Peroneal Tendon & Ankle Joint Injections

Ankle
Equipment & Medications

Equipment

14 MHz Linear Probe 25g 1.5″ Needle 5 cc Syringe (lidocaine) 3 cc Syringe (steroid mix) Procedure Tray

Medications

Lidocaine 1% — 5 cc Kenalog 40 mg/cc — 1 cc Ropivacaine 0.5% — 1 cc
Peroneal Tendon Sheath Injection
1

Standard pre-procedure workup: consent, indications, contraindications, allergies, and baseline pain level.

2

Position patient with the affected ankle in slight plantar flexion and inversion to relax the peroneal tendons. The patient may be supine or lateral decubitus with the affected side up.

3

Place the linear probe transversely over the posterior lateral malleolus. Identify the peroneus brevis (anterior, flat) and peroneus longus (posterior, rounder) tendons within their common sheath. Assess for tenosynovitis, longitudinal splits, or subluxation.

4

Mark the needle entry site just posterior to the lateral malleolus. Confirm the sural nerve (superficial, posterolateral to the tendons) is not in the needle path.

5

Prep with betadine or chlorhexidine × 3. Place sterile drape and sterile probe cover.

6

Under ultrasound guidance, create a superficial skin wheal with 1% lidocaine using the 25g needle.

7

Advance the 25g needle into the common peroneal tendon sheath. Test-inject with lidocaine — confirm easy flow and sheath distention along both tendons.

8

Once correct position is confirmed, exchange for the steroid/ropivacaine syringe and inject. The sheath is a continuous structure — a single injection point is usually sufficient unless a complete tenosynovitis partition is present.

9

Scan to document sheath distention proximal and distal to the injection site.

10

Remove needle, clean skin, and place bandage. Reassess pain level.

Additional Ankle Injection Approaches

The following joints are accessed using the same general technique (25g needle, lidocaine test-injection, then steroid/ropivacaine mixture). Positioning and probe placement differ by target.

A
Tibiotalar (Ankle) Joint — Anterior Approach

Position supine with ankle in plantar flexion. Place probe longitudinally over the anteromedial ankle. Target the joint line between the distal tibia and talar dome, medial to the tibialis anterior tendon. Advance needle from distal to proximal at a shallow angle.

B
Lateral Gutter / Tibiotalar — Lateral Approach

Position supine or lateral decubitus. Place probe over the anterolateral ankle, identifying the lateral gutter between the fibula and talus. Advance needle from anterior to posterior, avoiding the peroneal tendons posteriorly.

C
Posterior Subtalar Joint

Position prone with foot hanging off the table. Place probe longitudinally over the posterior subtalar joint. The joint space between the posterior calcaneus and talus is the target. Advance needle from lateral to medial, away from the posterior tibial neurovascular bundle medially.

D
Sinus Tarsi (Anterior Subtalar)

Position supine. The sinus tarsi is palpable as a soft spot anterolateral to the lateral malleolus. Place probe over the sinus tarsi and target the space between the anterior facets of the subtalar joint. Advance needle from anterolateral to posteromedial.

E
Talonavicular Joint

Position supine with ankle in slight plantar flexion. Place probe longitudinally over the dorsomedial midfoot, identifying the joint between the talar head and navicular. Advance needle from distal to proximal at a shallow angle into the joint space.

References

  1. Fram BR, Harston A, Lee JT, et al. Ultrasound-guided injections of the ankle and foot. Foot Ankle Int. 2019;40(8):888–894.
  2. Muir JJ, Curtiss HM, Hollister M, et al. Ultrasound-guided injections: accuracy, efficacy, and safety. Am J Phys Med Rehabil. 2011;90(7):564–571.
  3. Sofka CM, Adler RS, Saboeiro GR, Pavlov H. Sonographic evaluation and sonographically guided procedures of the ankle and foot. HSS J. 2010;6(2):177–181.