's pretty superficial as I scan approximately, I don't see a drop off in the bone indicating that might've been the talus. I didn't see any cartilage and it's, it's nice and smooth. And here's where that drop off is. So as I start to drop off is the lip of the tibia where the capsule, the capsular portion is that you saw in the diagram. And then I'm just gonna fall off just a little bit more distal. And then here we are on the cartilage of the tailless. So that tells me where I'm at. I'm just gonna rotate the transducer to a longitudinal plane. There we go. And here's that same bony landmark. So you can see lots of cortical detail with ultrasound. You will even catch some fractures, which is pretty neat. But following that cortex distally, distally distally until that bone drops off and then we isolate another bone. Now this bone has cartilage. That's another reason I think it's probably the Alis. It has the tailored dome and then that neck of the Alis, which indicates that we've left the articular space where the cartilage is. So anywhere there's cartilage, you're accessing the joint. So that's kind of a nice shortcut. Any any injection in the ankle. Actually right around here on the, on the tail is if you find cartilage anywhere, even as far laterally as where we get into the ligament scanning here in a minute, that is access to the joint. So if you, if you find this approach to be a tough stick, depending on your trajectory, your needle, the vessels that you don't want to hit this large amount of fat here. If they have a lot of bone spurring down here at the distal TAUs and you just don't wanna run a needle through that much distance, you can actually just pan over laterally where this gutter gets a lot shorter and you could drop your needle on top of the cartilage here. Just be careful not to scrape the cartilage. So we pan medially to lateral. We're looking for joint effusions, we're looking for erosions, we're looking for osteophytes, we're looking for cartilage damage. Loose bodies we can extend by dorsa, flexing the foot a little bit and see the articulation of the ankle. If you're on a particularly thick ankle and it's kind of hard to image, don't forget to drop the frequency on these transducers. The density of the tissue can sometimes be challenging. So I'm just gonna drop this particular machine into gin mode and you're gonna see probably the, the deeper part of this ankle joint down here will light up really nice. So I'm just gonna drop it down to gin there. So if you're on a particularly difficult or thick large ankle dropping the frequency can kind of help there. Even though it's not a deep, deep structure, if there's not a lot of acoustically enhancing tissues above the, the area of interest, it can be very hard to image. And what do I mean by acoustically enhancing? This is kind of why you join a live webinar to learn these tricks on a lot of ankles, especially ankles, not like our athletic ankle we have here today are model is a runner who has a very long lengthened extensor lysis longest, which we'll get to, but that muscle belly here is relatively fluid filled, right? So this EHL that we'll get to in a minute is acoustically enhancing what's under it like a big, like a bladder or something. So it's making my image look really, really nice. But if you don't get that, if you have an atrophied ankle and you and not so muscular dropping your frequency will definitely enhance the tissues underneath. So just don't forget that when it comes to optimizing for your image, you will lose a little bit of detail. Like right now I just went back to res mode and we're catching some more fine details on the capsule for example. But from a anatomy and trajectory standpoint for an injection, people typically come in from this direction here and they'll drop the needle right on top of the cartilage and start shooting. So that really does it for just a anterior joint recess shot. And I'm, I'm gonna go ahead and switch back over to presentation. - Gimme one second. All right, so now we're gonna - Move to the anterior ankle ligaments. So we're not gonna move the transducer very far, but a new palpation landmark instead of the tibia, I want everybody to focus on the fibula and that outside bone on the ankle, it is a non-weightbearing bone. The fibula just a little FYI. So if you do see fractures and things like that, it may not inhibit weightbearing activity, but we're gonna bridge this gap between the tibia first and then we're gonna come down here to the tailless. But this is our common pivot point. We can see that the anterior inferior talo fibular ligament originates here at the fib and works its way to the tibia. There's some anatomical variants here where you can have a group of three ligaments here and you could even have an accessory ligament on the bottom that we're not gonna talk about today. As we pivot the transducer, you want to plant that lateral side of the probe and then just rotate the rest of the transducer until you pass the cartilage. And once you go past the cartilage, you'll see a little tubercle pop up on the tailless and that's the anterior talo fibular ligament that that should come into view. If you don't see it, come into view right away, pan the transducer distally back and forth without rotating, spinning or tilting until you see this kind of bow string, which will show up on the next slide. Come in, come into effect. Origin is one centimeter proximal to the lateral malar tip. So here's that lateral malar tip and we're gonna come about a a centimeter up if you don't, if you're not seeing those fibers, maybe you're not distal and up. All right, so let's colorize the first ligament, the AI TFL. We've got the fibula, the tibia, and here's the A IT ffl. So just very simple, there's no long axis, short axis scanning of here typically unless we suspect some pathology. But just to identify the syndesmotic ligament, the space underneath it being the syndesmosis, the space between the fibula and the tibia. And you can dorsiflex the foot and see if this thing opens up or even dorsiflex with a little bit of force and try to get the tailless to push up into this space. And we'll do that in the live scan. Next, moving down, you saw the pivot and I'm just gonna toggle the slide back and forth so you can see that pivot here. We've got position one and then we're gonna plant the lateral side of the probe for position two. And we're just swinging like a windshield wiper the rest of the transducer down until we see the tailless. We should see this knife bony prominence here. So here's that ligament, you can see all the fibers really nicely. Here's the fibula. And you notice how most tendon and ligament insertions and origins all have this common tuberosity looking feature, kind of like a rotator cuff or a tibial tuberosity in the knee, which we covered last time. You can see that that tuberosity in profile, that's very, very common. You shouldn't give up on scanning these ligaments until you see these inflection points on the bone where the insertions and ordinances are. Otherwise you can't really be confident. Also notice the lack of cartilage that's underneath this ligament. There is a joint space here. This is, this is the articular space under the ligament. It is joint fluid under here, but I don't see that big tailored dome of cartilage. So if you see that tailored dome of cartilage, you're just not quite on that tubercle that begins the neck right here, the neck of the tails. So here's the rest of the body of the tails here, right as the neck forms, we get this, this high writing tubercle and that's where you should find the thesis point of this A TFL ligament. So like you saw me jump ahead, we're gonna move to the live scan mix and see how this looks on our model here. Bear with me while - I switch over to the live demo. Alright. All right, so back - Here at the ankle and like I mentioned before, our common palpation point is gonna be the the fibula. I'm gonna move our ankle into frame, maybe rotate our knee just a little bit, make this a little bit easier to see exactly what I'm doing with my hand. This is definitely one of those structures that I scan while hanging a finger down by far one of the most useful scanning tips you can have. And I'm gonna hang my finger down right here underneath the transducer and I'm gonna place it on the backside of the malleolus. And the reason I'm doing it on the backside of the malleolus is while my finger falls on the backside of the lateral malleolus, the rest of the transducer will fall on the top of the malls. And then I have my thumb here to pivot like a windshield wiper and I get to pick my ligament at that point. We're gonna start at the A-I-T-F-L on on the top side pivoting here. So I'm looking for my first bony landmark. I'm not gonna make it too easy. So bony landmark first and then I'm gonna lay down the rest of the transducer here across until I see the tibia and to make sure it is the tibia, I'm just gonna climb up even further until I fall off there We are kind of on a nice oblique plane. Very easy to see, easy ligament to scan. This is a great ligament to learn the nature of ligaments and angle artifact and that the ligament fibers are very tightly compact and the more tightly compact fibers are in musculoskeletal ultrasound, the more susceptible to an isotropic artifact they are. So if a ligament is nice and level and you can see me leveling out this transducer with the surface of the fibers, we get really, really nice pretty fibers. Okay? So ligaments are very, very an isotropic. So watch even the slightest tilt, this ligament starts to turn darker and darker and darker and in most cases we identify ligaments based on a dark strap going from bone to bone. But this is one of those ligaments, kind of like in the wrist we have a scapholunate ligament and in this case it behaves very much similar. If we tilt the probe the right direction, we can almost enhance every one of those little fibers in there really showing the, the beautiful detail that we get with musculoskeletal ultrasound. There are some linear little koic spaces between, and don't confuse those for there in spaces and certain anatomical between some of these structures. So for example, this is the A-I-T-F-L body right here and I expect as I go distally a gap right here. And then there's an anatomical variant that can take place between the main body of the A-I-T-F-L and a BASSETT'S ligament, which lives just south of the main body of the A-I-T-F-L. So don't take all of these an coic gaps right here as pathology. Just know that there are anatomical variations of the A-I-T-F-L and there can be three sections to the A-I-T-F-L. Kinda like we see the spaces between the subscapularis fibers. We can see little spaces between some of these ligament layers, but I, I wouldn't get too excited about that little black gap right there. In fact, if I do go short axis on the ligament fibers, I would expect to see, yeah, I see these ligament layers laying on top of each other diagonally. And if you go check out your cadaver dissection atlases, you'll see much the same thing they lay on top of each other. Kinda like a, kinda like a fan would like fan blades and that's kinda what I was seeing in that long axis. So I just take the same pivot point, I've got my, my arrow on the fibula here and I'm gonna drop my thumb south until I fall off the tibia. Okay, no tibia there. So this is the space between the tibia and the and the alis. And then I'm gonna keep dropping and I see the cartilage of the alis. So the tailored dome getting into the mortis, you can see that squared off mortis of the facets of the alis. And I know I'm not quite to where the ligament's gonna attach because nothing attaches to cartilage. Okay? That helped me very early on when scanning ligaments is when you see the cartilage fiber surface like that. Keep going because we're not quite to anything where a ligament can attach. Nothing attaches to the lene cartilage. So we have to keep looking and all I did there was just fall a little bit further south on the fibula and I'm, I'm moving my thumb across this distal surface. So proximal left fibula, here's Alis with some cartilage and some joint space right there. Here's that little tubercle I was talking about on the Alis that that begins where the Taylor neck is and does delineate the articular space. So this is our models kind of small A TFL, it's very thin. Might be a good time to switch over to a 19 megahertz view of this exact same ligament just to get more, more, more detail. The 15 megahertz does a great job, but I think I am gonna just make that that change over to a 19 megahertz transducer and let's see what those differences are. But here I've got the L 19 five transducer, which is it, it really does its best work. Very shallow. You're not gonna use this transducer for the deeper stuff in the forearm or shoulder or anything like that, but I'm gonna bring my depth up more shallow and the machine will optimize for superficial structures much better. But yeah, there we go. Now we're seeing a really, really nice ligament starting on the fibula. Get my arrow back up here. So here's the, here's that nice A TFL here and then here's that little cle I was talking about on the tailless. So don't stop scanning until you see that little inflection point. Everybody's got one. So here's cartilage. So you could get a joint injection in here out a plane for example, drop your center line right down the, the center of the screen and that helps a lot of people right there. So I'd find the ligament and just drop either I think anterior is our best shot where we, we fall off the ligament into a fat pad and you could go out a plane into the joint that's pretty common. Keeps you away from the dorsals pitus artery as well. But that's, that's about as complex as the, the ligament scanning gets, keeping the, the fibers very level with the surface of the transducer palpating with a finger underneath the transducer while you scan so that you have a pivot point. Okay? And then the L 19 five handle is a traditional ultrasound handle. So it's very easy to go long to short axi scanning. I grew up on a hockey stick transducer and, and I, I really did not like how unergonomic it was, for example, when I was going long to short axi scanning. So a traditional pivot on a traditional handle of a transducer's been very nice with an L 19 five transducer. Getting into the higher frequencies and getting away from a hockey stick has been nice. So case anybody's wondering what it's like scanning with a, the small transducer in your hand, it's very easy to pivot. Long to short axis. I'm gonna get started on our next section. - Just bear with me right quick. I'm gonna go back to my slides. Okay, so now we're gonna move - To the more challenging anatomy on the anterior ankle and we're gonna break it down tendon by tendon. So the next subject or just the tendons, as you can see these guys are grayed out. That's where we're going with the next few slides. Four slides, anatomy and then we'll we'll cover the imaging between each one. But let's start from far medial to lateral and work our way across the tibia. First, ignore everything distal to the tibia until you're confident with what's happening at the tibia level and proximal. Okay, so we should see this. If we were to cut this in cross-section, we'd see a nice oval here and that's the tib anterior tendon. And just to show how far medial it goes, which we kinda lose it on this oblique shot of the ankle, we'll go to the medial lateral view and just see how it rides over that main joint space that we just got done. Imaging goes past the Alis all right past the navicular onto the qaa form, the medial most qaa form and even some fibers stretch on the undersurface and on the side surface to the first metatarsal. So right at the base of the metatarsal you'll see a little inflection point there, a tuberosity or tuber full. But we're gonna follow these fibers, the live scan with more detail, but just kind of pointing out the anatomy and, and where it goes. Here's that 10 minute bo string across the joint. It's very easy to see how that bo stringing would take place in the, in the long axis. We don't focus on a lot of long axis scanning when it comes to the anterior ankle tendons. I'll, I'll be honest myself, I, when I'm doing an ankle protocol, I typically start all these tendons at the tibia level in short axis and I pan the transducer proximal to distal back and forth and little one inch movements at a time. And I, and I just observe the diameters of these or circumference as I should say, of these tendons. And when I see one belly out where it should not, then I might focus on a long axis study. If I see volume loss or any of the surrounding tissues herniate or a tenino synovitis or just a free joint or a, or a tendon effusion into the tendon sheath, then I might focus on a long access study. But for the most part we can just go proximal to distal scanning back and forth, up and down the tibial anterior tendon all the way until it meets its termination point, which we'll do on the life scan. And I'm not gonna focus on that on the slides here, but I will say this about scanning the ankle in general, the entire ankle front back media lateral is it if you stay at the tibia or malleolar level and proximal all the tendons are running the same direction. Everything runs nice and parallel until you hit the level of the malleolar, then that's where everything kind of goes haywire and runs all kinds of different directions. So your common lighthouse view for all of the ankle, no matter where you are, is gonna be in the mallor level, cross-sectionally and proximal and then work your way distal and and chase these ovals wherever they may go. And, and don't let them go off your screen side to side. That's good scanning that, we'll cover that in the last. Next is the extensor house's long as tendon, which is just neighboring in fact at the tibial level that that larger oval tendon that we saw borders, the, the extensor how's longest tendon and then we see this large muscle belly more laterally. We don't see a lot of the muscle belly between these two or even near these two tendons. So if we're at the tibia and we're taking that slice working our way laterally, we'll see a muscle belly after these two tendons neighbor up to each other. To get it to move you can just move the big toe. So as I put in the slide here, wiggle of the big toe, here's the extensor hallis long tendon right here. Number two in reference to where we were on the, the first one, the the tibials anterior. So here's tibial anterior, we're not gonna cover the retina inoculum in a lot of depths today, but this would be that, that superficial most extensor ulu here, lemme go back one, sorry about that. And then here's your extensor house's long as tendon. And my biggest tip for that is just to wiggle the big toe and we'll do that in a live scan. Go long axis if you feel like it's necessary. But here it is in long axis, it's a much thinner tendon, harder target to hit. And then you'll notice it sits just on top of this arterial structure as a, as another common landmark white house to the anterior ankle, the dorsal pettus or the the tibial artery which changes names just just about here to the do. But we'll cover that last, the neurovascular structures will be last, but this, this is our tendon wiggle the big toe and just know that this muscle mass right next door, this is all encompassing the extensor how as long as, and this is the muscle belly for extensor extensor, how as long? Alright, moving more lateral now the next neighbor over is extensor digitorum longus divides into four slips and covers the second through fifth digital phalanges. So we're, we're not looking at that first one. The extensor hollis helped us there. We wiggled the big toes. So now we're gonna wiggle these other toes. Just grab the distal phalanx of each toe individually and identify the individual slips. It's really, really cool to do. And then just know not a part of the protocol, but there is a large muscle mass underneath this. The only muscle mass in the dorsal foot is the extensor digitorum revis it, it originates at the anterior calcaneus and then it will extend right underneath each of these tendon slips merge and marry up with them for each of the phalanx that we just covered. But the extensor digitorum brevis only covers really phalanx four, three and two. And there's a contributing extensor digitorum hallis which is not labeled here writing over to the extensor digitorum, or sorry the extensor paralysis long they, they pair up to the distal phx here. So not covered there, but there are a large muscular bodies on top of the dorsal foot that may look like swelling or teno synovitis because of their relationship to these extensor digitorum slips. Just know that those are not 10 synovial swelling. Throw some color doppler on there if you're ever questioning that. But there is a large muscle belly on the dorsal foot. It's the extensor digitorum brevis. It's not a part of the protocol but it is important to know it's there in case you suspect some sort of swelling of a tendon sheath or something like that. Here's the scan of the tendon of the extensor digitor longest before it divides into its slips. As it gets into its slips and long axis you can, you can identify each slip and then that belly always talking about of the extensor digitorum brevis. And then you can see some of the, the landmarks here, not labeled here, the Ali. So Alis korm and metatarsal extensor digitorum brevis muscle and long axis. And then here's that din thin, thin, really thin extensor digitorum tendon. It's very important to have high frequency ultrasound for, for the evaluation of each of these tendons. Lastly for the tendon groups that we're gonna talk about today is the pro ter tendon, which is an anatomical variably there or not tendon. So it's a variant, not everybody has it, but it an originates on the anterior fibula, the distal probably past the one third mark of the anterior fibula. Then it has a short muscle belly before it dives through the superior extensor reticulum. And then it's just a tenus portion that looks a lot like the extensor digitorum but it's the lateral most extensor digitorum. So if you're tracing with your transducer this small oval, you're just gonna, you're gonna pan that transducer distally, distally, distally. And it sometimes helps. And I'll do this on the live scan to have your finger or thumb resting on the base of the fifth metatarsal as a eye hand coordination trick to draw your ultrasound transducer towards your thumb and keeping you here and away from the extensor digitorum. So to identify these two just literally cross-sectionally, scan this tendon over to the base of the metatarsal. Here it is taking its own path right over the extensor digitorum brevis that we talked about. Here's those tendon slips of the extensor digitorum back up. So that stent and thin layer, you can see 1, 2, 3, 4 slips here. And then here's that kind of rogue guy moving laterally. It looks a lot like an extensor digitorum. It's number four here, actually mislabeled number three, sorry about that, is our proteus Hershey tendon. And so we'll cross-sectionally chase that down to the base of the fifth. I don't see a lot of pathology there, but if you do have base of the fifth pathology say on our lateral ankle exam with Proteus brevis, we may wanna also evaluate the attachment of Proteus her. Now let's move to the live demo of the ankle, the anterior ankle tendons. - Just one moment while I switch over. All right, here we go - Back at it here on the anterior ankle, like I mentioned, I'm gonna, I'm gonna keep most of my exam relatively around the tibial. That's our roadmap, that's what's gonna keep us kind of centered. And I'll work my way from medial to lateral like I did in the PowerPoint. Left side of the screen is gonna be lateral and I'm gonna start right here on the anterior most structure on the tibia. And if I go even further over, you see a little superficial vein and I can see this hypoechoic wedge swinging around this extensor or the anterior tibialis or tibs anterior tendon right here. See that little dark area right there? It's a good landmark. That's our extensor reticulum right there. Just swinging right around, kinda like a rotator cuff interval where we get to see that nice sling of ligament structure going around the tendon. So that kinda gives you an idea of where you are in this whole complex. So here we have tibial the anterior, I'm gonna go distally distally distally. And like I mentioned, it's gonna, it's gonna dive, turn my arrow around, - It's gonna dive its way down to the medial qaa form, distal to - The navicular right there. I'm gonna do a quick survey with the larger linear L 15 transducer and then I'm gonna switch over to the L 19. So tibial the anterior, you can see the extensor reticulum wrapping around it there. And now let's go more lateral. So next, next door here we have the extensor, how ISIS longest this little guy right here in the corner, that's the tendon and the rest is the muscle belly right here. So dorsal pitus, which we've talked about a couple times, but this little corner, these two tendons border each other. And just to kind of check your work, I just want you to reach down and, and maybe put a hand under the foot and a finger on top of the toe. And that helps you give extension and flexion to the tendon of the EHL as you chase it all the way down to the tarsal level. And just keep following it. Like I said, it gets much easier to see even though this is a very high resolution transducer, it's a great image. In fact if I zoom on this, it's very impressive in itself. The the level of zoom quality we get on the sono side px. So here's the, just to check my work, let's follow it right back up top. There we go. And just moving the muscle belly, wiggling the toe, wiggling the toe, wiggling the toe. Like I said, I do one inch little segments at a time. Really check my work as I go. Check out these extensor like we're on the inferior extensor reticulum right now, which we'll cover just briefly later on. But as a landmark, we're, we're looking right here for any disconnection. Discontinuity and, and to see this extensor house as long as falling off either side or coming disengaged from that ulu. So those are things that we're looking for. Still still wiggling that toe. Wiggling the toe. I'm gonna move my arrow - Just for the sake of following it. Wiggle the toe all the way down here. Kind of bow strings over the MTP joint. Here's the cartilage of the MTP - Joint looking really nice healthy runner for our model today. Don't expect any crazy pathology. And then we'll just follow that on back up and just keep tracing it up. Check your work. Just know that this is not Tina synovitis, it's a muscle belly on lower resolution machines. It may average together and it looks very dark. Let's go on up and I can see the neighbor already kind of invading the space over here. I'm gonna unzoom, I'm gonna hit 2D. There we go. Get my arrow back up here. Here's where we were. So here, let's just go back in order tibial anterior extensor haliss longus. And then the next neighbor right here, we can see the slips already starting to form of the Accenture digitorum. We're gonna follow those distally, distally, distally. And then we should see them flatten out. They're so here, let's, let's look at our bones. Okay, so our roadmap, we're at the, we're at the tibia level here. It's, it's just this oval. You can kind of see two slips there. It's not quite the four that we will see. And now we're over the Alis. I can see the Taylor neck and cartilage right there. And, and if you lose these tendons you can use an isotropic artifact to your advantage. Okay? So let's follow, keep following, keep following if you, and also if you lose 'em, just come on down and smash the toes. Try to extend them. I wouldn't recommend smashing 'em, especially if your patient came in with pain. But now you can see it really separate out into four slips. And I'll hit zoom again and we can catch that just a little bit better. There we go. There's those four individualized slips. We have 1, 2, 3, and four and we'll just keep following those until they, they go out into their individual sub-segments and that's where you could choose to pick a slip like I'm over here on, on the second digit now, okay, I'm just gonna go long axis now and let's, let's pick that one guy out. So we're long axis second digit. So if you had to chase down individual 10 tendinosis for example, very prominent here, that's how you would do it. Just chase down each one of those but we'll, we'll, we'll climb on up and now we'll go just a little bit lateral and within the body of the extensor vernacular here and get into that perus tertius which originates on the anterior, on the anterior fibula. - And let's see if we can chase it down here today. If we can't, I'm not all that worried about it 'cause I don't really evaluate it very often, but it is there. - Okay, so I've zoomed out looking for that muscle that that kind of invades the lateral aspect of our extensor digitorum complex. And like I said earlier, I'm, I'm basically gonna fall down this way towards the base of the fifth and that's where the 19 megahertz gonna come in. So other structure not quite covered in the PowerPoint form, but I did point it out is all of this muscle belly down here is not belonging to the, to the extensor digitor properly, right as we go distally, this is that, this is that extensor - Digitorum, hang on, extensor digitorum brevis and I've, I've gone, I've, I'm I'm, I'm having a little bit of a blank here, checking my slides here. Yeah, extensor digitorum brevis. - All right, so just know that that's there so you're not contributing the swelling that's occurring somewhere to these tendons. These aren't the muscle bellies for example of the extensor digitorum longest tendons. These are the, the muscle bellies of the extensor digitorum brevis. And they do come down and marry up with each of these extensor digitorum tendons. They do, they do conjoin down here distally and contribute to these slits at theis. I think the extensor digitorum brevis is a, a medial attachment to the distal phx. And the extensor digitorum longest are the lateral attachments once you get down here distally. Just so if you ever want to know, even though the foot's not exactly what we're here for today, that's how you would find that. Alright, so last part, - Let's switch back over for the neurovascular structures and then we'll we'll get into some Q and a. Alright, lastly, for the formal ankle exam required by A IUM, - We're gonna follow the neurovascular structures of the inter tibial artery and the deep perineal nerve as it turns into the dorsal pitus artery distal to the tibia. And we're just gonna follow these two in parallel. It's the structure where my mouse is right here. You'll notice there's a lot of other veins and arteries in the area. There's a lot going on. Don't go chasing these little rabbit holes of all these little branches until you identify the deep cranial nerve, bordering the dorsal pitus artery lateral to the artery, kind of inferior lateral. When we see it in cross-section, it's, it's usually around five o'clock and and cross-section, assuming the right side of the screen is lateral. So I like to take a slice here at the tibia and just keep following the neurovascular complex here and just know and remember that these arteries are your roadmap anytime you scan nerves, except for the superficial perennial nerve, which we're not gonna cover today unless you wanna go go over q and a. Does not border an artery like a roadmap like we usually do it out pouches, the superficial retina macular up, up top that superior reac and then it just is extremely superficial with all its little branches. So we don't have that, that motor branch style deep arterial roadmap like we, like we would on a line of other nerves that we follow. It divides just above the ankle joint, the medial most branch is the one that we're seeing here. And then the, the lateral is is MA mainland motor. Okay, so you're gonna follow this division here it is, don't forget about color power doppler or color doppler directionally doesn't matter either way, but here's George Pettus artery and then here's the nerve that we're gonna be following today. So that's your deep perineal nerve. It's gonna be right underneath the muscle belly of the extensor lysis longus. So here's your EHL, here's the muscle belly of the tib anterior, so we're pretty proximal to see that much muscle belly. And then here's EHL and extensor digitorum more laterally. So EHL, muscle belly, dorsal pettus. In this case we're at four o'clock of the artery, we're gonna see the deep cranial nerve there. So we'll go ahead and get to the live scan again. - Let me switch over to the live studio. Alright, so - This is definitely part of the structures. I will start with a wide shot or a wide angle here. Larger transducer, get back up to the tibia where we're, we're very much at home. And then let's take a look at that. What we're really here for the deep perineal nerve, unless you're just doing joint injections, here's the artery, here's what to avoid. We're gonna hit the C button on the machine that stands for color. Very nice. We can also switch it to color powered doppler, which takes away direction and that makes it just a touch more sensitive because the processing power of the machine is not having to assign direction or velocity. So I, I typically live in the world of color powered doppler, which which is more sensitive especially for inflammation. But if you're moving the transducer a lot like this, it causes a lot of flash artifact when you're using color. And what we've done on the sono site PX and on the sono site LX is added a color compare feature. So I'm gonna use the top bottom and trace that out and I can use my arrow and I can be following this anatomy on the bottom without all the flash artifact and just to check my work, I'll look up and make sure I'm still following the artery and just keep going so that that will encompass the whole width of the transducer. I know that looks really small on your screen, so what I'll end up doing is just switching that back and doing a left right option there. So we can run these simultaneously, which is very useful for procedures if you're gonna run a needle near an artery and you're gonna do little nerve blocks or diagnostic nerve blocks. This is very helpful. So this is called the color compare tool. If you're reaching for it on your current cyte px and you haven't used it, it's under the color menu and, and you should see the color compare on the bottom left of your customizable touch screen. So following dorsals pitus, again, I'm gonna hit 2D, get out of all the color and let's, let's take a more zoomed in look because I can see, I can see the deep perineal nerve starting here screen right lateral to the artery, there's my arrow, so it's sitting here. I can compress and see the artery kind of chirping. That's the nerve right there. And as I go distally, watch, watch the nerve climb over the artery, which is pretty neat to see that in such high resolution. So here it is there, it started to really branch out into a bunch of crazy divisions, which we won't get into today, but this is the, this is the structure that we're gonna focus on. So check this out, Sal's pitus artery and you can see the little bitty tiny nerve fales jumping up and over when we go distal. So when we go distal, they climb up and over and you can see all those little faciles. Let's switch to the 19 megaherz transducer and really take a look at this - Again, we have the L 19 pull a little bit more transducer - Cable. All right, so it defaults to a, a deeper depth for perspective. So it's not like we're sticking our nose on the glass of the screen. I'm gonna, I'm gonna bring our depth up more shallow to optimize the image just a bit. There we go. Now I can really see if you're doing hydro dissection procedures for example, this is very nice to have this level of detail. So just as, just keep in mind as we go distal, you'll see that the perineal nerve climbs up and over the dorsal pettus. We're at this point the anterior tibial artery. Now we're at the level of the alis, we can see the cartilage of the tailored dome start to form right here. So we're just keeping on following to the extent we need to these branches. If you're doing a joint injection at, at this point for a lot of people it's, it's time to stop scanning and go ahead and mark your spot for an injection. So for a joint injection, I think that's usually about it. You're gonna be following and making sure that you're not gonna hit either of these branches. Here's our lateral branch and you can just pick a branch and follow it at 19 megahertz. You can kind of follow nerves until you get a headache. But really superior ultrasound resolution here allows us to do really, really super awesome things with ultrasound. So following nerves like we've never been able to follow 'em before is just one example of why you might wanna reach for a high frequency transducer. Here I am all the way down into the digital and interdigital bifurcation right there. The superficial part of this right here is, is one nerve branch coming off of that same group and now watch it bifurcate into two. But here, here we have one headed towards this metatarsal, whichever one it is, it looks like I'm in the first web space, which makes sense and that's exactly where it goes. So we followed the right branches and ended up in the first web space like I would expect. So here you can see that bifurcation we're looking for neuromas in this case distally. We're looking for all kinds of stuff but primarily I'm looking for changes in the diameter of the nerve or circum their circumference. Let's go back to real quick the tendon detail that we get with 19 megahertz. So I'm under the M MSS K exam type, no special settings, just the MSS K exam type. And you can see the retina macular better. I can see the tendon right here, the extensor or sorry, the tibs anterior. And then here's that extensor lysis and here's all of this is muscle belly of the extensor lysis right here, but that's, I'm just gonna wiggle the big toe. Then you can really see the interface very nicely right there. I gonna lower my arrow and you can see the musculo tendonous junction do the wiggling. I can go long axis and confirm that tendon is doing the moving, which is even way cooler with ultrasound than doing it under any other physical exam you could ever do. You can isolate entrapments, you can isolate tendinosis, you can isolate is it a nerve issue? So take your physical exam that you're already doing, apply ultrasound underneath your palpation basically and see what else is under there. See these nerves like you've never seen before. See these joints and these ligaments and these little spaces - Like you've never seen before. These little ligaments between the canfor. Alright, so at, at this point - Let's take a look at who's on Chris, if you don't mind helping me with any q and a. You guys can type in questions in the in the chat portal and, and we're prepared to take these questions live. We can scan while we answer questions together. If you have a question you can just type it in. Chris should be able to read it out. We don't do the questions over live audio, just make sure a better recording experience. Sorry about that, that we don't have that dialogue back and forth. But if you had any questions of what we captured today, feel free to type those in the chat portal. Next we'll be covering the posterior ankle and then we have the medial and lateral ankle also coming up, which I think is a bit more exciting because the ligaments are, are more difficult to image and we're gonna be going over tips and tricks and scanning pearls on how to do that and what dynamic maneuvers can bring out the ligaments and make them look better. But yeah, I'll just, I'll just kind of hang tight and we'll we'll wait on some questions to come in. If not, be sure to catch and share the recording as it comes through. - Yeah, as Daniel said, go ahead and put your questions in the q and a box. It should be either done below or to the right side of your screen. And as Daniel said, this is the first part in a four part series. The next one is Tuesday, September 13th and that one is save time and cost by using ultrasound to evaluate the posterior ankle. And you can go ahead and sign up for that at our webinarsPage@securesonosite.com slash behind the scan webinar. I don't see any questions coming through quite yet. We'll give you just a little bit more time just to make sure nobody has any burning questions in their minds. - Yeah, I mean the anterior ankle I would say is probably one of the lesser exciting, you know, ankle topics but it's gotta be covered, you know, and used to be for me these all following all these little anterior tendons to their various locations was kind of a headache and I kind of avoided it and I would normally just kind of scan with a reference and that's what I recommend anybody does if they're not familiar with each of these and where they go and the variance associated with them. So you're just doing simple joint injections. It it, it's very helpful to know what else is in the area. You know we didn't even get into the superficial perineal nerve but there it is superficially I can throw the arrow on there and it's just not part of the, the scanning protocol for the anterior ankle, but here it is. If you wanna learn how to avoid that with ultrasound, bring our depth up more shallow and we can follow each of these divisions of the superficial perineal nerve, which is just crazy to me that we have the ability with ultrasound. Here's those tenus slips that I talked about, the extensor digitorum. So here's one slip, two slip, three slip, four slip. Actually this is slip one going to digit number 2, 3 4 - And then here's the fifth right here. - And if this is the fifth, there's one more lateral that looks a lot like them and that's gonna be our perus ter that we talked about. Super cool though, just watching that little superficial perineal nerve jumping over all its little areas that it can get entrapped or smashed or just have paraesthesia in general. Look at that following it up. It's just the power of ultrasound. You know, your physical exam can do only so much before applying imaging can, can really enhance that and confirm or expand on what you might have already suspected. Look at that superficial per nerve. Look - At for here we go, we'll just - Keep following these branches. See how it lays out flat like a ribbon. Reminds me a lot of the lateral femoral cutaneous nerve, what it looked like in the hip when we did the diagnostic series on the hip, we did lateral cutaneous nerve scanning up there by the Sartorius and the TFL and that's a lot like what the nerve did. It flattened out like a ribbon or a ribbon cable in a computer and it just sits between these tissue planes right there. Here it bifurcates again. And then again, so here we have, we have 1, 2, 3 branches there and here's the inferior extensor reticulum here that is just laying on top of superficially. It's just super neat what you can do with ultrasound. So I see that we still have some people on and if, if there are any questions feel free to go ahead and interrupt me. Otherwise I can just sit here and scan and talk all day if you're gonna be out and about at trade shows. Our next one is aa, pmm and R in October and I'll be in the booth doing live demonstrations on the Soto site. Lx the big brother to the px. So if you like the imaging you've seen here, come check it out in person, come visit us in the booth, see what's new, interact with us, we'd love to visit with you and catch up with you. There's been a lot go on over the pandemic, so haven't seen a lot of people in a couple years and we're looking forward to seeing you again. - Absolutely. As Daniel said, come check us out at those, at those those workshops. And in the interest of giving, getting everybody out on time, it looks like there's no questions at the moment. So I'd like to thank Daniel for taking the time to put together this extremely detailed and excellent presentation for this webinar. We really appreciate you sharing your expertise with our audience and I'd like to thank everybody for joining us today and like I said, our next one is on Tuesday, September 13th for save time and cost using ultrasound to evaluate the posterior ankle. So thank everybody for joining us today and we'll see you at the next one. - Thanks Chris. , plain_text