Musculoskeletal Ultrasonography in Physical and Re

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Musculoskeletal ultrasonography in physical and rehabilitation medicine

Article  in  Journal of rehabilitation medicine: official journal of the UEMS European Board of Physical and Rehabilitation Medicine · March 2012
DOI: 10.2340/16501977-0959 · Source: PubMed

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J Rehabil Med 2012; 44: 310–318

Review Article

MUSCULOSKELETAL ULTRASONOGRAPHY IN PHYSICAL AND


REHABILITATION MEDICINE

Levent Özçakar, MD1, Fatih Tok, MD2, Martine De Muynck, MD3 and
Guy Vanderstraeten, MD, FRCP3
From the 1Hacettepe University Medical School, Department of Physical Medicine and Rehabilitation,
Ankara, 2İskenderun Military Hospital, Physical Medicine and Rehabilitation Service, Hatay, Turkey and
3
Gent University Medical School, Department of Physical Medicine and Rehabilitation, Gent, Belgium

Musculoskeletal ultrasound has gained a significant place in identify submarines. The first medical ultrasound was used in
the diagnosis and management of various musculoskeletal 1942 in an attempt to diagnose brain tumours (4). As the diag­
disorders due to its several advantages (being convenient, nostic potential of ultrasound grew, it gained applications in
inexpensive, non-invasive, repeatable, providing dynamic the fields of obstetrics, gynaecology, oncology and cardiology
imaging and not requiring any exposure to radiation). It has in the late 1950s and early 1960s (5). Although articular and
also become a valuable tool in the daily clinical practice­ of periarticular structures, such as muscles, tendons, cartilage and
physical and rehabilitation medicine physicians; the musculo­ bone, were first described by ultrasound in 1958 by Dussik,
skeletal ultrasound probe having become synonymous with it was not until 1972 when the first diagnostic application of
the physician’s stethoscope. In this paper, aside from draw- MSUS, to differentiate Baker’s cysts from thrombophlebitis,
ing attention to this growing issue in the agenda of PRM phy-
was published by McDonald (4, 6). Initially, diagnostic ultra-
sicians, we will touch upon its basic technical features and
sound applications were limited due to poor resolution and lack
certain aspects as regards muscle, tendon, ligament, nerve,
of real-time imaging capability. During subsequent years, PRM
joint lesions and ultrasound guided interventions.
physicians began to lead the medical community with the use
Key words: ultrasound; physical and rehabilitation medicine; of therapeutic ultrasound as a deep-heating modality. In the
tendon; muscle; nerve. 1980s, with the use of real-time detailed anatomical imaging,
J Rehabil Med 2012; 44: 310–318 diagnostic musculoskeletal ultrasound became capable of fully
Correspondence address: Levent Özçakar, Hacettepe Üniver- evaluating the musculoskeletal system. This is true not only for
sitesi Tıp Fakültesi Hastaneleri FTR AD, Zemin Kat, Sıhhıye, musculoskeletal physicians, but also for veterinary physicians
Ankara, Turkey. E-mail:[email protected] (7). With revolutionary advances in imaging resolution and
Submitted January 2, 2012; accepted February 15, 2012 capabilities, high-speed digital processing, transducer technol-
ogy and declining costs, in the past 20 years, the production of
high-quality images of musculoskeletal structures has become
INTRODUCTION
routine in daily clinical practice, even for the detection of
The role of musculoskeletal ultrasound (MSUS) in the diagnosis relevant prenatal diagnoses.
and management of musculoskeletal disorders has increased in
recent years, not only in clinical applications but also in research Advantages and limitations of musculoskeletal ultrasound
(1, 2). Ultrasonography is convenient, inexpensive, non-invasive, In addition to the aforementioned advantages, MSUS has several
repeatable, and does not require exposure to radiation. Further- other exclusive features in relation to basic radiography (X-rays),
more, because it can provide dynamic imaging and comparison, computed tomography (CT) and magnetic resonance imaging
it now has a paramount role in the diagnostic algorithm of a wide (MRI), especially in focused musculoskeletal and neurological
spectrum of diseases in physical and rehabilitation medicine examinations. Ultrasound is used in a hands-on, interactive
(PRM) (3). However, due to certain barriers (e.g. the lack of an examination, which allows the practitioner to use real-time
ultrasound device in the majority of PRM clinics and lack of high-resolution soft-tissue imaging. It can be performed con-
education), only a small minority of PRM physicians is able to veniently by physicians, and is readily accepted by patients.
use MSUS in clinical practice (1). By highlighting the general Rapid side-to-side comparison can be performed easily. This
principles and applications of MSUS in this paper, we aim to is not only an advantage, but also is an accepted prerequisite
remind PRM physicians of this increasingly useful technique. for prompt diagnosis among experienced sono­graphers. A large
number of joints in different regions of the body can be imaged
rapidly and selectively during a single examination session.
DEVELOPMENT AND USE OF ULTRASOUND
MSUS provides the best means of dynamic assessment of the
History of ultrasound movement of the musculoskeletal system. Changes in various
Ultrasound was utilized first for maritime purposes after the structures can be appreciated readily during active, resisted,
sinking of the Titanic in 1912 to detect icebergs and, later, to and passive motions. In addition, one can perform sonographic
J Rehabil Med 44 © 2012 The Authors. doi: 10.2340/16501977-0959
Journal Compilation © 2012 Foundation of Rehabilitation Information. ISSN 1650-1977
Musculoskeletal ultrasonography in PRM 311

palpation or “sonoauscultation” by moving the probe on the most an adjacent structure) and hyperechoic (a structure with low
painful area. For example, if the sonographer detects a patho­ water content, which has increased brightness of its echoes
logy exactly at the place where the patient indicates (which is relative to an adjacent structure).
also painful during compression with the probe), it is of utmost The transducer (probe) is an essential part of the ultra-
value for the diagnosis and quite convincing for the patient. sonography equipment and is responsible for the generation
Moreover, its high repeatability and sensitivity to change offer of the ultrasonography beam and detection of returning ech-
potential use in monitoring disease progression and evaluation oes. A variety of linear-array transducers (large (> 40 mm),
of the therapeutic efficacy of both local and systemic treatments medium-sized (< 40 mm) and small-field of view (hockey-
(8). Above all, it has no known contraindications. stick-shaped)) are currently available in the frequency range
Another important benefit of MSUS in clinical practice lies used for musculoskeletal examinations. Selection of the
in guidance for diagnostic and therapeutic interventions. MSUS most appropriate transducer primarily depends on the fre-
can be used to assist needle positioning to facilitate invasive quency (multi-frequency, high-frequency, low-frequency, etc.)
procedures, such as aspiration of fluid, drainage of abscess, whereby high-frequency probes (e.g. 10–25 MHz) are used to
tissue biopsy and local injection of therapeutic agents. Sono- visualize superficial structures and low-frequency ones (e.g.
graphic guidance is particularly useful when fluid collections 5–10 MHz) are used to visualize deeper tissues.
are very small or when the trajectory of the needle is adjacent Improvements in fast digital computer processing and mem-
to vital structures (e.g. nerves and arteries) that could be badly ory storage capacity have recently improved the possibility of
damaged during the procedure. applying 3-dimensional (3D) technology to ultrasonography.
The major limitation of MSUS is that it is user-dependent. 3D acquisition can be achieved with ultrasonography using
Accordingly, experience, and thus education, is mandatory either 2D conventional transducers equipped with a small
before one can confidently comment on the images of vari- electromagnetic positional sensor or with dedicated “3D-
ous pathologies. Because sound waves do not penetrate bony volume transducers”, which are larger than the standard probes.
structures, a further disadvantage is its limited field of view, Although the probes are difficult to handle, they provide better
potentially resulting in incomplete evaluation of the whole joint assessment of each scanning plane.
anatomy (8). However, this limitation can partly be overcome Newer ultrasonography techniques, including colour and
with certain manoeuvres (e.g. internal rotation of the shoulder power Doppler imaging, provide colour maps of tissues. The
for anteriorizing the rotator cuff). Therefore, in short, unless amount of colour is related to the degree of blood flow, which
it is inside the bone or covered with bony tissue, almost any may be of use in the assessment of vascular tissues, as in
structure of the musculoskeletal system can be visualized soft-tissue inflammation (8, 9). Power Doppler, which is very
with ultrasound. sensitive for illustrating inflammation, is commonly used in
rheumatic diseases (e.g. for the diagnosis and follow-up of
Basic concepts in ultrasonography and equipment synovitis) (10), traumatic injuries (e.g. healing tendinitis)
Ultrasonography is based on the emission and reception of (11) or in the assessment of mass lesions (i.e. benign vs ma-
sound waves with a frequency greater than the hearing range lignant) (12).
of the human ear, by piezoelectric crystals located inside the
transducer or probe. Depending on the technical features of the Applications and skills
particular device, wave frequencies of diagnostic ultrasono­ Ultrasonography produces a 2D view of a 3D structure. The
graphy systems generally range from 3 to 25 MHz. Ultrasound ability to skilfully manipulate the probe using specific move-
waves are transmitted through different structures depending ments (sliding, tilting, rotating, and heel-toeing) ensures that
on their composition, and are reflected at the interfaces between the targeted structures are examined completely. Because there
materials of different acoustic impedance. Most musculoskel- is gel between the skin and the probe, strict positioning can
etal work is performed using grey-scale, whereby images are sometimes be challenging. In this respect, it is better to hold
produced in black-and-white format, each white dot represent- the probe with the first and second fingers (sometimes with the
ing a reflected sound wave. During the travel of the sound third as well) of the hand being used and let the fourth and fifth
waves; the denser a material is (e.g. bone cortex) the more touch the patient for stabilization (Fig. 1). The probe should
reflective it becomes and, accordingly, the whiter it appears on be moved throughout the entire range of the structure to scan
the screen. On the other hand, water is the least reflective tissue substantially and to avoid errors of oversight. Each anatomi-
and it therefore appears as black, while the sound waves travel cal area should be explored on various scanning windows (at
straight through it. Herein, two factors influence reflectivity: least two perpendicular planes) so as to obtain all of the neces-
the acoustic impedance of materials and the angle of incidence sary information and for appropriate confirmation of a likely
of the sound beam. Acoustic impedance is the product of a diagnosis. If possible, it is suggested that a bony landmark
material density and the speed of sound within that substance. be kept on the screen for better topographic orientation. With
According to the intensity of the echo, images are categorized experience, a physician can easily develop scanning skills for
in 3 forms, as follows: anechoic (a structure with high water image optimization and probe manipulation. At this point, a
content that does not produce any internal echoes), hypoechoic standardized approach to the study of the various anatomical
(an area that has decreased brightness of its echoes relative to regions is also recommended.

J Rehabil Med 44
312 L. Özçakar et al.

Fig. 1. Positioning the probe for imaging the bicipital tendon, (A) axially
and (B) longitudinally, on the anterior side of the right shoulder.

In order to facilitate the detection of abnormalities it is Fig. 2. A 9-year-old boy, who had been operated for Legg-Perthes-Calvé
important for physicians to become familiar with the unique disease, was referred for ultrasonography evaluation of the thigh. The
image was obtained by inserting the probe inside the external fixator. The
appearance of each healthy musculoskeletal structure. An in-
two tips of the screws (white arrowheads) and their hyperechoic “comet
depth knowledge of musculoskeletal anatomy is also critical. tail” artifacts (black arrows) are observed.
In this regard, the presence of two textbooks (one on MSUS
and the other on anatomy) in the ultrasonography room will
always be useful for a sonographer. son (in case of bilateral involvement with that of a normal
subject);
Artifacts • is the structure/tissue present?
An artefact is an image attribute that is not present in the • is its shape/size normal?
original imaged object. It may be the result of incorrect opera- • is its echogenicity normal?
tion of the imaging equipment, or a consequence of natural • is its movement normal?
processes or properties of the human body. An artefact can be • is the Doppler evaluation normal?
false, multiple or misleading information introduced by the
imaging system or by interaction of ultrasonography with the
Diagnostic USE OF ULTRASONOGRAPHY
adjacent tissue. While some artifacts reduce the diagnostic
power of the scan (anisotropy, reverberation, refraction, speed Muscle lesions
of sound, beam width, motion, electrical noise and frame buffer Muscles are rather large structures, some even traversing over
dropout), others can be helpful (enhanced through transmis- two joints. Therefore, long linear probes are necessary for their
sion, shadowing, “comet tail”) (13). examination. On longitudinal view, the echotexture of a nor-
In clinical practice, the artifacts may be used bi-directionally. mal skeletal muscle is that of hyperechoic fibroadipose septae
In the first scenario, the sonographer, while visualizing the (thin, bright, linear bands (“veins on a leaf”) (14) and anechoic
condition or structure, recognizes and ignores its relevant contractile tissue. In pennate muscles, these parameters (penna-
artefact (Fig. 2). On the other hand, in the second scenario, tion angle and fascicle length) can even be quantified precisely
the sonographer, without being able to visualize the relevant (15, 16). On transverse view, the septae appear as spot echoes
structure or condition at first glance, initially recognizes the with short, curvilinear, bright lines spreading throughout the
particular artefact and thereafter finds the origin of it (e.g. using hypoechoic background (“starry night”) (14).
the “comet tail” artefact to localize an otherwise unseen small
foreign metallic object inside a large compartment).
The rest of this review will focus on ultrasonography
Table I. Typical ultrasound appearance of some musculoskeletal
imaging of different components of the musculoskeletal sys- structures
tem (muscles, tendons, joints, ligaments, peripheral nerves,
Structure Longitudinal view Transverse view
cartilage and bones) in various pathologies for which MSUS
has improved our diagnostic, follow-up and interventional Muscle “Veins on a leaf” “Starry night”
Tendon Hyperechoic ribbon-like Numerous joined dots in
abilities in daily PRM practice (Table I). The general points band round or oval structures
that should always be kept in mind by sonographers during Ligament Bright, echogenic, linear “Broom-end”
MSUS, regardless of the tissue or structure being examined, structure
are listed below: Peripheral nerve Hyperechoic lines with “Honeycomb”
• the pathology should be viewed in at least two planes; hypoechoic separation in
• the pathology should be confirmed with side-to side compari- between

J Rehabil Med 44
Musculoskeletal ultrasonography in PRM 313

MSUS can be used to evaluate a wide spectrum of muscle that there is a rupture and vice versa. In addition, it is worth
pathologies, including strain/rupture, haematoma, myositis mentioning that in small lesions, but not in occult ruptures, it is
ossificans (even in the early period when X-rays are non-con- recommended that ultrasonography be performed 24–48 h after
tributory), myositis, compartment syndrome, rhabdomyolysis, the injury and earlier (12 h) for unipennate muscles (18).
hernia and tumours (17). Its real-time capability is unique in
also providing a means to evaluate structures under dynamic Tendon lesions
conditions. This allows diagnosis of lesions (e.g. hernia) that
Similar to muscle scanning, the capability of MSUS to provide
would otherwise remain obscure. Furthermore, serial follow-up
dynamic real-time imaging makes it the first choice in the
examinations provide valuable information about the healing
diagnosis of tendon pathologies. During the ultrasonographic
process and prognosis of the injury. The availability of repeat
examination, it is important to apply a correct orthogonal
evaluations can provide the physician with useful information
direction to the ultrasonography beam, both for longitudinal
at any time during the course of management.
and axial views, in order to avoid an anisotropy artefact, which
The overwhelming majority of muscle pathologies are trau-
is the dropout of echoes that occurs if the ultrasound beam is
matic in origin, being either occupational or sports-related.
not perpendicular to the fibres of a tendon.
According to the causative factor and localization, the extent
Tendons are composed largely of parallel running fascicles
of the injury may vary considerably. For instance, in case of a
of collagen fibres that interweave and interconnect. In longitu-
small rupture of the muscle; local haematoma and disruption
dinal view, tendons appear as hyperechoic ribbon-like bands,
of the normal muscle architecture may ensue. However, in case
with fibrillar internal structure and marginal hyperechoic line
of a gross lesion at the myotendinous junction, the resultant
corresponding to the paratenon. In transverse view, they appear
haematoma may elongate next to the lining of the outer fascia
as round or oval structures, characterized by numerous closely
(Fig. 3). In general, rupture and haematoma are commonly
joined dots, which are homogeneously dispersed, correspond-
pronounced interchangeably; if there is a haematoma it is likely
ing to the intra-tendinous connective fibres.
Tendon pathology ranges in severity from tendinosis (tendon
degeneration) to intrasubstance or partial-thickness tears and
to more severe abnormalities such as full-thickness tears or
complete rupture (Fig. 4). Tendinosis occurs as a focal or dif-
fuse process, causing a heterogeneous or ill-defined hypoechoic
appearance without loss of tendon volume, whereas partial tears
demonstrate a more defined defect within the tendon. A focal,
hypoechoic, or anechoic gap or cleft through the tendon is
consistent with a full-thickness tear. Non-visualization of the
tendon with retrac­tion of its ends is diagnostic of a complete tear.
Herein, the sonographer should always be alert for anisotropy in
order to avoid misinterpretation as a tendon rupture. In case of
tendinitis/tenosynovitis, fluid within the tendon sheath, thickened
synovium, loss of the normal fibrillar echotexture, blurred tendon
and/or its margins (representing oedema) and increased flow on
power Doppler may be present in this condition (19) (Fig. 5).

Fig. 3. Bilateral ultrasonographic imaging of the gastrocnemius (G) and Fig. 4. (A) Positioning of a patient’s shoulder in internal rotation for better
soleus (S) muscles of a handball player with acute tennis leg. (A, B) visualization of the rotator cuff in axial view. (B, C) In a 63-year-old
Hyperechoic fibroadipose septae (white arrowheads) are observed forming lady with shoulder pain, bilateral – full-thickness, partial – supraspinatus
the pennate structure of the gastrocnemius muscle in longitudinal views; tendon (ssp) ruptures are seen as anechoic clefts (white arrows) over the
(C, D) and in the form of “starry sky” in axial views. (B, D) On the right cortical irregularities (black arrows) of the humeral heads (h). (C) Ssp is
side of the image, a haematoma (white stars) is observed between the thicker on the right side and the rupture extends in a wider base on the
fascia and the abnormal muscle tissue with irregular intrinsic pattern (subdeltoid) bursal surface. (B) On the left side, the deltoid muscle (d)
(black arrows). protrudes towards the rupture while compressing with the probe.

J Rehabil Med 44
314 L. Özçakar et al.

Fig. 6. A 55-year-old veteran athlete evaluated after an ankle sprain.


The arrows delineate the anterior talofibular ligament aligned between
the lateral malleolus (LM) and talus (T). While it is normal on (A) the
left side, it seems to be thickened (but intact) on (B) the right side. In
addition, anechoic accumulation of fluid (white stars) is present extending
from the sinus tarsi.

Fig. 5. Bilateral ultrasonographic imaging of the bicipital tendons of a Articular lesions


33-year-old man with bicipital tendinitis. Between the deltoid muscle
In a normal joint, bone profiles are seen as hyperechoic lines
(d) and humerus (h), the normal bicipital tendon (b) is observed as a
hyperechoic band in (A) the longitudinal view and (C) as an ovoid structure with shadowing underneath. Hyaline cartilage covering the
in the axial view. (B, D) On the right side of the image, the bicipital articular surfaces is depicted as a relatively anechoic, homo­
tendon is visualized as blurred and oedematous with surrounding fluid genous stripe with smooth contours covering the epiphyses. A
(white arrowheads) and synovial hypertrophy (white stars). (D) Doppler minimal amount of fluid can normally be found in the synovial
imaging reveals increased signal activity, consistent with synovitis (white recesses. Synovial tissue lining the joint is immeasurably
arrow). (C, D) Black arrows represent normal Doppler signals pertaining thin, with smooth, regular contours. Joint capsule is seen as
to anterior humeral circumflex arteries.
a hyperechoic line. In some cases dynamic assessment of the
joint by minimal active and passive movements may help to
localize it (24).
Ligament lesions In rheumatic diseases, the synovium undergoes significant
Ultrasonography imaging of ligaments is quite similar to that of changes leading to the formation of a mass of synovial tissue;
tendons. A normal ligament is seen as a bright, echogenic, lin- a result of oedema, multiple redundant folds, and villae. The
ear structure on MSUS; however, since the fibres of ligaments presence of joint, bursal or tendon sheath effusion is used
are more closely aligned, their echotexture is more compact as an excellent, indirect correlate of synovial inflammation.
and fibrillar. Ligaments are composed of dense connective Furthermore, the presence of fluid technically enables better
tissue, with variability in the amounts of collagen, elastin, visualization of the synovial thickening, proliferation and
and fibrocartilage. Therefore, imaging of ligaments may be villous formation during imaging. In the absence of an effu-
more variable than imaging of tendons. Likewise, the typical sion, synovitis is diagnosed by the presence of an abnormally
“broom-end” appearance on axial imaging at the entheseal sites thickened hypoechoic region, usually measured in a standard
can be used to distinguish ligaments from tendons (20). plane with reference to an established normal range or to the
Ligaments are best identified by placing the probe between contralateral normal joint. Therefore, MSUS can easily detect
the two bones that the ligaments connect. Ligamentous thicken- significant degrees of synovitis that are not determined by clini-
ing, heterogeneity, hypoechoic foci, and surrounding oedema cal examination and can reliably discriminate inflammatory
or haematomas may be seen in acute ligamentous injuries and non-inflammatory joint disease (5, 8, 25). This evaluation
(sprains) (Fig. 6). Even if the radiograph is negative, small has been enhanced on machines with power Doppler setting,
avulsion fractures of the adjacent bone can also be seen on which depicts the increased vascularity of the hypertrophied
MSUS. Calcifications may be observed in chronic lesions. The synovium by demonstrating microvascular flow. The Doppler
dynamic nature of MSUS evaluation can again be useful, in signal can distinguish between active and inactive synovitis,
this case, for testing the stability of the ligaments (21). correlating with clinical and laboratory data (26), MRI (27)
In addition, as regards the entheseal sites for both ligament and histology (28).
and tendon attachments, ultrasonography imaging plays a cru- Although it is non-specific, joint effusion is a valuable
cial role especially in the management of rheumatic diseases, indicator of active joint disease. Ultrasonography has been
e.g. by visualizing various degrees of tendon, ligament and shown to be one of the best methods for detection of increased
cortical inflammation or injury (22, 23). intra-articular fluid. Joint effusions are anechoic, compressible,

J Rehabil Med 44
Musculoskeletal ultrasonography in PRM 315

and devoid of Doppler flow (Fig. 7). However, ultrasonography


cannot yet accurately differentiate whether a fluid collection
is inflammatory, infectious or haematogenous in most cases,
and aspiration of fluid, which is more successful with MSUS
guidance, remains the gold standard. MSUS can give a basic
estimate of fluid viscosity, aiding selection of the appropriate
gauge size of the needle for fluid aspiration. Finally, it is im-
portant to appreciate that some types of chronic effusions can
be mistaken for synovitis, as the fluid will appear hyperechoic Fig. 8. A patient who had been operated for carpal tunnel syndrome 15
and is not easily displaceable by the probe (8). years previously was evaluated for recurrent complaints. (A) On the palmar
longitudinal view, normal median nerve (black arrows) is visualized as
Nerve lesions an anechoic tubular structure on the left side. (B) The median nerve,
over the flexor tendons (f), is observed to be enlarged both proximal and
Peripheral nerves are evident on the basis of their position and distal (white arrowheads) to the carpal tunnel level (white arrow) on the
internal structure. Normal nerves are quite uniform, closely re- operated side.
vealing their histological composition on MSUS. On transverse
views, nerves are observed as “honeycomb-like” structures DOPPLER ULTRASONOGRAPHY
composed of hypoechoic dots embedded in a hyperechoic
background, and fascicles run longitudinally within/around The capacity of high-frequency colour and power Doppler
the nerve. On longitudinal views, nerves typically assume systems to detect low blood flow and to correlate hyperaemic
an elongated appearance with multiple hypoechoic parallel changes with structural abnormalities has opened new perspec-
linear areas, which correspond to the neuronal fascicles that tives in the evaluation of a variety of musculoskeletal disorders.
run longitudinally within the nerve, separated by hyperechoic There has been significant growth in the application of Doppler
bands. Nerves are differentiated from tendons by their echo- systems in the diagnosis and semi-quantification (grading) of
texture, relative lack of anisotropy, location and proximity to synovitis because of its high sensitivity for the identification
the vessels (29). of increased blood perfusion in the synovium (39). The com-
Disorders detected accurately by MSUS include entrap- bination of high-resolution probes and the latest generation of
ment neuropathies, nerve luxations, masses, neuromas, colour/power Doppler workstations allow a clear depiction of
anatomical variants, inherited and developmental anomalies even a minimal increase in perfusion in several inflammatory
and traumatic injuries (30–37) (Figs 8 and 9). Noteworthy for conditions, such as tenosynovitis and enthesitis (40).
the imaging of entrapment neuropathies would be that, with Colour and power Doppler ultrasonography are also of use
the use of ultrasonography, one can both confirm entrapment in characterizing bursitis (Fig. 10), foreign bodies, infections,
(proximal swelling and compression at the site of entrapment),
but more importantly, one can also determine the underlying
cause (where one exists) (38). Lastly, ultrasonography may be
useful during a possible therapeutic injection or, in contrast,
sometimes may lead to refraining from intervention but instead
referring to surgery.

Fig. 9. (A) Longitudinal imaging of an ulnar nerve in a patient with


widespread involvement of neurofibromatosis type 1. Anechoic
Fig. 7. Comparative ankle joint imaging of a runner: anterior tibio-talar enlargements (white arrowheads) are seen throughout the nerve trunk
joint, longitudinal view. (A) Articular cartilage (white arrowheads) is in the forearm. (B) Median nerve imaging, performed for carpal tunnel
observed as a linear anechoic cap overlying the talus (t) on the normal syndrome, demonstrates a tri-fascicular nerve structure as a normal variant
side. (B) On the right side, the accumulation of anechoic joint fluid, (black arrows) at the level of the tunnel. (C) Ultrasonographic evaluation
indenting the joint capsule (black arrows) is visualized between the tibia of a common peroneal nerve, longitudinal view in a patient with knife
(T) and the talus (t). injury. The nerve trunk (white arrows) is enlarged inhomogenously, with
irregular echogenicities.

J Rehabil Med 44
316 L. Özçakar et al.

as to where and how deep to insert the needle. During the use
of the direct technique, according to the local anatomy, the
axes of the needle and the probe can be parallel (in-plane) or
perpendicular (out-plane). Each technique has its own advan-
tages and disadvantages.
Concerning joint fluid aspirations, it has been shown that
ultrasonography guidance is superior to blind interventions,
particularly in small joints (46, 47). Especially in chronic effu-
sions, septae may impede full aspiration of the collection and
it is not uncommon to finalize an attempt of blind aspiration
with a “dry tap”, even if the amount of joint fluid is obvious
during inspection. In those cases, ultrasonography guidance
(direct or indirect) will definitely provide better navigation for
needle insertion(s) inside the compartment(s).
MSUS may be used effectively for several purposes regard-
ing muscle pathologies, some of which include drainage of
intramuscular haematomas, intramuscular injection of BTX
and PRP. Haematomas are often seen as mixed echogenicity
lesions due to the concomitance of liquid, fibrous material
and coagulum. They can be drained, preferably with needles
16-gauge or larger due to the thickness of the fluid.
Although BTX injections can readily be performed blindly
or with electrical stimulation guidance, MSUS can also be used
Fig. 10. (A) Grey-scale and (B) ––Doppler imaging of olecranon bursitis conveniently for muscles that can otherwise not be promptly
in a 67-year-old man with elbow swelling. Anechoic fluid collection (white
delineated. In addition, MSUS has been used to assess the
arrows) and synovial thickenings (white arrowheads) with increased
Doppler signal activity are consistent with active synovitis. changes in the muscle architecture (thickness, pennation angle,
fascicle length) (14).
MSUS plays an invaluable role during the injections per-
soft-tissue masses and other soft-tissue inflammatory processes taining to tendons and ligaments. Depending on the lesion
(41). However, optimum technical adjustments as well as probe and the material to be injected, the direct method can be used
positioning and compression, which have been discussed else- to be sure that the tip of the needle is either inside or outside
where (42), are necessary for prompt Doppler imaging. the tendon. For example, one might wish to place the needle
inside a tendon if a PRP solution is to be injected for a resistant
tendinosis. On the other hand, one might wish to confirm that
ULTRASOUND-GUIDED INTERVENTIONS the needle is definitely not inside the tendon if a corticosteroid
preparation is to be injected for tenosynovitis.
The real-time capability of ultrasonography provides a clear
For calcified lesions, ultrasonography can be used for guiding
advantage in guiding a wide range of musculoskeletal interven-
aspirations or during application of shock-wave therapy (40).
tions, because the needle can be guided towards its intended
target. In other words, if the sonographer is able to see the
place/structure, he or she can indisputably reach it. In daily FUTURE DEVELOPMENTS
PRM practice, most of these procedures encompass aspiration
of fluid collections, injection of various solutions (corticoster- Innovations in ultrasound technology include acoustic mi-
oids, local anaesthetics, botulinum toxin (BTX), autologous croscopy or histosonography, sono-elastography and tissue
blood or platelet-rich plasma (PRP), etc.) into joint cavities, velocity imaging. Computing advances have allowed very
tendon/nerve sheaths, para-articular soft tissues or muscles and high-frequency probes (> 25 MHz) enabling depiction down
soft-tissue biopsies (43–45). The selected transducer should be to the level of histological details. The possibility of carrying
appropriate for the size and depth of lesion. Before starting the out a histosonographic study in order to understand the histo-
procedure, a complete ultrasonography examination (including logical background of musculoskeletal disorders is attractive
Doppler examination) of the selected area should be performed (48). Sono-elastography is a non-invasive method in which
not only to detect a precise trajectory, but also to determine stiffness or strain images of soft tissues are used to detect or
the critical structures nearby (such as nerves and vessels) to classify mass lesions (49). Tissue velocity imaging refers to
be avoided in case of potential injuries. detailed quantification of tissue dynamics (strain and strain
There are two principal techniques: (i) the direct technique, rate) using sound waves (50).
which requires real-time imaging of the needle tip while reach- Three-dimensional and 4D (3D in real-time) MSUS imag-
ing its target; and (ii) the indirect technique, which refers to a ing are booming and maturing techniques (4). With continual
blind injection after detailed measurements have been made refinement in image processing, the eventual search for virtual

J Rehabil Med 44
Musculoskeletal ultrasonography in PRM 317

live anatomy may be attained with comprehensive impact. ultrasonography in Achilles tendinopathy: a prospective study. Am
Other recent advances also include new technologies that J Sports Med 2007; 35: 1696–1701.
12. Lakkaraju A, Sinha R, Garikipati R, Edward S, Robinson P. Ultra­
combine MRI and high-intensity focused ultrasound for con-
sound for initial evaluation and triage of clinically suspicious
firmative diagnosis (8). soft-tissue masses. Clin Radiol 2009; 64: 615–621.
Apart from the above-mentioned technical issues, the role 13. van Holsbeeck MT, Introcaso JH. Artifacts in musculoskeletal
of ultrasonography as an adjunct to electromyography in the ultrasound. In: van Holsbeeck MT, Introcaso JH, editors. Muscu-
diagnosis and follow-up of neuromuscular disorders is worth loskeletal ultrasound. 2n edn. St Louis, MO: Mosby; 2001.
14. Pinzon EG, Moore RE. Musculoskeletal ultrasound. A brief over-
mentioning. It is  more sensitive than electromyography to view of diagnostic and therapeutic applications in musculoskeletal
detect fasciculations and it has recently been shown that even medicine. Practical Pain Management 2009; 1: 34–43.
the smaller fibrillations can be visualized with ultrasonogra- 15. Tok F, Özçakar L, Safaz I, Alaca R. Effects of botulinum toxin-A on
phy (51). Determining muscle thickness and echo-intensity the muscle architecture of stroke patients: the first ultrasonographic
with computer-assisted grey-scale analysis can be helpful for study. J Rehabil Med 2011; 43: 1016–1019.
16. Malas FU, Özçakar L, Kerimoğlu U, Yörübulut M. A germane link
the detection and differentiation of certain neuromuscular between piriformis muscle atrophy and lumbar disc herniation. Eur
disorders (52). J Phys Rehabil Med 2009; 45: 69–71.
17. Snoecx M, De Muynck M, Van Laere M. Association between
muscle trauma and heterotopic ossification in spinal cord injured
CONCLUSION patients: reflections on their causal relationship and the diagnostic
value of ultrasonography. Paraplegia 1995; 33: 464–468.
In conclusion, the benefits of MSUS described above provide 18. Zamorani MP, Valle M. Muscle and tendon. In: Bianchi S, Martinoli­
C, editors. Ultrasound of the musculoskeletal system. 1st ed.
overwhelming support for its use by PRM physicians in their
Berlin: Springer; 2007.
daily practice. The ultrasound probe can be thought of as syn- 19. van Holsbeeck MT, Introcaso JH. Sonography of tendons. In: van
onymous with the physician’s stethoscope. Thus, after taking Holsbeeck MT, Introcaso JH, editors. Musculoskeletal ultrasound.
a substantial medical history and carrying out prompt physical 2nd ed. St Louis, MO: Mosby; 2001.
examination, PRM physicians should use the ultrasound probe 20. McDonald S, Fredericson M, Roh EY, Smuck M. Basic appear-
ance of ultrasound structures and pitfalls. Phys Med Rehabil Clin
to make a more thorough examination of their patients.
N Am 2010; 21: 461–479.
21. Ahmed R, Nazarian LN. Overview of musculoskeletal sonography.
Ultrasound Q 2010; 26: 27–35.
REFERENCES 22. Kiris A, Kaya A, Ozgocmen S, Karakoc E. Assessment of enthesi-
tis in ankylosing spondylitis by power Doppler ultrasonography.
1. Özçakar L, Tok F, Kesikburun S, Palamar D, Erden G, Ulaşli A, Skelet Radiol 2006; 35: 522–528.
et al. Musculoskeletal sonography in physical and rehabilitation 23. Ozgocmen S, Kiris A, Ardicoglu O, Karakoc E, Kaya A. Gluco-
medicine: results of the first worldwide survey study. Arch Phys corticoid iontophoresis for achilles tendon enthesitis in ankylosing
Med Rehabil 2010; 91: 326–331. spondylitis: significant response documented by power Doppler
2. Ulaşli AM, Kara M, Özçakar L. Publications of physical and reha- ultrasound. Rheumatol Int 2005; 25: 158–160.
bilitation medicine physicians concerning musculoskeletal ultra­ 24. van Holsbeeck MT, Introcaso JH. Sonography of large synovial
sonography: an overview. J Rehabil Med 2011; 43: 681–683. joints. In: van Holsbeeck MT, Introcaso JH, editors. Musculoskel-
3. Özçakar L, Malas FU, Kara G, Kaymak B, Hasçelik Z. Musculo­ etal ultrasound. 2nd ed. St Louis, MO: Mosby; 2001.
skeletal sonography use in physiatry: a single-center one-year 25. Karim Z, Wakefield RJ, Conaghan PG, Lawson CA, Goh E, Quinn
analysis. Am J Phys Med Rehabil 2010; 89: 385–389. MA, et al. The impact of ultrasonography on diagnosis and manage-
4. Kane D, Grassi W, Sturrock R, Balint PV. A brief history of mus- ment of patients with musculoskeletal conditions. Arthritis Rheum
culoskeletal ultrasound: “From bats and ships to babies and hips”. 2001; 44: 2932–2933.
Rheumatology (Oxford) 2004; 43: 931–933. 26. Naredo E, Bonilla G, Gamero F, Uson J, Carmona L, Laffon A.
5. Kane D, Balint PV, Sturrock R, Grassi W. Musculoskeletal ultra- Assessment of inflammatory activity in rheumatoid arthritis: a
sound – a state of the art review in rheumatology. Part 1: Current comparative study of clinical evaluation with grey scale and power
controversies and issues in the development of musculoskeletal Doppler ultrasonography. Ann Rheum Dis 2005; 64: 375–381.
ultrasound in rheumatology. Rheumatology (Oxford) 2004; 43: 27. Szkudlarek M, Court-Payen M, Strandberg C, Klarlund M, Klausen
823–828. T, Ostergaard M. Power Doppler ultrasonography for assessment of
6. McDonald DG, Leopold GR. Ultrasound B-scanning in the dif- synovitis in the metacarpophalangeal joints of patients with rheu-
ferentiation of Baker’s cyst and thrombophlebitis. Br J Radiol matoid arthritis: a comparison with dynamic magnetic resonance
1972; 45: 729–732. imaging. Arthritis Rheum 2001; 44: 2018–2023.
7. Cauvin ER. Musculoskeletal ultrasonography: seeing is believing. 28. Walther M, Harms H, Krenn V, Radke S, Faehndrich TP, Gohlke F.
Vet J 1999; 158: 4–5. Correlation of power Doppler sonography with vascularity of the
8. Tok F, Demirkaya E, Özçakar L. Musculoskeletal ultrasound in synovial tissue of the knee joint in patients with osteoarthritis and
pediatric rheumatology. Pediatr Rheumatol Online J 2011; 9: 25. rheumatoid arthritis. Arthritis Rheum 2001; 44: 331–338.
9. Hau M, Schultz H, Tony HP, Keberle M, Jahns R, Haerten R, et al. 29. Valle M, Zamorani MP. Nerve and blood vessels. In: Bianchi S,
Evaluation of pannus and vascularization of the metacarpophalan- Martinoli C, editors. Ultrasound of the musculoskeletal system.
geal and proximal interphalangeal joints in rheumatoid arthritis 1st ed. Berlin: Springer; 2007.
by high-resolution ultrasound (multidimensional linear array). 30. Kara M, Erkin G, Malas FU, Kaymak B, Uysal H, Özçakar L.
Arthritis Rheum 1999; 42: 2303–2308. Carpal tunnel syndrome in two cases of all ulnar hand: a word for
10. Vreju F, Ciurea M, Roşu A, Muşetescu A, Grecu D, Ciurea P. Power nerve’s ultrasound. Acta Reumatol Port 2010; 35: 403–405.
Doppler sonography, a non-invasive method of assessment of the 31. Kara M, Akyüz M, Yılmaz A, Hatipoğlu C, Özçakar L. Peripheral
synovial inflammation in patients with early rheumatoid arthritis. nerve involvement in a neurofibromatosis type 2 patient with plexi-
Rom J Morphol Embryol 2011; 52: 637–643. form neurofibroma of the cauda equina: a sonographic vignette.
11. de Vos RJ, Weir A, Cobben LP, Tol JL. The value of power Doppler Arch Phys Med Rehabil 2011; 92: 1511–1514.

J Rehabil Med 44
318 L. Özçakar et al.

32. Kara M, Yilmaz A, Ozel S, Özçakar L. Sonographic imaging of 11: 174–191.


the peripheral nerves in a patient with neurofibromatosis type 1. 42. Kiris A, Ozgocmen S, Karakoc E, Ardicoglu O. Power Doppler
Muscle Nerve 2010; 41: 887–888. assessment of overall disease activity in patients with rheumatoid
33. Kılıç E, Özçakar L. Ulnar nerve compression possibly due to aber- arthritis. J Clin Ultrasound 2006; 34: 5–11.
rant veins: sonography is elucidatory for idiopathic cubital tunnel 43. Louis LJ. Musculoskeletal ultrasound intervention: principles and
syndrome. Rheumatol Int 2011; 31: 139–140. advances. Radiol Clin North Am 2008; 46: 515–533.
34. Göktepe AS, Özçakar L, Kömürcü E, Safaz I, Yazicioğlu K. Sono- 44. Bava ED, Barber FA. Platelet-rich plasma products in sports
graphic evaluation of the sciatic nerve in patients with lower-limb medicine. Phys Sportsmed 2011; 39: 94–99.
amputations. Muscle Nerve 2010; 41: 763–766. 45. Del Buono A, Papalia R, Denaro V, Maccauro G, Maffulli N.
35. Kara M, Kaymak B, Malas FU, Tiftik T, Yazar F, Erkin G, et Platelet rich plasma and tendinopathy: state of the art. Int J Im-
al. The purview of multifascicle ulnar nerves in cubital tunnel munopathol Pharmacol 2011; 24: 79–83.
syndrome: single-case sonographic observation. Muscle Nerve 46. Balint PV, Kane D, Hunter J, McInnes IB, Field M, Sturrock RD.
2009; 40: 664–665. Ultrasound guided versus conventional joint and soft tissue fluid
36. Özçakar L, Cakar E, Kiralp MZ, Dinçer U. Static and dynamic aspiration in rheumatology practice: a pilot study. J Rheumatol
sonography: a salutary adjunct to electroneuromyography for 2002; 29: 2209–2213.
cubital tunnel syndrome. Surg Neurol 2009; 72: 311–312. 47. Eustace JA, Brophy DP, Gibney RP, Bresnihan B, FitzGerald O.
37. Kaymak B, Ozçakar L, Cetin A, Candan Cetin M, Akinci A, Comparison of the accuracy of steroid placement with clinical
Hasçelik Z. A comparison of the benefits of sonography and electro­ outcome in patients with shoulder symptoms. Ann Rheum Dis
physiologic measurements as predictors of symptom severity and 1997; 56: 59–63.
functional status in patients with carpal tunnel syndrome. Arch 48. Ng WL. Musculoskeletal ultrasound in rheumatology. The Hong
Phys Med Rehabil 2008; 89: 743–748. Kong Medical Diary 2005; 10: 8–10.
38. Hundrfund AN, Boon AJ, Mandrekar JN, Sorenson EJ. Sonography 49. Iagnocco A, Perella C, D’Agostino MA, Sabatini E, Valesini G,
in carpal tunnel syndrome. Muscle Nerve 2011; 44: 485–491. Conaghan PG. Magnetic resonance and ultrasonography real-time
39. Kane D, Grassi W, Sturrock R, Balint PV. Musculoskeletal fusion imaging of the hand and wrist in osteoarthritis and rheuma-
ultrasound-a state of the art review in rheumatology. Part 2: Clini- toid arthritis. Rheumatology (Oxford) 2011; 50: 1409–1413.
cal indications for musculoskeletal ultrasound in rheumatology. 50. Peolsson A, Brodin LA, Peolsson M. A tissue velocity ultrasound
Rheumatology (Oxford) 2004; 43: 829–838. imaging investigation of the dorsal neck muscles during resisted
40. D’Agostino MA, Said-Nahal R, Hacquard-Bouder C, Brasseur JL, isometric extension. Man Ther 2010; 15: 567–573.
Dougados M, Breban M. Assessment of peripheral enthesitis in the 51. Pillen S, van Alfen N. Skeletal muscle ultrasound. Neurol Res
spondylarthropathies by ultrasonography combined with power Dop- 2011; 33: 1016–1024.
pler: a cross-sectional study. Arthritis Rheum 2003; 48: 523–533. 52. Pillen S, Scholten RR, Zwarts MJ, Verrips A. Quantitative skeletal
41. Smith SE, Salanitri J, Lisle D. Ultrasound evaluation of soft tissue muscle ultrasonography in children with suspected neuromuscular
masses and fluid collections. Semin Musculoskelet Radiol 2007; disease. Muscle Nerve 2003; 27: 699–705.

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