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Transcript

- Hello and welcome to the sauna site

behind the scan webinar.

Today's webinar will be the examination

of the posterior ankle using point of care ultrasound.

This is the second of a four part series

that we're currently doing on ankle ultrasound

and we'd love it if you could join us for both a third

and fourth part of the series of of these ankle webinars.

The next one will be Tuesday, September 27th

and that will cover the medial ankle.

And then lastly, we'll wrap up the series on October 11th

with the ultrasound evaluation of the lateral ankle.

So with all of that outta the way, let's get started

with today's presentation.

My name is Jody Miller

and I'll be your moderator for today's webinar.

Before we begin, please be advised

that all attendees are muted

and you may type your questions into the q

and a box in the toolbar

that is located at either the bottom

or the side of your screen.

We will conduct a q

and a session at the end of the presentation

and at the end of the live demonstration,

just please also be advised

that this webinar is being recorded

and will be archived

for future reference on our webinars page.

So to get us started, I'd like

to introduce our speaker for today.

Our speaker is 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 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, GR has a lot of great info

to share with you today.

So I'll hand it over to Daniel

and Daniel will take it away from here.

Thanks very much. Thank

- You Jody, for that introduction

and welcome everybody to the ultrasound

of the posterior ankle.

So again, I'll go over these indications from the A IUM,

which is where we're keeping our protocol based, not just

for the anterior ankle, which we just did,

but now the posterior medial and lateral.

But typically an ankle ultrasound.

We're looking for focal abnormalities such

as plantar fasciitis, plantar fibromatosis, morton's neuroma

or Morton neuroma, sorry, ganglion cysts, teno synovial,

giant cell tumors, ligament

and tendon ruptures, 10 tendinosis, teno synovitis,

joint effusion, and nerve pathology.

So those are the indications that we typically look

for by the A IUM.

As you can see, last webinar we covered the anterior

and these grayed out structures are

what were in the A IUM protocol

and we went ahead and covered those.

Today we're gonna cover the posterior ankle

and these structures, which is pretty simplified list

when compared to last time.

And then you'll really want to catch the medial

and lateral ankle

because I will say as, as fun as it is

to look in achilles tendon

or a plantar fascia, I find that most

of the really exciting ankle pathology comes in the the

deltoid ligament complex, which is really fun

and difficult to view.

If you haven't had anybody show you any

scanning tips or tricks.

And these other flexor tendons are also a big deal

and the tibial nerve is a big deal.

And then laterally, not just the Perus brevis

and longest tendons, but how to scan them to the arm

to their distal enthesis is is often not taught.

And we're, we're gonna be checking out some

of these other ligaments such

as the calcaneal F fibular ligament.

But today we're gonna cover the achilles tendon,

the plantars tendon.

There's a little asterisk there

because it is anatomically variable

retrocalcaneal bursa, the retro achilles bursa

and then the plantar fascia.

We'll go ahead and get started. Here's some reference points

for you to go back and check out the bones.

You're familiar with the lateral view

that we had at the last webinar.

Here's the posterior aspect of this, the ankle joint.

And here we've got the posterior tibia,

fibula, ALIS, and calcaneus.

So not a lot has changed in terms of the joints

that we're gonna be looking for,

but we're primarily gonna be focused on the calcaneal

insertion for this portion.

The achilles tendon, its origin is the medial

and lateral head of the gastro anus and soleus muscles.

They converge down to become the achilles tendon.

The insertion is on the posterior calcaneal tubercle.

The function is planter flexion of the foot

and it's the largest and strongest tendon of the body.

It is also the most ruptured tendon.

It does not have a tendon sheath, but it does have a peron.

So keep that in mind.

So we're looking at this insertion right here across the

calcaneal tubercle primarily.

And here's the CT slice.

So we've taken a 3D CT

and also the mid sagittal section just to give you an idea

of what's going on soft tissue wise under this achilles.

So here we have calcaneal tubercle in blue,

and then we have the Achilles tendon number four up here,

kind of out of the shot is the soleus muscle.

It's just this little tip of gray that you see here.

But you can see how high up that CAGR fat complex can go.

Number five is a flexor hallis long as muscle.

And in the live demo you'll see a really cool way

to visualize that by wiggling the big toe

zero down to the insertion.

There's a couple more things to look at.

So on top of the actual thesis

of the achilles tendon here at the calcaneal tubercle,

we've got the retro achilles bursa

and the retrocalcaneal bursa to look for.

I will usually see a retrocalcaneal bursal interface on most

people, especially now that the sono cyte PX

and the Sono cyte LX have a 19 megahertz transducer.

It's very easy to see a normal retrocalcaneal bura,

but I will say a retro Achilles bura I typically don't see

unless pathology is there.

So I'll see the, the bursal interface

of number one here Retrocalcaneal,

but I won't always see a retro achilles bura.

So just keep that in mind. If you do see a retrocalcaneal

bura look for the normal pathology,

things like thickening debris, solid viscous

fluid inside, things like that.

But just to see an interface

with some fluid in it is pretty normal.

So here's a breakdown of where the transducer would be

just right over the Achilles.

I would say what you're noticing at the top

of the screen here is a lot of gel.

So we will use a gel heap when we go to the live scan

and then the, the breakdown of anatomy,

you can see the beam goes

through the achilles tendon extremely

superficially right under the skin.

And then it inserts to the calcaneal tubercle,

which is this asterisk here.

And then don't forget about the deeper structures like the

joint while not mentioned in the A IUM protocols.

We, we should still go over the anatomy.

So here's an MRI, correlation midsagittal view,

and you can see the the tendon here.

This this dark area representing an area

of no moisture on an MRI.

So that's why tendons are black, inserting

to the calcaneal tube when you can see the cortex.

If you're not familiar with reading MRIs, the cortex,

here's this black line and there's

no moisture in that either.

So we see varying shades of gray depending on

how much moisture's in the tissue.

And then deep to that is CAGR fat pad, this very bright and

and fat's very oil dense.

So it responds very well on MRI

because there's a lot of moisture.

It's closer to fluid than something like bone

marrow for example.

And then deep to that is a flexor haliss

longest muscle that we talked about.

Just wiggle the big toe if you wanna see that.

Not imaged here, Seuss is out of view,

but it just goes to show just how proximal

that fat pad really does go.

Then we have the posterior tibia, Ali and calcaneus.

And then, so this is a proper articulation

of a posterior subtalar joint,

which we won't be covering today with a IUM protocol.

So we're just gonna stick to the achilles tendon here.

We don't see the retrocalcaneal bursa in the MRI

or a retro achilles bursa,

but those are the structures

that we're gonna be covering plantar tendon.

So if you scan an achilles tendon

and you not come across to plantar tendon,

don't get too frustrated because it's, it's very hard to see

unless something's wrong with the Achilles for example,

the swelling can offset the, the characteristics

that are imaged of a plantar make it look really nice.

If you rupture an achilles tendon

and you see one one cable hanging on by a thread medially,

it is the plantar tendon still able to maybe

mimic an intact portion of the achilles tendon.

So plantar tendon, we're gonna trace that proximally.

It does insert, pardon me,

that should say insert on the medial calcaneal tubercle

and it will be medial to the achilles tendon.

So it just follows that border

and it does kind of climb underneath it

as we go more proximally.

And it rests superficial to the soleus muscle.

So you can follow this little thin cord

down until you see it.

We're gonna, we're gonna watch that here.

So watch for the yellow arrow.

But here is our, our plantar tendon resting over

the soleus muscle

before it becomes up more superficially

medial lateral heads of the gastro care.

So got our arrow

and we're gonna be looking for this dense little cord

and you'll see it come up.

Here's the achilles tendon starting to form

as we go distally.

So this broadband of a structure, I'm just gonna pause it

'cause the video's making me dizzy.

Here we go. So this broad structure here is the Achilles

forming from the fibro musculo musculotendinous portion

of the, the two heads of the gastroc

and then climbing up superficially and medially.

You'll get the plantars tendon,

but it starts right over the soleus,

right here's this dense little cord.

Much easier to see in my opinion,

when you go more proximally than trying

to start at the calcan insertion.

Kinda like in a hip when you're scanning something like a

piriformis for example, it's easier

to view the more musculotendinous portion than it is the

distal tendon on the greater trca.

I find the plantars is easier

to find when you go more proximal.

All right, so with that we're going to get the studio ready

for a live demo of that Achilles and the plantar tendon.

Bear with me while we switch over.

Alright, so now we'll get ready for the live scan.

Today I've got the sauna site px.

Primarily we're gonna stick with the L 15

to four workhorse transducer for MSK,

but periodically we're gonna switch back

and forth to the L 19 five.

Super awesome high frequency transducer.

Small footprint gets into those tight spots,

usually like medial and lateral ankle.

It's gonna make a bigger difference.

But the detail that we're gonna need for some

of the smaller bursa that were described,

I think the L 19 does a wonderful job.

So we're gonna switch back and forth to that.

But for a general anatomy survey, the L 15

to four, you can't beat it.

And we'll go ahead and switch over to the cameras here.

There we go.

Actually, before we get started, since we,

I know we're gonna be scanning a plantar fascia,

something I recommend people do is go ahead

and put, I gel on the patient's heel,

especially if their heels are really bad

and cracked from wearing flip flops and and whatnot.

You know, your patients and how bad their heels get.

A big scanning pearl here is if you anticipate a plantar

fascia scan that you go ahead and moisturize the heel

because moisture is absolutely

essential for ultrasound.

Air is the enemy of ultrasound.

You see that in bowel, you see it in lung,

but on the skin level we can't see

through those dead skin cells that contain air.

So they immediately straight out of the chute,

degradate your ultrasound beam

and make it extremely weak working with a a lot less power.

So I go ahead and start moisturizing a heel

before I even get down there.

We're gonna go ahead and scan the achilles tendon,

but we're gonna let the moisture

of the gel sink into the heel.

So benefits of joining a webinar like this

or getting the scanning tips like that

that you might not get out of just looking at slides

or attending a meeting.

If you have any questions about this stuff in the

future, just let us know.

But that has been a huge lifesaver,

especially in older patient populations

where their heels are really big and crusty.

But we'll switch over to the life scan now, the achilles.

All right, so we have the L 15 four queued up, ready to go.

I wrap the cord around my wrist like this to take a lot

of weight off because of this kind

of bo string effect on the Achilles.

Either really need to flatten it out the foot

that is and and tighten it.

Most people hang the foot off the bed.

But for the camera today, I just did a bolster here,

but you need to add a lot of gel.

So when you're using a lot of gel,

just like any other small part like the wrist

or the the anterior ankle, as I've shown

before the elbow, I hang a finger down the side of the probe

to act like a stilt so I don't compress all the gel.

So you'll see my finger go down first on the calcaneal

tubercle and I'm just gonna lay the transducer flat.

Lemme hit unfreeze here.

There we are right across that calcaneal tubercle.

So that looks like it's coming across.

Okay, I'm gonna reduce a lot of my far field gain.

There we go. Actually,

I'm gonna just hit auto.

So auto gain does a good job gain up just a little bit

and let's start pointing out some structures.

So I'm gonna bring my, my arrow up.

Okay, got the arrow up now.

So here's the enthesis right here.

This is the insertional achilles.

And you can see this rounded part here

that's not insertional.

It starts right here at the the flat area.

So this rounded part doesn't have any insertion.

In fact, that is the interface.

We'll see that retrocalcaneal bursa right here.

We'll switch over to the L 19 to show that.

And then the retro achilles burs, I don't see so much,

but let's follow the body of the achilles tendon.

So here we've got achilles tendon go into the insertion,

maybe a couple little flecks

of bone spurs starting to show up right here.

See these little high level echoes, they're not shadowing

yet, so they're pretty early on

and maybe one day they'll grow into a spur.

But that is the typical spot where we look for a spur.

But since it's not shadowing,

it's not gonna show up on plane radiograph either.

But typically you can see the gross anatomy

and long axis just fine.

So what I'm doing is just climbing up

the body of the Achilles.

I am hanging a finger down the side

and it will ride the inside

of the achilles, kinda like a track.

It makes it a lot easier to scan.

So achilles tendon, let's just follow it up until it tapers

to a really, really thin and notice how nice

and parallel the fibers are.

So now I'm gonna go back to distal. Here we go.

And just notice how I don't see any outer belly shape

of the Achilles it.

It's not turning into like a snake

that's swallowed an egg or something.

These, these fibers are relatively parallel and healthy.

Okay, there we go.

So we might just see a little bit of bellying out here,

but we are ultrasounding an active runner, so I expect

to see some achilles swelling here and there.

So deep to that, we see this, this unorganized area,

this fat pad, this is CAGR fat and it is pretty deep.

It's a big triangular wedge

and it does track out approximately

and start to lower underneath the sous

and above the flexor lysis longest.

So I know this is the sous

because I can trace it back pretty easy,

but how do I know this is the FHL?

So I could, I could increase my depth

and shoot a little deeper.

I'd like to see the tibia back there. Here we go.

Really nice tibia on a lot of your patients,

they may be a lot larger.

So if you're not seeing the tibia, really nice switch over

to gen mode and I'm gonna hit gin just

by dropping my frequency

and it should really brighten the tissues in the far field.

Now what I'm gonna do is just wiggle the big toe

and isolate the FHL.

Here we go. So all I'm doing is just flexing and

and extending the big toe

and showing that that is the FHL riding all the way up until

that posterior tibial tailored joint

where it takes a sharp dive medially into the tarsal tunnel.

But you can catch fluid collections climbing all the way up

into this area too.

So very important to scan distally approximately looking

for space occupying masses like fluid collections or cysts.

But that's definitely about as far as you need to go.

Just pointing out the anatomy again, sous, FHL.

Let's go over our skeletal

references that we did on the lecture.

There was the posterior tibia, posterior TAUs,

and then the calcaneus.

That's where that joint is right there.

You see the air gap, that's why it's

so important to have all that gel.

So if your image is ever bad, the cure

and ultrasound is always to add gel.

Then we're gonna shoot through the gel like that

and then it should allow me to bridge that air gap

and allow me to evaluate this all the way down to

that little leafy joint capsule.

How nice is that, right? So I'm gonna increase my far field

gain by going to TGC

and just open that zone down at the bottom

of game so I can, I can see

that there's no ganglion cyst fluid collection, there's no

extra bony abnormalities in the area like os

trigonum, everything looks pretty good.

I'd go to short axis at this point.

And this is where I will say short axis

grabbing the smaller transducers typically necessary.

But come down here to the calcaneal tubercle,

you can see those little spurs

and cross-section now just like we expect little spurs here

and then we're gonna keep following using Antio

atropy to our advantage.

So what is Achilles and what's not Achilles?

You just tilt the transducer back forth.

Back forth, go distal

or sorry, proximal tilt the probe again.

Healthy tendon will turn dark,

disease tendon will stay bright.

So if half of this tendon stays bright

and is looking unorganized

and you don't see fibers, then you're,

you're probably dealing with some sort of tendinosis

or old degenerative change like a scar.

But, so let's follow this achilles.

As it turns into an oval,

it kicks off this muscle belly right here

and the muscle belly is, is spilling laterally a little bit

and that's a soleus and we can keep following the soleus

and then it turns into a full muscle belly.

Here's that underlying FHL, which I can isolate

with the big toe again.

So there I'm just getting that same muscle to move

and going approximately, approximately, approximately.

So as we, as we saw in the lecture, we're gonna be looking

for a plant terrace tendon.

And I look for those, I look for their borders medially.

I come down to the calcaneal tubercle

just for an obvious one.

And I don't see an obvious one here, maybe right there,

but I find it easier if you just follow this edge.

Here's the sous. So I expect to see

plantars drop in this zone at some point, right?

So we're just following this corner right here,

the medial corner of the Achilles.

And then here we see a septum start

to form right there on that belly.

So let's follow this septum right here.

And it should drop an oval tendon.

And this is where angle dependency really matters.

Stay medial. Here we go. There's the tendon right there.

See that little oval tendon?

Now let's go distally, distally distally

and just keep following that very,

very thin little tendon right there.

Again, there's nothing wrong with it,

so it's not popping out at us, but this is the plant terrace

and it rides on top of the soleus under the medial gastroc,

primarily stays pretty midline

and we could trace it all the way up way out of the camera,

but it will eventually fall on the lateral proximal condyle

of the femur just proximal

to the pop if you feel like chasing it up that way.

But that's pretty much it.

We're following Achilles short axis, long axis, couple

of dynamic maneuvers you can do.

And then for those bursa I did mention

that we could see very nicely on the L 19 transducer.

So let's switch over to the L 19.

So again, 19 to five megahertz.

We're gonna float a little bit of gel,

bring my depth up a little bit more shallow, wrap the cord

around my wrist, floating that gel.

Let's take a look and see if we can find

that bursal interface I was talking about.

There it is. Turn the gain up a little bit.

Depth down, grab my arrow right there.

Normal bursal interface of the retro calcaneal bursa.

It will ride on the rounded portion

of the calcaneal tubercle.

Actually, we're not quite to the tubercle yet

until we hit this flat inflection point.

Like any tuberosity,

just like we talked about on the anterior ankle, on

the A TFL insertion or the supraspinatus

or the lateral epicondyle, we see these flat ridges,

these tubercle or tuberosities

or epic condyles, those flat surfaces are

where everything inserts.

So see the round surface here, no insertion,

but we see a little bit of normal CAGR fat pad herniating

into this, this area here where the bursa is.

But I can use my finger over here and poke

and get that fat to move freely

and further show where the bursa begins

and ends if you felt the need to inject one of those

retro achilles.

Again, I never see those until there's something wrong.

So I don't expect

to see a retro achilles interface really.

But you could try a few dynamic maneuvers like rocking the

transducer forward

and backward on a lot

of structures in the body will will cause the subcutaneous

fat to roll over the area of interest.

And I just, again,

I'm not seeing anything impressive to look at here.

But those bone spurs look a lot bigger at 19

megahertz, that's for sure.

So 19 megahertz, a little easier to see, define,

see if it's shadowing, it's early on, it's not shadowing,

so we're not quite to that hard calcium that we'd expect

to show up on a radiograph.

But here it is in long axis, bone spur

and short axis, bone spur starts

to look a lot like little teeth coming off the

calcaneus like that.

So it could be a pain generator one day,

something to keep an eye out for.

But we'll switch over back to the lecture

and get going on our plantar fascia study.

Okay, so we'll get right to the plantar fascia slides.

There's just a couple of slides,

this should be fairly quick,

but per the A IUM protocol,

plantar fascia is still considered part of the ankle.

So we're gonna cover that. Now I have people start on the

calcaneus as a bony landmark in reference,

but there, this is primarily a very superficial structure.

It is enveloped by a very thick fat pad on the heel,

which I'm not showing in illustrations very much here.

But when we get to the live scan,

I'll show you some scanning tips on not only how

to prepare the site for ultrasounding dense tissue on the

heel and dry skin,

but dynamic maneuvers that you can do

to offset the soft tissue from the ligament of interest

or the fascia that we're looking at here.

And then machine settings that help us image

through a thick dense heel

and make a plantar fascia pop more better.

But calcaneal tubercle, looking at the planter aspect

of the foot landmarks, as you can see there's a lot

of structures underneath the plantar fascia.

Here's the proper plantar fascia in the middle

and that is the, the central corridor or the medial

or the, the middle cord.

But there are three portions

of the plantar fascia they extend from the calcaneal

tubercle to the transverse metatarsal ligaments of the toes.

So we can see that up in here.

The medial cord is very thin, it's superficial

to the abductor hallis muscle.

So abductor hallis muscle, all the lysis go

to the toe, the big toe.

So keep that in mind. If you hear the word haus in there,

it's, it's headed to the big toe for the most part.

And then on the flip side of that, we've got digit minimi,

which we had one of those in the wrist just next door

to the digitorum also.

So that's one way to remember as we keep going

to the pinky toe, just like the pinky side of the wrist,

the digit mini is next,

but the big guy in the middle is flexor digitorum, brevis

and brevis typically means short, right?

It, that's not what it means, but that's how we find things

brevis versus longest.

If I was looking at PS brevis, for example,

laterally in the ankle, it's a shorter tendon than the Perea

longest, which has a longer way to go.

Same way in the wrist when we're looking at the, the

extensor lysis brevis versus the extensor lysis longest,

the longest has the longest way to go,

so that's one way to remember it.

But these brevis ones are shorter.

And so while this is a digitorum, just like here,

this is extensor digitorum,

or sorry, flexor digitorum,

longest FDL on the medial ankle right here,

which we'll get into on the next webinar.

It's a very long tendon all the way up the, the,

the posterior tibia

and it climbs down through the tarsal tunnel here,

which which we're not gonna get into.

And then as you can see it, it still spans the arch

of the foot and spreading out to all five toes.

So here we have flexor digitorum longest,

and then here, superficial to that is flexor digitorum.

Brev is, it's a big meteor muscle, mid sagittal to the foot

and that's where the main portion

of the plantar fascia is gonna gonna lie.

There's a few more structures in here,

but we're not gonna mention them.

But there are other muscular structures, even superficial

to this one, like quadratus plant here or quadratus plante.

And, and, and we won't be imaging that,

but we'll look at it on the live scan.

But just know that there's a muscle directly deep

to the plantar fascia

and it's not associated with our measurement,

although it is a large part of the image,

we're looking very superficially here.

You can see the probe placements on the extreme medial

calcaneus and i i I would like to put in here that we need

to be angling in laterally.

So you'll place your probe medial to the calcaneus, almost

to the point you fall off the calcaneus

and then you'll, you'll aim

and shoot your probe slightly lateral to get a really shot.

And we'll go over that in the, in the live scan.

So taking a lateral shot here of the calcaneus

and profile, it doesn't take a lot of imagination to know

that, you know, here, here we go.

This is the calcaneus calcaneus, here's the plantar fascia,

which is the star of the show.

This is that, that middle or central band

or cord right here.

And we're focused primarily right here

where it leaves the calcaneus.

And we take this measurement, it needs

to be four millimeters

or less, virtually no, no matter how large the patient,

that, that size is pretty standard.

Also, notice how parallel the fibers are.

I don't see any focal swelling,

I don't see fibers bellying out away from themselves.

So it's a nice parallel strand

and I don't see any big focal swelling here.

So that's one thing to look for.

Other, other things that might make it difficult

to find the absolute part

to measure is if you have a bone spur,

if you have a calcaneal heel spur coming off like a big

diving board protruding way out, it can make some

of these other muscles and,

and potentially other pain

generators deep to the plantar fascia.

Kind of hard to see, but,

but for today's purpose we have a nice normal

plantar fascia to look at.

But here they are in profile

and the big deal here is four millimeters is the

measurement that we're going for.

Now we'll cut to the live demo and

after this live demo, I will say it will be time to open

for question and answer.

We will not record the q and a typically

and keep those offline.

So don't, don't be afraid to ask questions,

type them in the chat portal, we'll get 'em queued up.

We'll read 'em one by one in the order they come

and we can answer any of your questions.

All right, so back to the heel.

But this time on the bottom side.

So we're gonna go from the achilles side

and wrap around to the calcaneus.

I still have the gel that's been

working its way into the skin,

eliminating all the dry dead skin from stopping our sound

beam straight out of the gates.

So we'll go over a few things.

The anatomy is pretty straightforward.

I think the most benefit of a a lesson like this is,

is traditionally on how

to make the image look as good as it can.

Most people are tempted

to go midsagittal when it comes to the heel.

And I'll say this from the get go, start on the medial side

of the calcaneus and aim towards the lateral side.

So I'll show you midsagittal and what that looks like.

Let me hit go here and I see calcaneus, it looks dark

and we'll get to that, but there's not a lot of fascia

to look at, so it's very, very thin.

But watch what happens when I go medial medial,

medial medial, you see the fascia start to bulk up,

turn our gain up a little bit

and we're on a dense part of the heel, okay?

All this fat pad is very different than a lot

of the traditional fat throughout the body.

So the fat pad and the heel, it's pretty neat.

You should go check it out in anatomy references,

but it's built in stacked columns.

So we have these vertically oriented columns

of fat coming at our transducer

and that alone is enough

to make the ultrasound beam act a little bit funny.

So because of the orientation of those fat cells being

so different than the rest

of the subcutaneous fat in the body,

it already makes it hard to penetrate

on an even normal heel.

So today we have a normal heel.

So let's go through a few other imaging

parameters that we can change.

So one of the ones that I am gonna change

and we already talked about a little bit was

going to gin mode.

So I'm just gonna drop the frequency and hit gin

and that immediately has a, a great effect.

I can see, I can see this neck

of the calcaneus much better.

I can see flexor digitorum brevis a lot better.

I can see quadratus plante down here a lot better.

Everything comes into full view, really, really nice.

But again, if I'm over the mid sagittal calcaneus,

you get this kind of frustrating.

Where's the fascia image?

It's kind of gone and that's

because you're somewhere between the lateral cord,

which we talked about briefly, which is here.

And I'm just orienting the probe to the base

of the fifth metatarsal.

So there's a lateral cord of the plantar fascia,

now we're mid sagittal to the heel

and we're somewhere in between.

So there is some fascia there.

It is an AP neurosis, it does kind of spider web across

to the rest of the main plantar fascia.

But now I'm just gonna keep working my way to the medial

calcaneal tubercle

where we get this very large hump in the calcaneus.

And then we get this very, very good looking plantar fascia.

So keep panning medially until you fall off of that part.

And we can get over here to the, to the medial cord,

not the middle cord or central cord.

So here we're over the central cord or middle

and then extremely medial and thinner

and pointed to the,

to the first metatarsal area would be your

medial cord, which we don't really image that often,

so I'm just gonna stick to the middle

or central cord the most.

Another thing we can do

to make the image have a little bit more punch

and take advantage of that primary kind

of fundamental frequency is take off THI.

So on this on site px, I'm just gonna go down

to more controls and scroll down

and let's see what happens when I turn off THI.

So the tissue harmonic imaging is really taking a lot

of advantage of our reflective echoes coming back

to the transducer, giving us a, a higher quality image,

but it does, it's, it's not a super strong beam.

So I'm gonna go turn off THI

and turn up the gain a little bit

and we'll get a, a bit more

of a fundamental more primary beam.

Now it, it is kind of an uglier image,

but it is something you can try if you have some

difficult anatomy.

But I think for today's patient

we had great anatomy, no need to do that.

So we'll turn THI back on,

turn the gain back down a little bit.

Other things you can do is change your dynamic range a

little bit, go down

and to a negative zone of dynamic range.

Right now I'm at negative three,

I'm gonna go to negative two.

And then if you're still not delineating those margins

of the plantar fascia with confidence, let's,

let's do some dynamic maneuvers.

So first thing I'm gonna rock the transducer,

teeter totter it and I can see the subcutaneous fat

and that fat pad of the heel roll over the plantar fascia

margin right there.

So that's one way.

Another way is to go cross-sectionally here.

So we'll just rotate the probe.

Left side of the screen is medial

and we'll go up here to the calcaneus.

So here we're on the calcaneal tubercle

and remember what I said about the achilles tendon

where the, the healthy fibers will turn dark

to the an isotropic artifact

and that's what's happening here.

So I'm just gonna walk the probe down the heel

rock as we go.

Keep rocking and I'm just using the,

an isotropic artifact to my vantage.

And here's that flexor digitorum brevis right underneath.

So you can see it's muscle mass right here really nicely.

And then here's the, the main plantar fascist still.

So plantar fascist starts to widen out superficially,

it's all of this guy up here.

And if we haven't seen any fibromas or fibroma

or any thickening at that point, we'll head back up

to the calcaneal tubercle where we look

for things like spurs fluid collections, tears.

You can also compress

or even use your finger laterally immediately.

So here's a lateral push to get that fat to show itself

and to show the margins of where

the plantar fascia begins and ends or medially.

So what I do is I just take my fingers on each side

and I roll back and forth

and get that fat to glide over the fascia right there.

So you can see the interface where the arrow is.

And all I'm doing is just using that mobile fat pad

to delineate the margins of where fascia begins and ends.

And I can keep doing that as I go distally.

You can see how a static image wouldn't do this justice.

All the layers kind of look similar.

What I'm gonna do is just pinch and push back and forth

and I can get the fat on top of the fascia to roll

and show its margins real nice, very easy to do.

When people inject these, they typically go from medial

and this orientation here

and they will pop their needle just under the fascia

right here.

I know it's been described, you can

inject these superficially or deep,

but it seems like the is to go deep

and try to envelop the fascia as much as you can

and try to keep the steroids outta the fat pad

so you don't cause any kind of cavitation down the road.

All right, so as far as finding the margins of

that central cord,

you're staying slightly medial on the calcaneal tubercle

using angle artifact to your advantage,

using the highly mobile superficial overlying fat pad

of the heel to to see

where the plantar fascist starts and stops.

All right, so with that, I think that's safe

to conclude our plantar fascist

study on that note.

So I'm just gonna stop my image here.

Oh, I didn't go over how to measure it. So here we go.

So what we're gonna do is just find the,

the thickest portion of

that medial calcaneal tubercle portion of the central cord.

Work on our angle until everything's nice and bright.

Okay, get it as bright as you can and hit freeze

and go to caliper

and automatically your distance caliper comes up.

So we're just gonna move it right here to this bottom corner

and hit select and come right up here

where the fascia starts to dive.

It needs to be less than four millimeters,

hers is 3.4 millimeters,

but here's the margin that we're measuring right there.

So you can see the fascia comes up and then it takes a dive.

So I wouldn't wanna measure here

because it's oblique, that'd be taken not quite a,

a true cross section 'cause it's diving.

I need the shortest path right there. So here we are again.

So save my shot there and we have that image saved.

All right, well thanks for joining the

posterior ankle webinar.

Be sure to join us for the medial and lateral coming up.

And if you have any questions about future webinars

or requests, just go ahead

and email them to, to the same email address

that sent your invitation to the webinar.

Thank you all and have a great day.

Extend the physical examination of the ankle while reducing the cost of care with ultrasound imaging. View this webinar to review normal sonoanatomy and commonly imaged structures of the posterior ankle. Our expert presenter will scan live how to assess the main joint recesses, commonly-imaged complex tendons, muscles, bursa, and fatpad. A question and answer session to clarify points and assist with overcoming learning plateaus from previous ultrasound education about the ankle is also included. This webinar will be especially beneficial to beginner and intermediate ultrasound users.

What You'll Learn

  • Confidently identify the boney landmarks to help navigate the structures in the posterior ankle
  • Identify anatomy to avoid during an injection of the posterior ankle
  • Review the advantages and disadvantages of ultrasound imaging of the posterior ankle
Daniel Shelton
Presenter: Daniel Shelton, RT(R)
Job title: Director, Musculoskeletal Market Development, FUJIFILM Sonosite

Daniel Shelton, RT(R) is the Director of Musculoskeletal Market Development for FUJIFILM Sonosite. Daniel spent 18 years as a dedicated musculoskeletal sonographer and 12 of those years have been here at Sonosite. He now leads musculoskeletal market development, where he works to spread the word about the benefits of point-of-care ultrasound.

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This educational webinar is intended for healthcare professionals and not for patients or consumers. The material is provided for general educational purposes, as a reference and a supplement to professional experience, education and training, and should not be considered the exclusive source for this type of information. This educational webinar is not intended to recommend any device for a particular indication or to provide indications for use for any device. At all times, it is the professional responsibility of the practitioner to exercise independent clinical judgment in each particular situation. Fujifilm assumes no responsibility or liability for any misuse of the information imparted in this webinar. This educational webinar does not supplement, replace, or supersede device labeling, including instructions for use, which accompanies any FUJIFILM Sonosite product.