Performing a Tibiotalar injection
A tibiotalar joint injection is typically used to help treat symptoms associated with ankle arthritis. The tibiotalar joint is a hinged synovial joint that includes the distal end of the tibia and the talar dome (2). Plantarflexion and dorsiflexion are the primary motions of the tibiotalar joint (7). Ultrasound guided injections are preferred to palpation guided injection in order to avoid the neurovascular structures overlying the ankle joint. A palpation guided injection has been found to have an accuracy of 77-85%, while an ultrasound guided injection can near 100% in its accuracy (5).
A 12-4 MHz linear transducer is typically used for an ankle joint injection. The needle can range from a 1.5 to 2 inch needle. Needle gauge can vary from an 18g for an aspiration to a 25g for a corticosteroid injection. The total volume injected into an ankle joint should typically be between 2 and 4 mLs (2).
There are multiple injection routes, but we will discuss an in-plane long and short axis injection in this review. For both injections, the foot will be placed flat on the exam table with the patient supine or semirecumbent (3,7).
The probe is first placed in short axis to the tibia and the tibialis anterior tendon. Then, for the long axis injection, the probe is rotated so that it is now in long access to the tibiotalar joint just medial to the tibialis anterior tendon (1). The ultrasound image shows the distal portion of the tibia and the talar dome (1). The tibia and talus should make a V-shape (3).
Doppler should be used prior to needle insertion to visualize the dorsalis pedis artery (3). The probe is typically placed medial to the anterior tibial tendon because the artery is usually found lateral to the tendon (5,6). The needle is guided in plane towards the anterior joint recess (7).
Alternatively, you can take a more lateral approach with the tibiotalar joint in short axis (1). The ultrasound image should show the fat pad and the talar dome (1). Providers should first find the distal fibula nerve and the dorsalis pedis artery prior to inserting the needle (2). The injection is then guided in a lateral to medial direction, coursing under the neurovascular structures (1).
An ultrasound guided injection of the tibiotalar is a safe and accurate way to help relieve symptoms associated with ankle arthritis. The injection can be performed via a long or short axis approach. Multiple injections have been studied, as injection options for the tibiotalar joint including corticosteroids, hyaluronic, or platelet rich plasma.
By Gregory Rubin, DO
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2) Kruse, Ryan C., and Brennan Boettcher. “Image-Guided Foot and Ankle Injections.” Foot and Ankle Clinics, vol. 28, no. 3, Sept. 2023, pp. 641–65. PubMed, https://doi.org/10.1016/j.fcl.2023.04.005
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