Ankle tendonitis

Ultrasound guided peroneal & tibialis posterior tendon sheath steroid injection

Ultrasound guided peroneal tendon steroid injection

What is ankle tendonitis?

Ankle tendonitis refers to inflammation of the tendons around the ankle joint. There are three groups of tendons that run around the ankle joint, termed the peroneal, flexor and extensor tendons.

Relevant anatomy

The peroneal tendons are made up of two tendons: the peroneus longus, which forms above the ankle, and the peroneus brevis tendon, which forms at the ankle level. They are located on the outer edge of the ankle, behind the bony protrusion known as the lateral malleolus. These tendons play a crucial role in maintaining stability and movement in the ankle and foot and they are responsible for foot eversion (outward tilting the ankle).

Peroneal tendinopathy refers to changes in the tendons and the layer surrounding them (known as the tendon sheath). These changes can range from thickening and inflammation of the tendons to thinning and tearing. Overuse of the tendons, such as during activities like running, can cause this condition. In addition, inflammation of the peroneal tendons can be associated with inflammatory arthritis, such as Rheumatoid arthritis.

The peroneal tendons are held in their place behind the lateral malleolus (the space is called the retro malleolar groove) by a special band of tissue (called the superior peroneal retinaculum). Peroneal tendons subluxation refers to abnormal clicking at the outside of the ankle due to persistent movement of the peroneal tendons outside the groove on ankle movements. This is usually secondary to a previous injury to the superior peroneal retinaculum. This, in turn, can result in peroneal tendon inflammation/tendinopathy.

Among the flexor tendon group, the tibialis posterior tendon is the most frequently affected by issues. The tibialis posterior tendon forms above the ankle level and descends towards the foot, passing at the inner aspect of the ankle, just behind the bony prominence at the inside of the ankle (called the medial malleolus). The tendon plays an important role in providing support to the arch of the foot.

The tibialis posterior tendon at the ankle level is susceptible to tendinopathy, which refers to unusual changes in the tendon, such as thickening, inflammation, thinning, or tearing. This condition is more prevalent in females over 40 who experience repetitive stress. It progresses over time, and symptoms vary based on the extent of the changes.

What are the symptoms of Ankle tendinosis?

Peroneal tendinopathy usually results in pain and swelling at the outer aspect of the ankle. If there is peroneal tendons subluxation, you may experience clicking on ankle movements.

Tibialis posterior tendinopathy will result in pain at the inside of the ankle and weakness in the foot. If the condition progresses and the tendinopathy worsens, there will be a flattening of the foot arch.

How to diagnose ankle tendinopathy?

When ankle tendonitis is suspected clinically, you will be referred for further imaging to confirm the diagnosis. A specialist musculoskeletal ultrasound assessment performed by a radiologist is very useful. It will establish the diagnosis, assess the severity of the condition, and rule out other causes of ankle pain. Ankle tendonitis has different types and grades, and an ultrasound examination is useful for the evaluation. Ultrasound also allows performing a dynamic assessment of the tendons where abnormal tendons movement and tendon subluxation can be seen directly, allowing for accurate diagnosis. Ultrasound also allows for direct comparison with the other side to increase accuracy. MRI can also be useful for the assessment, but ultrasound is preferred given its high resolution and ability to perform a dynamic assessment.

What conditions can mimic ankle tendonitis?

Other conditions that can be mistaken for ankle tendonitis include:

What is the treatment for ankle tendonitis?

Initial treatment includes simple measures like activity modification, anti-inflammatory tablets like ibuprofen and local ice packs. A physiotherapy program to strengthen the calf and small muscles in the foot can also be useful. A podiatrist can also help to ensure you are using the appropriate shoe wear and reduce unnecessary stress upon the ankle tendons.

Can a steroid injection help in ankle tendonitis?

Ultrasound guided peroneal or tibialis posterior tendon sheath steroid injection can be considered in the management if the above conservative measures are not helping. The steroid is accurately injected under ultrasound guidance into the tendon sheath, a thin layer of tissue surrounding the tendon, to help reduce the inflammation. It is essential to perform these injections under ultrasound guidance to ensure accurate needle placement to increase efficiency and reduce local side effects. A small dose of steroids reduces the possibility of tendon weakening.

If the above treatment options are not useful, you may need a referral to a foot and ankle surgeon to consider surgical treatment options, including tendons repair and reconstructions. A specialist foot and ankle orthopaedic surgeon will be the best person to advise you about this.

What is a cortisone injection?

Cortisone is a potent anti-inflammatory medicine routinely used to manage inflammatory conditions. It will allow effective rehabilitation and enable you to engage in a physiotherapy program. To find out more, please see our FAQs. The medicine is usually combined with a numbing agent (local anaesthetic) to enhance the pain relief effect.

Should ankle tendonitis injections be done using ultrasound guidance?

This is our routine practice, as ample evidence supports ultrasound guidance when performing musculoskeletal injections. Performing ankle tendonitis injections under ultrasound/imaging guidance allows for direct visualisation of the needle to ensure accurate placement into the inflamed and thickened tendon sheath. Ultrasound guidance results in more accurate, less painful, and faster procedures, with better outcomes than these injections without guidance. The medicine will be accurately injected into the tendon sheath surrounding the inflamed tendon. Ultrasound guidance avoids sensitive structures (like nerves and vessels) during the procedure.

How long will the effect of a cortisone injection last?

Evidence suggests that cortisone can improve pain and function for a prolonged period of time, up to 3 months, but in some cases, it can last longer. Pain relief duration depends on the condition's diagnosis and severity. The steroid injection will provide a window of opportunity to undergo effective rehabilitation and attempt to address the underlying cause to enhance the pain relief achieved from the injection.

How soon will a steroid injection start to work?

A steroid injection usually takes a few days (1-3) before you notice the effect, although sometimes the pain relief can start on the same day. The injected area will often feel sore for the first few days. This is referred to as (steroid flare) and can be seen after a steroid injection. To find out more, please see our steroid injections FAQs.

Do steroid injections just hide/mask the pain?

Steroid injections do not just mask or hide the pain, but they act by reducing the inflammation in the targeted area, thus providing a strong and local anti-inflammatory effect to help control the symptoms and allow the patient to manage the condition, usually by undergoing effective rehabilitation.

How many steroid injections can I have?

If possible, we advise reducing the number of cortisone injections by combining any injection therapy with an effective physiotherapy programme to address the underlying cause. Repeated steroid injection into the same area should be avoided if the previous injection was less than 3-4 months ago.

What if injection therapy is not helping?

In the case of ankle tendonitis that fails to respond to conservative management and ultrasound-guided injection treatment, or if there is an ankle tendon tear, you may require a surgical referral to a specialist foot and ankle orthopaedic surgeon to see if surgical treatment is a suitable option.