Ultrasound in Foot & Ankle Overuse Injuries

Introduction

Foot and ankle injuries are some of the most common problems seen in both everyday patients and competitive athletes. Many of these are overuse injuries stress fractures, tendinopathies, or impingement syndromes that build silently over time until pain forces people to stop.

Traditionally, clinicians have leaned on X-rays or MRI to make the call. But research spanning from Teh et al. (2011)  to recent physiotherapy-focused reviews (Papadopoulos & Mani, 2025; Leineweber, 2025) suggests musculoskeletal ultrasound (MSK US) is becoming an indispensable part of this puzzle fast, radiation-free, and increasingly portable.

The Overuse Spectrum in the Foot & Ankle

According to Teh and colleagues (2011), overuse injuries here include:

• Stress fractures (metatarsals, navicular, calcaneus)

• Tendinopathies (peroneal, tibialis posterior, Achilles)

• Plantar fascia injuries (fasciitis, rupture)

• Impingement syndromes (anterior, posterior, anterolateral, sinus tarsi)

• Nerve entrapments (tarsal tunnel, Baxter’s neuropathy)

These are notoriously hard to diagnose on clinical exam alone. Imaging closes that gap. Where Ultrasound Adds Value

Stress fractures

• X-rays miss early-stage stress injuries in up to 80% of cases .

• Ultrasound detects periosteal reaction, cortical irregularity, and Doppler hypervascularity earlier than plain films.

• MRI is still the gold standard but ultrasound is a great first-line tool or bedside adjunct, especially in athletes, military recruits, or pregnant patients .

Metatarsal stress fracture. Longitudinal extended field-of-view ultrasound image showing periosteal reaction (arrowheads) at the fracture site.  

Tendinopathies

• Ultrasound shows loss of fibrillar structure, thickening, partial tears, or hypervascularity in tendons like the peroneals or tibialis posterior.

• Dynamic scanning captures subluxations or impingement that static MRI might miss.

Left Achilles showing hypoechogenicity and thickening

Plantar fascia

• Fasciitis appears as fusiform thickening and loss of echogenicity; rupture as a discontinuity with surrounding edema.

• Ultrasound is fast and can be used to monitor recovery in real time.

The study reveals a thickening and minimal hypoechoic echoparttern of the right plantar fascia (only proximal part).

Impingement syndromes

• Posterior ankle impingement (common in ballet dancers, soccer players) can be picked up by ultrasound showing synovial thickening or FHL tenosynovitis .

• Anterolateral impingement lesions may also be seen dynamically on ultrasound.

Advantages Over Other Imaging

• Radiation-free (safer for young athletes, pregnant patients).

• Dynamic (movement, load tests in real time).

• Portable & cost-effective (sideline, clinic, or ICU use).

• Patient engagement (showing the injury live builds understanding & compliance).

But as both Teh (2011) and Leineweber (2025) stress operator training matters. MSK US is powerful but highly user-dependent, which is why structured education for physiotherapists and sports clinicians is key.

Clinical Takeaway

• Use ultrasound early when overuse injuries are suspected but X-rays are negative.

• Lean on MRI when deeper structures or surgical planning is required.

• Integrate both: ultrasound as a rapid, first-line and follow-up tool; MRI/CT for gold-standard confirmation.

For sports clinicians, this means faster return-to-play decisions, fewer missed injuries, and more confidence in managing overuse problems that once lingered for months.

Conclusion

Overuse injuries in the foot and ankle are common, complex, and often missed. Ultrasound is not about replacing MRI, but about making diagnosis faster, safer, and more accessible. As the technology becomes more portable and training expands, it’s likely ultrasound will move from a “nice-to-have” to a must-have tool in everyday sports medicine.

References

1. Teh, J., Suppiah, R., Sharp, R., & Newton, J. (2011). Imaging in the assessment and management of overuse injuries in the foot and ankle. Seminars in Musculoskeletal Radiology, 15(1), 101–114. https://doi.org/10.1055/s-0031-1271962 

2. Leineweber, F. A. J. (2025). Evaluating the efficacy and diagnostic potential of musculoskeletal ultrasound imaging in stress fractures (Master’s thesis). Lithuanian University of Health Sciences, Faculty of Medicine, Department of Radiology. 

3. Papadopoulos, E., & Mani, R. (2025). The value of musculoskeletal ultrasound imaging in physiotherapy clinical assessment and practice. Health & Research Journal, 11(3), 282–296. https://doi.org/10.12681/healthresj.39362