Abstract

Objectives: In this systematic review, we assess the accuracy and effectiveness of ultrasound (US)-guided injections compared to alternative modalities for the treatment of tibiotalar joint.

Materials and methods: A systematic review was conducted following the Cochrane process from April 2023 to August 2023 utilizing PubMed, Ovid Embase, Web of Science, and Scopus. Branched logic was used to include articles containing terms regarding the tibiotalar joint, US and injections. Studies were screened for eligibility by two authors, and any disagreements were resolved through discussion with a third reviewer. Risk of bias assessments were performed.

Results: A total of five studies were included in the review, comparing various local delivery techniques for the treatment of tibiotalar joint. Three of these studies were cadaveric, while two studies were performed in surviving patients. In general, both the cadaveric studies and studies in surviving patients demonstrated increased accuracy of US-guided compared to landmark (LM)-guided injections of the tibiotalar joint. In a randomized-controlled trial of US-guided versus LM-guided injections in patients with inflamed joints, there was a greater improvement in pain control according to Visual Analog Scale (VAS) scores at six weeks (30.6 mm vs. 21.2 mm; p = 0.030). A retrospective study demonstrated 2.3 times greater success with image-guidance (US or fluoroscopy) compared to LM, with no significant difference between US and fluoroscopy (p = 0.09).

Conclusion: This systematic review provides evidence that US-guided injections demonstrate a higher level of accuracy as compared with LM-guided injections. However, risk of bias concerns, the limited number of included studies, particularly in vivo studies, and the lack of published, high-quality randomized-controlled trials investigating efficacy limit our ability to make definitive conclusions regarding clinical outcomes of US versus LM-guided tibiotalar injections.

Introduction

The tibiotalar joint, commonly referred to as the ankle joint, is a synovial hinged joint formed by the distal tibia, fibula and the talus bones. Ligaments surrounding the joint provide stability and restrict excessive movement. The tibiotalar joint belongs to the larger ankle complex which additionally comprises the subtalar and talocalcaneal joints.[1] The tibiotalar joint is susceptible to pathologies such as degenerative or post-traumatic osteoarthritis, inflammatory arthropathies with synovitis, repetitive overuse injuries, or impingement syndromes which may benefit from injection therapies.[2,3]

Injections of the ankle joints are used for diagnostic and therapeutic purposes in several conditions.[4-10] Accurate needle placement is critical in ensuring delivery of injectate that could potentially impact the diagnosis, treatment, and outcome.[11] Ultrasound (US), fluoroscopy, and palpation have been used to guide these injections.[12-15]

In this systematic review, we assess the accuracy and effectiveness of US-guided injections compared to alternative modalities with the aim of improving understanding of their comparative performance in guiding clinical decision-making, enhancing patient outcomes, and optimizing the delivery of musculoskeletal interventions.

Material and Methods

Search strategy

A systematic review was done following the Cochrane process from April 2023 to August 2023.[16] The protocol for this review was not registered. Review guidelines were established prior to the search process. A multisystem search was performed (PubMed, Ovid Embase, Web of Science, and Scopus) for English published articles. We utilized branched logic to include articles containing terms regarding (Ankle OR Ankle Joint OR Tibiotalar Joint OR Tibiotalar OR Talocrural Joint OR Ankle Injury) AND (Ultrasound OR Ultrasonography OR Sonography OR Ultrasound-Guided)) AND ((Ultrasound-Guided Injection OR Injection OR Intra-Articular Injection OR Tibiotalar Injection OR Steroid Injection) OR (Anatomic Landmark OR Fluoroscopy OR Saline Solution OR Placebo OR Sucrose OR Physical Therapy OR Watchful Waiting). Two researchers screened studies for eligibility, and any disagreements were resolved through discussion with a third reviewer.

Outcome measures

The main outcome for this systematic review was to evaluate the accuracy of US- versus non-US guided tibiotalar joint injections. Accuracy was usually defined as the successful deposition of injectate within the tibiotalar joint capsule, as confirmed by imaging (US or fluoroscopy) or dissection (in cadaveric studies). The methods for assessing accuracy varied across studies, including sonographic visualization of fluid distension, fluoroscopic confirmation with contrast, or identification of injected dye within the joint during dissection. Non-US guided injections were primarily performed using anatomical LM guidance based on palpation. Due to a paucity in available research, we reviewed the efficacy of US-guided intervention in alleviating pain compared to an alternative injection modality as a secondary outcome measure.

Data abstraction

Data abstraction was completed by a standardized approach for each study. In our data abstraction, we included the following fields where appropriate: first author, study objective, study design, country location of the study, age of the participants, eligibility criteria outlined by the study, number of cases and controls, and results of the study. Results of these studies could include efficacy of the injection treatment, delivery method, and patient reported outcomes (Table 1).

Table 1. Characteristics of studies included

Table 1. Continued

Assessment of study quality

For our systematic review, we employed two assessment tools: the Newcastle-Ottawa Quality Assessment Scale (NOS) and the Revised Cochrane Risk of Bias Tool for Randomized Trials (RoB 2).[16,17]

The NOS is tailored for evaluating the quality of non-randomized studies, such as observational, cohort, and case-control studies, in the context of systematic reviews and meta-analyses. It evaluates studies across three main domains: selection bias, the comparability for addressing confounding variables, and the assessment of outcomes or exposures. Higher scores on the NOS typically indicate lower risk of bias and higher study quality (e.g., a score of 7 or higher is often considered high quality). Meanwhile, the RoB 2 tool is a comprehensive and widely recognized method for evaluating the risk of bias in randomized-controlled trials (RCTs) included in systematic reviews and meta-analyses. It focuses on five key areas: the risk of bias from the randomization process, deviations from the intended interventions, missing outcome data, bias in outcome measurement, and bias in the selection of reported results. Reviewers use a series of guiding questions within each domain to assess and categorize the risk of bias as “low” (minimal risk of bias), “some concerns” (some doubt about the reliability of the result due to potential bias) or “high” (substantial risk of bias likely to affect the result) for each study based on responses to the signaling questions. The overall risk of bias for a result is the least favorable domain-level judgement.

Results

The initial search found 2,871 manuscripts excluding any duplicated (Figure 1). Of those manuscripts, 56 were found to meet the eligibility criteria for screening. From that point, the authors excluded 19 studies due to incorrect study design, 27 studies due to wrong intervention, three studies due to wrong indication and two studies due to wrong setting. After completion of the review, a total of five studies met the inclusion criteria (Table 1). Those studies were, then, analyzed by the NOS (Table 2a) and ROB 2 (Table 2b). The single RCT notably showed a low risk of bias, while the other four studies exhibited moderate to high risk of quality bias.

Figure 1. Identification of studies.

Table 2a. Quality Assessment using the Newcastle-Ottawa Quality Assessment scale of included studies

Table 2b. Quality assessment using the Revised Cochrane Risk-of-Bias Tool for Randomized Trials

Of the five studies selected for this review, a broad nonblinded cadaveric study assessed provider confidence and accuracy in LM guidance and US for arthrocentesis in the hip, ankle, and wrist.[18] In that study, saline was injected into tibiotalar joint of cadavers by emergency medicine residents and success was denoted by a sonographically visualized effusion post injection. Ultrasound-guidance demonstrated 100% accuracy, while LM guidance demonstrated 94% ( p = 0.31). Additionally, an increase in post-training confidence while comparing US to LM (2.0 to 4.3, delta 2.3 vs. 2.3 to 3.8, delta 1.5; p < 0.001) was noted. A second follow-up comparative cadaveric study demonstrated a similar finding.[2] The aforementioned study found 100% accuracy with US compared to 85% accuracy with LM (p = 0.1154). To further establish the increased accuracy of US, an additional study demonstrated an accuracy of 100%.[15] These three cadaveric studies showed that US was more accurate than LM for tibiotalar arthrocentesis. While compiling these cadaveric studies, US demonstrated an accuracy of 100% of the 47 tibiotalar joints injected compared to 89% of the 37 tibiotalar joints injected by LM.

A double-blind RCT in 2010 attempted to investigate whether US could improve accuracy and clinical outcomes in patients with inflamed joints.[19] The aforementioned study found that, while injecting the tibiotalar joint, there was an accuracy of 85% with US compared to 58% with LM (p = 0.131). Additionally, with increased accuracy, there was a greater improvement in pain control according to Visual Analog Scale (VAS) scores at six weeks (30.6 mm vs. 21.2 mm; p = 0.030).

A high-quality retrospective study assessed the success of hyaluronic acid injections into the ankle joint comparing US, LM, and fluoroscopic guidance.[20] In this study, success was defined based on patient satisfaction and efficacy outcomes rather than sole needle positioning. That study demonstrated 2.3 times greater success with image-guidance compared to LM, with no significant difference between US and fluoroscopy (p = 0.09). This study also demonstrated increased accuracy and efficacy of imaged guidance, compared to LM guidance (p = 0.03).

Discussion

In this systematic review, we identified five studies, which met criteria to assess for accuracy as well as efficacy of the US-guided tibiotalar joint interventions. It is important to note that efficacy was not evaluated as a primary outcome in all included studies. All the studies compared tibiotalar joint interventions to either image-guided interventions (US and fluoroscopy) or LM-guided interventions. The results of this systematic review showed high accuracy of US tibiotalar joint injections, with all included studies reporting superior accuracy compared to LM injections. While US demonstrated improved precision in needle placement, evidence on its impact on clinical efficacy, such as pain relief and functional improvement, remains limited. One study, indicated that increased accuracy of US correlated with better pain control in patients with inflammatory arthritis of the tibiotalar joint,[19] but this finding has not been consistently replicated across other patient populations or conditions due to a paucity of studies investigating this correlation.

Nonetheless, one of the major limitations to this review is the relatively small number of studies that focus on both accuracy and efficacy in a clinical setting, particularly those assessing long-term outcomes such as sustained pain relief and functional improvement. Also, most of the available studies, including the cadaveric investigations, are limited to short-term assessments of accuracy. Furthermore, only two studies assessed patient-reported outcomes, which are critical for understanding the full clinical benefit of US. This highlights the need for future research to prioritize high-quality, RCTs that not only evaluate injection accuracy, but also incorporate patient-centric outcomes such as quality of life and long-term joint function. Finally, the heterogeneity of studies included in this review precluded the ability to perform a meta-analysis.

In conclusion, this systematic review provides evidence that US injections demonstrate a higher level of accuracy as compared to LM injections. However, risk of bias concerns, the limited number of included studies, particularly in vivo studies, and the lack of published, highquality RCTs investigating efficacy limit our ability to make definitive conclusions regarding clinical outcomes of US-versus LM-guided tibiotalar injections. Nevertheless, considering a consistent demonstration of increased accuracy with US injections, clinicians should weigh the benefits of increased accuracy against the lack of definitive evidence for improved long-term clinical outcomes when selecting between US and alternative guidance methods.

Citation: Gharib M, Cleland T, Peraka V, Özçakar L, Jain NB. Accuracy and efficacy of tibiotalar joint injections under ultrasound guidance: A systematic review. Arch ISPRM 2026;1(2):99-105. https://doi.org/10.5606/archisprm.2026.31.

N.B.J., L.Ö.: Idea/concept; M.G., T.C., V.P., L.Ö., N.B.J.: Design, control/supervision, data collection and/or processing, analysis and/or interpretation, literature review, writing the article, critical review, references and fundings, materials.

The authors declare that there are no conflicts of interest with respect to the research, authorship, and/or publication of this article.

AI Disclosure
The authors declare that artificial intelligence (AI) tools were not used, or were used solely for language editing, and had no role in data analysis, interpretation, or the formulation of conclusions. All scientific content, data interpretation, and conclusions are the sole responsibility of the authors. The authors further confirm that AI tools were not used to generate, fabricate, or ‘hallucinate’ references, and that all references have been carefully verified for accuracy.

This research received no specific grant from any funding agency in the public, commercial, or not‑for‑profit sectors.

Data Availability
The datasets generated and/or analyzed during the current study are available from the corresponding author on reasonable request.

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