Tibialis Anterior Injection
Other Names
- Tibialis Anterior Injection
- Tibialis Anterior Tendon Sheath Injection
- Tibialis Anterior Bursa Injection
Background
Key Points
- Transducer: high frequency linear
- Needle: 25 gauge, 1-1.5 inch
- Easy to find in short axis
- Take care to avoid the dorsalis pedis artery, deep peroneal nerve
Anatomy of Tibialis Anterior
- Origin: upper two thirds of lateral surface of tibia
- Insert: medial surface of medial cuneiform, plantar aspect of base of first metatarsal
- Contained by the inferior extensor retinaculum, transverse retinaculum band[2]
- Anterior Compartment of the Leg
- In addition to tibialis anterior, also contains extensor hallucis longus, extensor digitorum longus, peroneus tertius
- Tibialis anterior is largest, most medial tendon
- Approximately twice the size of the other tendons in cross section
- Anterior tibial artery lies deeper, just lateral to EHL tendon
- Deep peroneal nerve lies medial to the vessels, then crosses over to descend laterally[3]
Palpation Guidance vs Ultrasound Guidance
- There are no published papers looking at image-guided injections or comparing them with palpation guided injections
- We strongly recommend using ultrasound to guide the needle and avoid the neurovascular bundle
Indications
- Tibialis Anterior Tenosynovitis
Contraindications
- Absolute
- Anaphylaxis to injectates
- Overlying cellulitis, skin lesion or systemic infection
- Relative
- Can be treated with less invasive means
- 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
- Best visualized in short axis
- Transducer is dorsal medial ankle
- Can look in both long and short axis
- Abnormal ultrasound findings include:
- Thickened, hypoechoic, mildly hypervascular tendon
- Fusiform swelling of the tendon in long axis
- Enthesophytes at the insertion
- Swelling of the synovium of the tendon sheath
- Hyperemic and hyperechoic tendon sheath
- Fluid in the tendon sheath
Technique: Short Axis, In Plane
- Patient Position
- Supine, knee flexed
- Foot flat on the examination table
- Transducer Position
- Short axis over the tibialis anterior tendon
- Needle Approach/ Orientation
- In plane, short axis
- Medial to lateral
- Target
- Tibialis anterior tendon sheath
- Pearls and Pitfalls
- Distal tendon tapers over the medial cuneiform
Technique: Short Axis, In Plane
- Patient Position
- Supine, knee flexed
- Foot flat on the examination table
- Transducer Position
- Short axis over the tibialis anterior tendon
- Needle Approach/ Orientation
- In plane, short axis
- Medial to lateral
- Target
- Any of the potential bursa of the tibialis anterior
Aftercare
- Motor exam should be intact
- No major restrictions in most cases
- Can augment with ice, NSAIDS
Complications
- Infection
- Damage to surrounding tissue
See Also
Internal
References
- ↑ 1.0 1.1 1.2 Malanga, Gerard A., and Kenneth R. Mautner. " Atlas of ultrasound-guided musculoskeletal injections." (No Title) (2014).
- ↑ Kelikian, Armen S., and Shahan K. Sarrafian, eds. Sarrafian's anatomy of the foot and ankle: descriptive, topographic, functional. Lippincott Williams & Wilkins, 2011.
- ↑ Bianchi, Stefano, and Carlo Martinoli. "Shoulder." Ultrasound of the musculoskeletal system. Berlin, Heidelberg: Springer Berlin Heidelberg, 2007. 189-331.
- ↑ Laurell, Louise, et al. "Ultrasonography and color Doppler in juvenile idiopathic arthritis: diagnosis and follow-up of ultrasound-guided steroid injection in the ankle region. A descriptive interventional study." pediatric rheumatology 9.1 (2011): 4.
Created by:
John Kiel on 2 October 2025 16:50:43
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Last edited:
2 October 2025 18:30:22
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