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usculoskeletal sonography is a
rapidly evolving technique that is
gaining popularity for the evaluation and treatment of joint and soft-tissue diseases. Inherent advantages of sonography
Doppler sonography, and extended field-ofview function have facilitated the progressive
development of sonography [13].
One notable drawback of sonography is operator-dependency; the quality and consistency
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Received December 8, 1999; accepted after revision February 10, 2000.
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All authors: Department of Radiology, The University of Michigan Medical Center, 1500 E. Medical Center Dr., TC 2910, Ann Arbor, MI 48109-0326. Address correspondence to J. Lin.
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of sonographic studies rely on the expertise of
the examiner. Other limitations include a long
learning curve and a physician timeintensive
examination, particularly for beginners. Musculoskeletal sonography is a widely accepted
and available tool in Europe and other parts of
the world, in which it is often the principal
technique performed for many clinical indications. However, in the United States, sonography is relatively underused because of the wide
availability of MR imaging and the small number of training programs offering instruction
and experience in musculoskeletal sonography.
Additionally, physicians, including radiologists, are often unaware of the potential applications of sonography for the assessment of
joint and soft-tissue disease. Sonography offers
a cost-effective alternative for imaging musculoskeletal disorders in many situations [13].
We discuss basic principles, advanced imaging functions, scan artifacts, and general
characteristics of key musculoskeletal structures. Subsequent articles will feature abnormalities pertaining to specific joints, and the
final installment will focus on musculoskeletal tumors, sonographically guided interventions, and miscellaneous topics. Our intent is
to review current accepted clinical applications of musculoskeletal sonography and
generate interest in what we believe to be an
underused technique. We hope to inspire
physicians to consider musculoskeletal
sonography as a viable, and frequently primary, option in the assessment of joint and
soft-tissue disorders.
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Fig. 2.30-year-old woman without symptoms. Longitudinal sonogram reveals normal ulnar collateral ligament (black arrows) of elbow. Note medial epicondyle
(M and white arrows) and proximal ulna (U and arrowheads). d = distal.
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B
Fig. 4.32-year-old asymptomatic man.
A and B, Transverse (A) and longitudinal (B) sonograms of carpal tunnel of wrist show normal appearance of median nerve (black arrows) and flexor tendons (white arrows). r = radial, u = ulnar, p = proximal, d = distal.
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Calcifications typically exhibit increased
echogenicity with associated posterior acoustic shadowing (Fig. 9). However, the presence
of shadowing depends on the size of the calcification [8]. When calcification is present
within the substance of a tendon, it commonly represents calcific tendonitis (Fig. 10).
Examination
and the patient is invaluable. Additional clinical history about the precise location and
character of symptoms, direct feedback
about tenderness with probe palpation, and
positions or movements that elicit or aggravate symptoms can assist in the accurate interpretation of findings.
The flexibility and dynamic capability of
sonography allow a targeted examination, specific for each individual. Dynamic imaging
can readily reveal certain transient conditions
Fig. 5.36-year-old woman with patellar fracture. Longitudinal sonogram shows mildly displaced fracture of patella
(arrows) that was not revealed on radiographs of knee. p = proximal, d = distal.
Fig. 6.80-year-old woman with rotator cuff tear. Transverse sonogram reveals small full-thickness tear (curved arrows) in distal supraspinatus tendon. Note hypoechoic hyaline articular cartilage (black arrowheads) of humeral
head. Fluid present within defect of supraspinatus tear accentuates echogenicity at surface of hyaline cartilage
(white arrowhead ). a = anterior, p = posterior.
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Color and power Doppler sonography features show the degree of vascularity associated with inflammatory processes and solid
masses. Power Doppler sonography can be
used to characterize musculoskeletal inflammation in cellulitis, abscess, synovitis, myositis, and bursitis [9] (Fig. 15).
The split-screen function that is available
on most sonography units can expand the
field of view to approximately double the
width or can be used for side-by-side comparisons (Figs. 13 and 14). The extended
field-of-view function, available on the
Sonoline Allegra sonographic unit (Siemens
Medical Systems, Iselin, NJ), can display
very large continuous sections of anatomy,
Fig. 7.37-year-old man with shoulder pain. Transverse sonogram of posterior glenohumeral joint shows
normal posterior glenoid labrum (arrows). Note glenoid (G) and humeral head (H). Pain was caused by
torn rotator cuff tendon (not shown).
preserving spatial resolution without distorting structural relationships [10, 11] (Fig. 16).
Recent innovative functions such as threedimensional imaging (Fig. 17) and tissue
harmonics (Fig. 18) may provide further improvement in the diagnostic effectiveness of
sonography. The role of these functions in
the assessment of musculoskeletal disorders
is currently under investigation [3].
Artifact
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B
Fig. 11.50-year-old man with intermittent ulnar nerve subluxation.
AC, Transverse dynamic sonograms of cubital tunnel region reveal transient dislocation of ulnar nerve (black arrows) out of cubital tunnel (white
arrowheads) with progressive flexion. Note medial epicondyle (white arrows) and origin of common flexor tendons (black arrowheads), which
appear hypoechoic because of anisotropy artifact (see Figs. 17 and 18).
v = volar.
Fig. 12.64-year-old man with rotator cuff tear. Splitscreen image shows complete full-thickness tear of
distal supraspinatus tendon. Manual compression
(COMP) of transducer (right-sided image) reveals volume loss (solid arrows) and bursal contour deformity
(arrowheads) confirming diagnosis of full-thickness
tear. Note echogenic debris (open arrows) present in
tear defect. Secondary sonographic findings of fullthickness rotator cuff tear will be discussed in part 2,
Upper Extremity.
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Fig. 13.48-year-old woman with left Achilles tendinosis. Longitudinal split-screen image compares abnormal focally thickened left Achilles tendon (white
arrowheads, left-sided image), consistent with tendinosis, with asymptomatic normal-caliber right AchilAJR:175,
September
les tendon (black arrowheads
, right-sided
image).2000
Fig. 17.66-year-old woman with left shoulder pain. Three-dimensional image of intact
long head of biceps tendon with joint effusion extending into bicipital tendon sheath shows
three standard orthogonal planes: axial (solid arrowhead ), coronal (straight arrow ), and
sagittal (open arrowhead). Oblique plane (curved arrow ) was chosen by sonographer. Clinical use of this function for musculoskeletal sonography is under investigation.
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Fig. 18.62-year-old man with left shoulder pain. L = lesser tuberosity, G = greater tuberosity.
A, Standard transverse sonogram of long head of biceps tendon is poorly visualized because of deep location of biceps tendon caused by large body habitus of patient.
Note bicipital groove (arrowheads).
B, Transverse sonogram with tissue harmonics function reveals intact long head of biceps tendon (arrows) discretely in bicipital groove (arrowheads).
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specular reflectors and an artifactual hypoechoic to anechoic appearance [4] (Figs. 19 and
20). The sonographer should be aware of
proper transducer position and may need to
manipulate the heeltoe and foreaft angulation of the probe to avoid this artifact [12].
References
1. Jacobson JA, van Holsbeeck MT. Musculoskeletal ultrasonography. Orthop Clin North Am 1998;
29:135167
2. Jacobson JA. Musculoskeletal sonography and
MR imaging: a role for both imaging methods.
Radiol Clin North Am 1999;37:713735
3. Adler RS. Future and new developments in musculoskeletal ultrasound. Radiol Clin North Am
1999;37:623631
4. Martinoli C, Derchi LE, Pastorino C, Bertolotto
M, Silvestri E. Analysis of echotexture of tendons
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10.
11.
12.
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