Point-of-Care Ultrasound (POCUS) is emerging as an essential tool for podiatrists, offering dynamic, real-time imaging to enhance diagnostic accuracy and guide intervention to treat foot and ankle pain.

A recent webinar, “POCUS Essentials in Podiatry: Enhancing Foot and Ankle Assessments,” hosted by Clarius in partnership with Sonoskills and featuring sonographer Marc Schmitz, provided valuable insights into integrating ultrasound into podiatric evaluations. The one-hour session delved into how POCUS can significantly improve patient journeys through more focused management plans, reduced waiting times, and empowering patients with a clearer understanding of their diagnosis.

As Shelley Guenther, Clinical Marketing Manager at Clarius, noted from a literature review, the perceived benefits among participating podiatrists included “an improvement in the patient journeys through tighter focused management plans and reduced waiting times” and the capacity to “better inform patients of their diagnosis, which they believe led to improved engagement and consequent empowerment of patients in their treatment plans”.

Watch the webinar at your convenience and scroll down for detailed video demonstrations using the Clarius L15 HD3 wireless handheld ultrasound scanner.

Key Clinical Takeaways for Podiatrists:

Ultrasound is a Preferred Imaging Modality: For many common foot and ankle pathologies, ultrasound is now considered the preferred imaging technique. Referencing the European Society of Musculoskeletal Radiology’s consensus statement, Marc Schmitz highlighted that ultrasound received high scores for assessing conditions such as plantar fasciitis, Achilles and peroneal tendon abnormalitiess, and lateral ankle ligament injuries.

Tips for Assessing the Foot

Plantar Fascia

• Scan the plantar fascia with the foot in dorsiflexion to stretch the fascia for better visualization. Marc Schmitz demonstrated this technique, stating, “With this dorsiflexion, the plantar fascia comes on a stretch and with this stretch it’s better to visualize”.

• Observe the thickness and echogenicity of the fascia. Hypoechoic appearance and thickening can indicate swelling and plantar fasciitis. “If it’s dark, that could be due to swelling,” explained Marc Schmitz.

• Look for bone irregularities or calcifications at the insertion point, which may suggest partial tearing in severe cases. Marc noted that in severe cases of plantar fasciitis, “the bone is not smooth, and that could indicate partial tearing”.

Watch this 2-minute video to see Marc Schmitz demonstrate scanning the plantar Fascia with the Clarius L15 HD3.

Achilles Tendon Evaluation:

• Scan the Achilles tendon longitudinally and transversely with the foot in dorsiflexion. Assess tendon thickness, fiber alignment, and echogenicity.

• Dynamic compression can help identify softening of the tendon, indicating severe tendinopathy or tearing. When asked if a normal tendon would be compressible, Marc Schmitz replied, “No. So the usual tendon is quite hard and not so squishy”.

• Be aware of the retrocalcaneal bursa and Kager’s fat pad. Janaye Smith demonstrated how “just in this little cove here is where we would see the retrocalcaneal bursa. And if we compress, we can see the fat from that fat pad moving into that bursa right there”.

In this 4-minute video, Marc Schmitz demonstrates how to scan the Achilles tendon and muscles of the lower half of the posterior calf.

Peroneal Tendon Examination:

• Scan the peroneal tendons behind the lateral malleolus in transverse view.

• Follow the tendons distally, checking for integrity or tenosynovitis. Marc Schmitz showed an example of tenosynovitis with “Lots of effusion there” in the tendon sheath.

• Dynamic assessment is crucial for ligaments: Marc Schmitz described stretching the ligament and letting “the peroneal tendons bounce on the ligaments, then you know that the ligament is intact”.

Watch Marc’s 3-minute video of how to scan the peroneal tendons – peroneus longus and brevis – to assess for tendinopathy, fluid, and avulsion fractures.

Lateral Ankle Ligament Assessment:

• Techniques vary slightly depending on the ligament being assessed (Calcaneofibular, Anterior Talofibular, Tibiofibular Syndesmosis).

• Look for continuity of fibers, thickening, or complete ruptures. Marc Schmitz showed a case of a calcaneofibular ligament rupture with “a large gap and with an effusion and of course an interruption of the fibres”. He emphasized that for these ligaments, ultrasound scores a three, “meaning it is the preferred imaging technique”.

Marc demonstrates how to scan the calcaneofibular, anterior talofibular, and tibiofibular ligaments of the ankle in this 3-minute video.

Talocrural Joint Analysis:

• Scan the anterior recess in plantar flexion to assess for effusions, capsular thickening, or spurs. Marc Schmitz noted that “Join the effusions and synovitis capsular problems are really easy to see”.

In this video, Marc shows patient positioning and scanning technique for assessing the talocrural joint – the joint between the distal tibia-fibula and the talus.

Morton’s Neuroma Diagnosis:

• Employ a dynamic scanning technique using plantar pressure. Marc Schmitz stated, “It’s important indeed to do it dynamically because this… shows you indeed much better the nerve swelling, the neurofibroma, than if you would do it statically”.

• With this technique, “you will see the thickening of the Morton’s neuroma coming more towards superficial and in many cases also surrounded with a fluid, which is a sign of a bursa”.

Marc describes his scanning technique when looking for the presence of a Morton’s neuroma between the 3rd and 4th metatarsal bones in this video.

Q&A Highlights from the Webinar:

Q: Is the MSK preset or the Foot and Ankle preset preferred on the L15?

A: Marc Schmitz recommended using more dedicated presets, stating, “If you can use more dedicated presets, then this is always much better. So, if you can work with the ankle and foot preset, definitely do so.”

Q: Do you ever do a plantar neuroma approach for examination?

A: Marc Schmitz explained that while other protocols exist, his preferred dynamic technique with plantar thumb pressure is “the easiest way, but it’s definitely not the only way”.

Q: What is the best way to inject for a neuroma, dorsally or in between the web space?

A: Marc Schmitz noted that while he might personally prefer a dorsal approach, “practice has shown that it is less painful” to inject in the web space, which patients prefer.

Q: Do you assess plantar plates with the L15? Can you see enough to grade a plantar plate pathology?

A: Marc Schmitz confirmed, “You can definitely see the plantar plates. You can also do the stability testing. Yeah, so you can definitely see this plantar plate.”

Q: The learning curve for ultrasound appears steep. How can one learn this without an expert beside them?

A: Marc Schmitz described ultrasound as “easy to learn and hard to master”. Sonoanatomy is quick to learn, but pathology recognition requires extensive practice. He recommended courses with hands-on training and e-learning.

Q: What is the normal thickness of the plantar fascia?

A: Based on the AI measurement shown by Janaye Smith, the normal thickness is “under four millimeters”. Marc Schmitz added that he typically uses left-right comparisons but would increasingly use the AI tool for its ease of use.

Q: Is there a visible difference on ultrasound when assessing gout crystals versus pseudogout versus hydroxyapatite crystals?

A: Yes, Marc Schmitz explained that in CPPD (pseudogout), crystals are seen “in the middle of the hyaline cartilage,” whereas in gout, “the top layer of the cartilage is different and is more hyperechoic”.

Benefits of Using Clarius Ultrasound for Podiatry:

Embracing POCUS can significantly enhance your diagnostic capabilities and treatment planning in podiatry. With advanced, user-friendly systems like Clarius, integrating ultrasound into your practice is more accessible than ever. Shelley Guenther highlighted these advantages of the Clarius HD3 portable ultrasound scanners for podiatry practices:

• High Resolution Imaging: Clarius delivers best-in-class wireless ultrasound with high-resolution MSK imaging.

• Artificial Intelligence (AI) Assistance: “With AI replacing complex knobs and buttons, it’s as easy to use as your smartphone”. Marc Schmitz added that “the MSK AI tool is really cool » and “the automated measurement, it’s really fantastic… it gives you so much extra information”.

• Portability & Convenience: Clarius is “wireless, freeing up space with zero footprint for ultra portability in a variety of settings”.

• Cost-Effectiveness: Offers significant savings, “about an 85% savings” compared to larger systems.

• Procedure Guidance: Useful for “safe ultrasound-guided procedures like PRP injections”.

To learn more about how easy and affordable it is to add Clarius HD3 to your podiatry or MSK practice, contact us today or request a personalized virtual ultrasound demo.