Ankle Joint Injection

Other Names

Ankle Joint Injection
Tibiotalar Joint Injection
Ankle Joint Aspiration
Ankle Joint Arthrocentesis

Background

Ultrasound guided approach in plane

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

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

Authors:

John Kiel, Jesse Fodero

Last edited:

22 May 2025 18:14:40

Category:

Procedures

[1] Image courtesy of fpnotebook.com

[2] 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.

[3] 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.

[malanga-4] 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).

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