Ankle Joint Injection
Other Names
- Ankle Joint Injection
- Tibiotalar Joint Injection
- Ankle Joint Aspiration
- Ankle Joint Arthrocentesis
Background
Key Points
- Needle: 1.5 inch, 22 - 25 gauge (injection), 18 - 20 gauge (aspiration)
- Transducer: high frequency, linear array
- This technique is useful for aspiration and injection
- This page refers to injections of the ankle joint
Anatomy of the Ankle Joint
- Formed by the articulation of the distal tibia, distal fibula and talus
- Hinge joint permitting dorsiflexion and plantarflexion
Palpation Guidance vs Ultrasound Guidance
- We recommend ultrasound guided aspiration/injection when possible
- Wisniewski showed 100% accuracy with ultrasound guidance compared to 85% accuracy with palpation guidance in cadavers[2]
Indications
- Ankle Arthritis
- Many potential others causes of ankle pain
Contraindications
- Absolute
- Anaphylaxis to injectates
- Overlying cellulitis, skin lesion or systemic infection
- Relative
- Can be treated with less invasive means
- Tendon tear or rupture
- Hyperglycemia or poorly controlled diabetes
- Lack of symptom improvement with previous injection
Procedure
Equipment
- Sterile prep (i.e. chloraprep, chlorhexidine, iodine, etc)
- Gloves
- Needle: typically 21-25 gauge, 1.5 inch
- Syringe: 5-10 mL
- Gauze
- Ethyl Chloride
- Bandage
- Injectate
- Local anesthetic
- Corticosteroid
- Sterile probe cover
Ultrasound Findings
- Ultrasound should and can clearly identify the joint space
- Recommend evaluating the entire anterior joint space
- Must identify space free of any nerves or of the dorsalis pedis artery
- Findings
- Joint effusion with hypoechoic fluid, anterior displacement of the fat pad
- Up to 1.8 mm of joint fluid can be physiologic
- Synovium may be thickened or inflammed
- Osteophytes and other degenerative changes can sometimes be observed
Technique: Palpation Guided Anterior Approach
- Position
- Patient is supine
- Hip and Knee flexed, foot in plantarflexion resting on examination table
- Anterior/ Medial Approach Landmarks
- Target: between medial malleolus and tibialis anterior tendon
- Palpate 1 cm anterior to medial malleolus, identify tibia and talus
- Identify extensor hallucis longus, tibialis anterior tendons (ask patient to dorsiflex great toe and foot respectively)
- Mark skin between medial malleolus and the two tendons
- Note: this allows avoidance of the dorsalis pedis and posterior tibial neurovascular structures
- Lateral Approach Landmarks
- Target: just anterior to lateral malleolus
- Palpate and mark skin anterior to lateral malleolus
- Prep skin, provide cutaneous anesthesia as indicated
- Injection
- Needle is directed slightly posterior across the ankle joint
- Needle is roughly parallel to dorsum of foot
- Advance needle until you feel a pop, entering the synovial membrane
- The needle vector may require subtle redirection to ensure placement in the joint space
- Aspirate to ensure there is no blood return, then inject
- After procedure, apply pressure to tamponade any bleeding
- Apply bandage
Ultrasound Guided Technique: Long Axis, In Plane
- Patient Position
- Seated/supine, knee flexed to 90 and ankle flat on the examination table
- Joint should be in approximately 30-45 degrees of plantarflexion
- Transducer Position
- Long axis of the ankle
- Just medial to tibialis anterior
- Needle Approach/ Orientation
- In plane
- Distal to proximal
- Target
- Anterior joint space
- Pearls and Pitfalls
- Possible to hit tendon/nerve/artery if you do not perform a careful preprocedural evaluation
- Angle of entry can be steep
Ultrasound Guided Technique: Long Axis, Out of Plane
- Patient Position
- Seated/supine, knee flexed to 90 and ankle flat on the examination table
- Joint should be in approximately 30-45 degrees of plantarflexion
- Transducer Position
- Anterior ankle, long axis to the joint
- Needle Approach/ Orientation
- Out of plane
- Medial to lateral/ lateral to medial
- Target
- Anterior joint space
- Pearls and Pitfalls
- Step wise approach may allow you to track your needle into the joint space
Ultrasound Guided Technique: Short Axis, In Plane
- Patient Position
- Seated/supine, knee flexed to 90 and ankle flat on the examination table
- Joint should be in approximately 30-45 degrees of plantarflexion
- Transducer Position
- Anterior ankle, short axis to the joint
- Needle Approach/ Orientation
- In plane
- Medial to lateral/ lateral to medial
- Target
- Anterior joint space, mid portion
- Pearls and Pitfalls
- Slide the probe in short axis between the distal tibia and talus to find optimal space
- Can rotate probe into long axis to confirm depth
Aftercare
- Motor exam should be intact
- No major restrictions in most cases
- Can augment with ice, NSAIDS
- Consider Ankle Compression Sleeve
Complications
- Infection
- Damage to surrounding tissue
See Also
References
- ↑ Image courtesy of fpnotebook.com
- ↑ Wisniewski, Steve J., et al. "Ultrasound-guided versus nonguided tibiotalar joint and sinus tarsi injections: a cadaveric study." PM&R 2.4 (2010): 277-281.
- ↑ Soneji, Neilesh, and Philip WH Peng. "Ultrasound-Guided Interventional Procedures in Pain Medicine: A Review of Anatomy, Sonoanatomy, and Procedures." Regional Anesthesia & Pain Medicine 41.1 (2016): 99-116.
- ↑ 4.0 4.1 4.2 4.3 4.4 Malanga, Gerard A., and Kenneth R. Mautner. "Atlas of ultrasound-guided musculoskeletal injections." (No Title) (2014).
Created by:
Jesse Fodero on 14 July 2019 20:36:29
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Last edited:
22 May 2025 18:14:40
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