CME OnDemand: Novel Imaging and MIS Techniques in Foot and Ankle Care (2026)-Ultrasonography of the ankle joint

Ultrasonography of the ankle joint

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This review article outlines how ultrasonography (US) is used to evaluate ankle pain, emphasizing its advantages for assessing tendons, ligaments, and nerves. Ankle injuries are common—about 14% of sports-related orthopedic emergency visits—and may arise from trauma, overuse, inflammation, infection, or degeneration. Compared with CT or MRI, US is inexpensive, radiation-free, offers real-time imaging, enables side-to-side comparison, and is particularly valuable for dynamic assessment (muscle contraction/passive motion) and stress testing. Doppler imaging can help distinguish vascularity from small intrasubstance tendon tears and gauge inflammatory activity.<br /><br />The authors review normal ankle anatomy and scanning technique by compartment (medial, lateral, anterior, posterior). Tendons are best seen in transverse imaging, while ligament evaluation commonly relies on longitudinal views. Key tendon pathologies include tendinosis (thickened, hypoechoic tendon with preserved fibrillar pattern), tenosynovitis/tendinitis (synovial thickening and sheath fluid with “target” and “rail-track” signs; Doppler hyperemia), and partial or complete tears (fiber disruption with hypoechoic/anechoic gaps and possible retraction).<br /><br />A major focus is peroneal tendon disorders: tenosynovitis, longitudinal split tears of the peroneus brevis, intrasheath subluxation (tendons switching positions within an intact superior peroneal retinaculum), and frank dislocation from the retromalleolar groove—best detected dynamically during dorsiflexion-eversion maneuvers. Achilles tendon conditions include tendinopathy (thickening, loss of normal contour), paratendinopathy (peritendinous edema), partial/complete rupture (often 2–6 cm proximal to insertion), Haglund syndrome (bursal fluid plus distal Achilles tendinosis and calcaneal prominence), and xanthomas (marked thickening with reticular appearance).<br /><br />For ligaments, US criteria differentiate mild sprain, partial tear, and complete tear; dynamic stress improves confidence, especially for ATFL and CFL injuries. Nerve evaluation highlights tarsal tunnel syndrome due to ganglia or talocalcaneal coalition and describes lipomatosis of the nerve with characteristic “coaxial cable/spaghetti” appearance. The article concludes US should be first-line imaging for many ankle tendon, ligament, and nerve problems, particularly when dynamic maneuvers are needed.

Keywords

ankle ultrasonography

ankle pain evaluation

dynamic ultrasound stress testing

Doppler imaging tendon hyperemia

peroneal tendon disorders

peroneus brevis longitudinal split tear

superior peroneal retinaculum subluxation

Achilles tendinopathy and rupture

ATFL and CFL ligament sprain/tear

tarsal tunnel syndrome nerve ultrasound