Ankle Joint Injection

This article is a stub.

Ankle Joint Injection
Indication	Ankle Osteoarthritis, and various rheumatological conditions
Syringe	3mL
Needle	23G 30mm
Steroid	30mg triamcinolone
Local	2mL 2% lidocaine
Volume	2-3mL

Anatomy

Main article: Ankle Joint Anatomy

The ankle joint is a hinged synovial joint. It is created by the articulation of the distal end of the tibia, fibula, and the superior aspect of the talus. It provides dorsiflexion and plantarflexion. The classic mnemonic "Tom, Dick, and Harry" is used to remember the muscles that cross the anterior ankle joint in the medial plane - tibialis anterior, extensor hallucis longus, and extensor digitorum longus. These structures are held by the superior and inferior extensor retinacula. The lateral muscles are peroneus longus and brevis. These are supported by the superior and inferior peroneal retinaculum. The medial ligaments are the deltoid ligaments, and the lateral ligaments are the talofibular ligament (ATFL), calcaneofibular ligament (CFL), and the posterior talofibular ligament (PTFL). The deep peroneal nerve and anterior tibial artery (anterior neurovascular bundle) cross the ankle joint between the extensor digitorum longus and extensor hallucis longus, and then descend into the dorsal aspect of the foot. The anterior tibial artery becomes the dorsalis pedis artery. The superficial peroneal nerve is found anterolaterally to the ankle joint.

Pre-procedural Evaluation

In the setting of significant joint space narrowing, the anteromedial approach may be difficult. The lateral approach may be more successful here.

Technique

Ultrasound Guided

• Position: Supine with foot in neutral position
• Confirm location of the anterior neurovascular bundle, and tibialis anterior tendon.
• Insert needle into the anteromedial joint space Insert needle into the anteromedial joint space.

Landmark Guided

Lateral and medial ankle arthrocentesis approaches

Medial Approach (tibiotalar)

• Position: Supine with foot perpendicular to leg
• Identify and mark sulcus lateral to the medial malleolus and medial to the tibialis anterior and extensor hallucis longus tendons
• Plantarflex the foot with needle entering the skin overlying the sulcus
• Angle the needle slightly cranially as it passes between the medial malleolus and tibialis anterior tendon

• 

  Medial approach: enter space between anterior border of the medial malleolus and the tibialis anterior tendon

• 

  Medial approach: have patient lie supine, and plantar flex the ankle so the angle is close to 90 degrees.

Lateral Approach (subtalar)

• Keep foot perpendicular to leg
• Enter subtalar joint just below tip of lateral malleolus
• Direct needle medially toward joint space

Literature Review

Literature Review

Reviews from the last 7 years: review articles, free review articles, systematic reviews, meta-analyses, NCBI Bookshelf

Articles from all years: PubMed search, Google Scholar search.

TRIP Database: clinical publications about evidence-based medicine.

Other Wikis: Radiopaedia, Wikipedia Search, Wikipedia I Feel Lucky, Orthobullets,