Ankle Joint Injection

Other Names

• Ankle Joint Injection
• Tibiotalar Joint Injection

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Background

Ultrasound guided approach in plane

• This page refers to injections of the ankle joint

Anatomy

• Ankle Joint
  • Formed by the articulation of the distal tibia, distal fibula and talus
  • Hinge joint permitting dorsiflexion and plantarflexion

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Indications

• Ankle Arthritis

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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

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Procedure

Patient positioning with knee and hip flexed, ankle plantarflexed and foot flat on the table

Equipment

• Sterile including chloraprep, chlorhexadine, iodine
• Ultrasound with sterile probe cover
• Gloves
• Needle: typically 25 gauge, 0.5-1 inch
• Syringe: 1-3 mL
• Gauze
• Ethyl Chloride
• Bandage
• Injectate
  • Local anesthetic
  • Corticosteroid

Preparation

• Place ultrasound on opposite side of patient
• Identify sonographic landmarks

Palpation Guided Anterior Approach

Anteromedial approach for palpation guided injection. The anterior edge of the medial malleolus and tibialis anterior tendon represent the boarders.

• 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 Approach

Ultrasound guided approach in long axis with in-plane technique

• Position
  • Patient is supine
  • Hip and Knee flexed, foot in plantarflexion resting on examination table
• Position
  • Place probe in long axis just medial to the tibialis anterior tendon
  • Confirm location of the anterior neurovascular bundle
  • Localise the anterior recess of the tibiotalar joint
• Prep skin, provide cutaneous anesthesia as indicated
• Needle insertion
  • Long axis: distal to proximal at about a 30° angle passing over the talar dome aimed cranially
  • Short axis is also an option
  • Position needle tip just past the joint capsule in the anterior recess of the joint
• After procedure, apply pressure to tamponade any bleeding
• Apply bandage

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Aftercare

• No major restrictions in most cases
• Can augment with ice, NSAIDS

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Complications

• Infection
• Damage to surrounding tissue

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See Also

• Procedures Main
• Ultrasound Main
• Ankle Pain Main

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