Introductory Guide

to Musculoskeletal
Ultrasound for the
Rheumatologist
George A.W. Bruyn
Wolfgang A. Schmidt

Bohn Stafleu van Loghum

Houten, the Netherlands 2006
© 2006 Bohn Stafleu van Loghum, Houten, the Netherlands
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 Table of contents

Foreword 9

Preface 11

1 Introduction 13
1.1 Historical Perspective 14
2 Fundamentals of musculoskeletal ultrasound 17
2.1 Frequency and wavelength 17
2.2 Generating ultrasound waves 17
2.3 Reflection and transmission 17
2.4 Attenuation 18
2.5 A glossary of ultrasound 18

3 Choosing an ultrasound system 21

4 General ultrasonographic anatomy 23

4.1 Distinguishing between the anatomic structures 25

5 Shoulder 27
5.1 Standard Scans of the shoulder 27
5.1.1 Transverse view of the biceps tendon (Standard Scan 5-1) 27
5.1.2 Longitudinal view of the biceps tendon (Standard Scan 5-2) 28
5.1.3 Anterior transverse view of the shoulder (Standard Scan 5-3) 29
5.1.4 Anterior longitudinal view of the shoulder (Standard Scan 5-4) 30
5.1.5 Lateral transverse view of the shoulder (Standard Scan 5-5) 31
5.1.6 Lateral longitudinal view of the shoulder (Standard Scan 5-6) 32
5.1.7 Posterior transverse view of the shoulder (Standard Scan 5-7) 33
5.1.8 Posterior longitudinal view of the shoulder (Standard Scan 5-8) 34
5.1.9 Transverse view of the acromioclavicular joint (Standard Scan 5-9) 35
5.1.10 Axillary longitudinal view of the glenohumeral joint (Standard Scan 5-10) 36
5.1.11 View of the sternoclavicular joint (Standard Scan 5-11) 37
5.2 Pathology of the shoulder 38
5.2.1 Tenosynovitis and calcifications of the long biceps tendon 38
5.2.2 Dislocation and rupture of the long biceps tendon 39
5.2.3 Bursitis of the subdeltoid bursa 40
5.2.4 Tears of the rotator cuff 41
5.2.5 Calcifications and inflammation of the rotator cuff 42
5.2.6 Synovitis/effusion of the glenohumoral joint 43
5.2.7 Synovitis and luxation of the acromioclavicular and sternoclavicular joints 44
 TABLE OF CONTENTS

6 Elbow 45
6.1 Standard Scans of the elbow 45
6.1.1 Anterior longitudinal view of the humeroulnar joint (Standard Scan 6-1) 45
6.1.2 Anterior longitudinal view of the humeroradial joint (Standard Scan 6-2) 46
6.1.3 Anterior transverse view of the elbow (Standard Scan 6-3) 47
6.1.4 Posterior longitudinal view of the elbow (Standard Scan 6-4) 48
6.1.5 Posterior transverse view of the elbow (Standard Scan 6-5) 49
6.1.6 Lateral longitudinal view of the elbow (Standard Scan 6-6) 50
6.1.7 Medial longitudinal view of the elbow (Standard Scan 6-7) 51
6.1.8 Transverse view of the ulnar nerve in the elbow (Standard Scan 6-8) 52
6.1.9 Longitudinal view of the ulnar nerve in the elbow (Standard Scan 6-9) 53
6.2 Pathology of the elbow 54
6.2.1 Synovitis of the elbow 54
6.2.2 Enthesopathy of the elbow 55
6.2.3 Cubital tunnel syndrome and rheumatic nodules 56

7 Wrist and fingers 57

7.1 Standard Scans of the wrist and the fingers 57
7.1.1 Dorsal radial longitudinal view of the wrist (Standard Scan 7-1) 57
7.1.2 Dorsal ulnar longitudinal view of the wrist (Standard Scan 7-2) 58
7.1.3 Ulnar longitudinal view of the wrist (Standard Scan 7-3) 59
7.1.4 Dorsal transverse view of the wrist (Standard Scan 7-4) 60
7.1.5 Ulnar transverse view of the wrist (Standard Scan 7-5) 61
7.1.6 Volar radial longitudinal view of the wrist (Standard Scan 7-6) 62
7.1.7 Volar ulnar longitudinal view of the wrist (Standard Scan 7-7) 63
7.1.8 Volar transverse view of the wrist (Standard Scan 7-8) 64
7.1.9 Volar longitudinal view of the MCP joints (Standard Scan 7-9) 65
7.1.10 Volar transverse view of the MCP joints (Standard Scan 7-10) 66
7.1.11 Dorsal longitudinal view of the MCP joints (Standard Scan 7-11) 67
7.1.12 Volar longitudinal view of the PIP joints (Standard Scan 7-12) 68
7.1.13 Volar transverse view of the PIP joints (Standard Scan 7-13) 69
7.1.14 Dorsal longitudinal view of the PIP joints (Standard Scan 7-14) 70
7.1.15 Volar longitudinal view of the DIP joints (Standard Scan 7-15) 71
7.1.16 Dorsal longitudinal view of the DIP joints (Standard Scan 7-16) 72
7.2 Pathology of the wrist and the fingers 73
7.2.1 Synovitis of the wrist I 73
7.2.2 Synovitis of the wrist II 74
7.2.3 Tenosynovitis of the wrist I 75
7.2.4 Tenosynovitis of the wrist II 76
7.2.5 Carpal tunnel syndrome 77
7.2.6 Erosions of the MCP, CMC and DIP joints 78
7.2.7 Synovitis/effusion of the MCP and PIP joints 79
7.2.8 Tenosynovitis of the finger flexor tendons 80

8 Hip 81
8.1 Standard Scans of the hip 81
8.1.1 Anterior longitudinal view of the hip (Standard Scan 8-1) 81
 TABLE OF CONTENTS

8.1.2 Anterior transverse view of the hip (Standard Scan 8-2) 82

8.1.3 Lateral longitudinal view of the hip (Standard Scan 8-3) 83
8.1.4 Longitudinal view of the greater trochanter (Standard Scan 8-4) 84
8.1.5 Transverse view of the greater trochanter (Standard Scan 8-5) 85
8.2 Pathology of the hip 86
8.2.1 Synovitis/effusion of the hip I 86
8.2.2 Synovitis/effusion of the hip II 87
8.2.3 Iliopsoas bursitis 88
8.2.4 Osteoarthritis/osteonecrosis of the hip 89
8.2.5 Loose bodies and arthroplasty of the hip 90
8.2.6 Greater trochanter pathologies 91

9 Knee 93
9.1 Standard Scans of the knee 93
9.1.1 Suprapatellar longitudinal view of the knee (Standard Scan 9-1) 93
9.1.2 Suprapatellar transverse view of the knee (Standard Scan 9-2) 94
9.1.3 Lateral longitudinal view of the knee (Standard Scan 9-3) 95
9.1.4 Medial longitudinal view of the knee (Standard Scan 9-4) 96
9.1.5 Infrapatellar longitudinal view of the knee (Standard Scan 9-5) 97
9.1.6 Infrapatellar transverse view of the knee (Standard Scan 9-6) 98
9.1.7 Posterior transverse view of the knee (Standard Scan 9-7) 99
9.1.8 Posterior longitudinal view of the knee (Standard Scan 9-8) 100
9.2 Pathology of the knee 101
9.2.1 Synovitis/effusion of the knee I 101
9.2.2 Synovitis/effusion of the knee II 102
9.2.3 Enthesitis/tendinitis of the knee 103
9.2.4 Prepatellar and infrapatellar bursitis 104
9.2.5 Baker's cyst 105
9.2.6 Osteophytes, erosions and loose bodies of the knee 106
9.2.7 Osgood Schlatter disease and paratenonitis 107
9.2.8 Chondrocalcinosis, tophus and tendon rupture of the knee 108

10 Ankle, foot and toes 109

10.1 Standard Scans of the ankle, foot and toes 109
10.1.1 Anterior longitudinal view of the ankle (Standard Scan 10-1) 109
10.1.2 Anterior transverse view of the ankle (Standard Scan 10-2) 110
10.1.3 Medial transverse view of the ankle (Standard Scan 10-3) 111
10.1.4 Medial longitudinal view of the ankle (Standard Scan 10-4) 112
10.1.5 Lateral transverse view of the ankle (Standard Scan 10-5) 113
10.1.6 Lateral longitudinal view of the ankle (Standard Scan 10-6) 114
10.1.7 Posterior longitudinal view of the ankle (Standard Scan 10-7) 115
10.1.8 Posterior transverse view of the ankle (Standard Scan 10-8) 116
10.1.9 Plantar proximal longitudinal view of the foot (Standard Scan 10-9) 117
10.1.10 Anterior longitudinal view of the midfoot (Standard Scan 10-10) 118
10.1.11 Anterior longitudinal view of the toes (Standard Scan 10-11) 119
10.2 Pathology of the ankle, foot and toes 120
10.2.1 Synovitis/effusion of the ankle and talonavicular joint 120
 TABLE OF CONTENTS

10.2.2 Tenosynovitis of the flexors of the foot and the peroneal tendons
10.2.3 Tendinitis and paratenonitis of the Achilles tendon
10.2.4 Achilles tendon rupture and retrocalcaneal bursitis
10.2.5 Heel pain: enthesopathy, calcaneal spur and effusion
10.2.6 Plantar fasciitis and pathologies of the midfoot
10.2.7 Synovitis of the MTP joints

11 Arterial ultrasound
11.1 Vasculitis
11.1.1 Temporal arteries (giant cell arteritis)
11.1.2 Large-vessel giant cell arteritis and Takayasu arteritis
11.2 Digital arteries

12 Ultrasound of the salivary glands 133

References 137

About the authors 141

Index 143
 9

Foreword

Musculoskeletal sonography is making constant progress and its applications within the
field of rheumatology have progressively expanded thanks to the many contributions to
research that have recently been published. Research has developed alongside activities
focused on education and training, which are no less demanding. The request for trai-
ning in sonography is in exponential growth. As the learning curve in sonography is
virtually endless, there is an urgent need for teaching material that can be of support for
those taking their first steps in sonographic training. George Bruyn and Wolfgang
Schmidt are the authors of this excellent, very readable and well-organized book that
provides a rigorous yet accessible introduction to the rapidly growing field of sono-
graphy in rheumatology. Compared with other work in this field, this book stands out
for its clear explanations of all the basic steps in performing rheumatological sono-
graphy, thus providing a very efficient tool for self-teaching. For anatomical areas of
interest, the novice investigator will be able to evaluate the correct positioning of the
probe, anatomical landmarks and the representative image that can be obtained.
The quality of the images is very good, bearing witness to the level of excellence reached
by the authors, who are renowned pioneers of musculoskeletal sonography. The authors
have also succeeded in outlining a panorama that represents the main sonographic ex-
pressions within rheumatic disease and this helps the reader to understand the added
benefit of sonography in daily practice and its relevant potential in depicting soft tissue
involvement in rheumatic diseases.
This book will be extremely useful for all those who are taking their first steps into the
fascinating world of rheumatological sonography, but it will also be useful for those
who, having already started their experience, would like to compare the quality of their
images with that of authoritative experts.
The authors should be congratulated on their excellent work that will surely contribute
to the dissemination of sonography in rheumatology.

Professor Walter Grassi

Department of Rheumatology
Universita Politecnica delle Marche, Ancona - Italy
 11

Preface

This book provides a comprehensive compilation of standard ultrasound scans in rheu-

matology. In the text, the more important normal and pathologic sonography findings
of various structures and disorders have been systematically incorporated. During the
preparation of this guide, much of the literature relating to sonography imaging of sy-
novitis and erosions of joints was reviewed and abstracted. The bibliography is not of
course complete; this guide is not meant to be a textbook on musculoskeletal ul-
trasound.
The format of this book is to present Standard Scans that cover a whole range of anato-
mic sites: shoulder, elbow, wrist, fingers, hip, knee, ankle, forefoot and toes. Each
Standard Scan is accompanied by a picture of the position of the probe, an anatomic
drawing, an ultrasound image and an explanation of the ultrasound scan. In addition,
new indications for ultrasound in rheumatology as vasculitis and connective tissue dis-
ease are discussed.
We both contributed an equal amount of experience and work to this book. Since 1999,
we have been conducting workshops together at the American College of Rheumatolo-
gy's annual meetings and have been involved in many international courses on muscu-
loskeletal ultrasound. This book summarizes our experience in a short systematic re-
view.
The preparation of the first edition of this book was made possible by the support of
Wyeth Pharmaceuticals Netherlands. The collaboration with Christopher Haydon of the
British Medical Society of Ultrasound is gratefully acknowledged. Nathalie Bruyn ex-
pertly prepared many photographs and was responsible for the drawings in chapters 5
to 7. We are also grateful to Caroline ter Meulen and Lydia Nieuwendijk, editors at Bohn
Stafleu van Loghum.
We would like to express our special gratitude to Professor Walter Grassi from the Uni-
versity of Ancona, Italy. His wisdom, enthusiasm and clear vision on the future develop-
ment of musculoskeletal sonography in the area of rheumatology planted the seeds for
this work.

George A.W. Bruyn, Medisch Centrum Leeuwarden, The Netherlands

Wolfgang A. Schmidt, Rheumaklinik Berlin-Buch, Immanuel Diakonie Group, Germany

1 Introduction
A patient with a rheumatological inflamma-
tory disorder usually presents with symp-
toms or signs including pain, stiffness, fa-
tigue, weakness, or joint swelling. In
rheumatology, history taking and physical
examination are the fundamentals of the di-
agnostic process in which a whole variety of
signs and symptoms are judged and have to
be weighted in terms of positive and nega-
tive predictive values. Although exact fig-
ures are lacking, it is estimated that by means
of history and physical examination, a cor-
rect diagnosis is made in 80 to 90% of pa-
tients at presentation. In the other 10 to 20°/o,
further diagnostic steps are required for es-
tablishing a diagnosis. Although X-rays can
be relevant for confirming a diagnosis, for
example by detecting periarticular bone ero-
sions in patients with symmetrical polyar-
thritis, in early arthritis bone erosions are so
small that they are hard to detect by conven-
tional radiography. Ultrasound and magnetic
resonance imaging (MRI) have been proven
to detect marginal erosions in many patients
with early rheumatoid arthritis (RA). In de-
tecting erosions in early RA it has been dem-
onstrated that ultrasound is about twice as
sensitive as conventional radiography. Ul-
trasound is also able to assess minute enthe-
seal abnormalities and similar characteristic
constellations, for instance rheumatoid osti-
tis. Such findings make ultrasound a valu-
able asset for differentiating RA from the
spondyloarthropathies. Another important
potential of ultrasound for clinical practice
is its ability to pick up synovitis and inflam-
mation, the two main characteristics of rheu-
matoid arthritis. The proof of the pudding, as
13
one knows, is in the eating. Thus, does ultra-
sound improve patient care? And if so, can
we assess its impact on daily patient care?
So far, limited data are available demon-
strating that the technique is useful for cor-
roborating clinical findings and guiding
needle punctures for diagnostic or therapeu-
tic purposes. An advantage of ultrasound is
that the patient does not need any extensive
preparation, which makes the procedure
time-efficient. The only clinical requirements
are good equipment and about 15 minutes of
time.
Care must of course be taken to avoid errors
in interpreting images. Therefore, knowledge
of the pitfalls of the technique is an essential
part of the clinician's training. Insight into
ultrasound findings in rheumatic diseases
requires familiarity with the anatomy and
pathology of the structures involved. Armed
with a sound knowledge of rheumatic dis-
eases, it is essential that the rheumatologist
masters the cross-sectional anatomy of the
musculoskeletal system. Rheumatologist-ul-
trasonographers have to bear in mind that
cross-sectional anatomy is quite different
from the classical anatomy lessons at medi-
cal school. Therefore, getting used to cross-
sectional thinking requires considerable in-
vestment in terms of time for training and
practice.
Despite these drawbacks, including the long
learning curve for the operator and the small
field of view, only musculoskeletal ultra-
sound has the potential to significantly
change everyday patient care in rheumatol-
ogy practice.
14 1 INTRODUCTION
1.1 Historical Perspective
A number of pioneers, including scientists,
engineers and clinicians, have contributed to
the development of diagnostic ultrasonogra-
phy.
During the early 1940s, the Austrian neu-
rologist-psychiatrist Karl Theodore Dussik
was probably the first physician to use ultra-
sound for diagnostic purposes. Although
John Wild published a landmark study on
breast nodules reporting a diagnostic accu-
racy of 90%, Ian Donald (obstetrician) was
responsible for the ultrasound boom in med-
ical diagnosis (Figure 1-1). In 1956, in part-
nership with a young engineer, Tom Brown,
Donald developed the first two-dimensional
direct contact scanner, which he first dem-
onstrated at a clinical meeting of obstetri-
cians at the University Department of Mid-
wifery in Glasgow. Many physicians in the
audience were totally opposed to the idea of
relying on a machine instead of their hands
when examining an unborn baby until, there
and then, a Glasgow Professor of Internal
Medicine happened to make the diagnosis of
malignant ascites in a female patient. On ex-
Figure 1-1 The Glasgow obstetrician Ian Donald with
the first automatic ultrasound scanner designed by Tom
Brown (1960).
amining the patient himself, Professor Don-
ald informed the audience that the finding
looked more like an ovarian cyst. Definite
clinical interest was aroused when this diag-
nosis was confirmed later in the operating
theatre.
At that time, another milestone was set at
the University of Lund in Sweden. Inge Edler,
one of the most prominent cardiologists of
the 20th century, together with scientist Carl
Hertz, introduced M-mode (M=motion) reg-
istration. M-mode is a method that uses a
single sound beam aimed in a fixed direction
through the heart. It formed a major contri-
bution to the understanding of cardiac dis-
ease. Edler and Hertz applied a transducer to
the human chest in the 3rd and 4th intercos-
tal space at the left sternal edge and reported
echo motion synchronous with the heart-
beat. In Rotterdam, many years later in 1969,
the Dutch Nicolaas Bom improved this early
concept with the introduction of the first lin-
ear array transducer. During the mid 1970s,
following its successful use in imaging horse
tendons in veterinary practice, ultrasound
imaging of the musculoskeletal system be-
gan to interest radiologists and orthopedic
surgeons. Seltzer published the first study on
the rotator cuff of rhesus monkeys before
and after fluid instillation and Graf reported
on the acetabular rim of infants in order to
detect congenital hip dysplasia. However, vi-
sualization of small joints was still a hazard-
ous endeavor because of the poor resolu-
tion.
Hence, three important technological ad-
vances paved the way for the use of ultra-
sound in rheumatology.
Firstly, the advent of high resolution
probes permitted the evaluation of
smaller and superficial structures, such
as finger tendons, small joints and
bursae. These "small part probes" have
a frequency of 10-20 MHz and an axial
resolution of 0.1 mm. Using these
probes, it became relatively easy to

assess the articular capsule or hyaline
cartilage of small joints such as MCP,
PIP or MTP joints. Broadband probes
with a wide range of frequencies (e.g.
5-10 MHz, 8-14 MHz) are becoming
increasingly popular because of the
ease in examining superficial and deep
anatomical structures at the same time.
Secondly, progress in data processing
by more powerful computer chips has
enormously advanced the science of
ultrasound, for example the spatial
compounding techniques in which the
transducer beam is electronically
steered to acquire overlapping scans
from different angles and produce
images with superior spatial resolution.
Thirdly, the development of the color
and power Doppler technique has
enabled assessment of soft tissue
hyperemia. Power Doppler mode
detects low-velocity blood flow at the
microvascular level, for instance of
synovium, organ transplants or malig-
nant masses. Since inflammation
INTRODUCTION 1 15
coincides with increased perfusion,
power Doppler ultrasound helps to
differentiate inflammatory synovitis
from degenerative disease, active from
inactive synovitis, and assists in
monitoring the response to therapy.
Color Doppler ultrasonography is used
to examine larger vessels for the
detection of stenoses. In rheumatology,
the technique is particularly applied for
the study of vasculitides, including
temporal arteritis.
Development of ultrasound in rheumatology
will not halt at this point. The research
agenda prompts grayscale ultrasonography
and power Doppler to be validated, espe-
cially in the field of joint inflammation.
Comparisons with golden standards, inclu-
ding MRI and arthroscopy, as well as intra-
and interobserver studies on inflammation
in various joints, continue to be carried out,
further strengthening and corroborating the
role of ultrasound in rheumatology.

2 Fundamentals of musculoskeletal ultrasound
2.1 Frequency and
wavelength
Ultrasound refers to any sound that is above
the audible range. The human ear is capable
of hearing sounds in a frequency range be-
tween 20 and 20,000 hertz, so 20 to 20,000
cycles per second (1000 cycles per second =
1 kilohertz = 1 KHz). Only young children
hear the high range while, with aging, the
upper limit drops to about 12,000 cycles per
second. Some animals are able to hear fre-
quencies as high as 100,000 cycles per sec-
ond. Thus, the ultrasonic range of frequen-
cies runs from 20 kilohertz to 1 gigahertz.
Medically applied ultrasound frequencies
range from 2,000,000 hertz (2 MHz) to
50,000,000 hertz (50 MHz). These sound
waves travel through the human body at a
velocity of 1540 meters per second, so after
0.0000649 seconds, a distance of 10 cm has
been traveled. Within the timeframe of one
second, about 1000 ultrasound waves can be
emitted and received from an object at a dis-
tance of 10 cm. Most structures relevant to
rheumatology are much closer, often situ-
ated in the skin no deeper than 5 cm from
the surface.
Frequency (f) and wavelength (k) are inver-
sely proportional, i.e. f~l/Lambda,, so the higher
the frequency, the shorter the wavelength.
There is also a relationship between fre-
quency, beam penetration and resolution.
Sound wave beams with a higher frequency
penetrate less than lower frequency waves,
but a sharper ultrasound image is outlined.
Conversely, a transducer producing a lower
frequency (longer wavelengths) will produce
greater depth of penetration but less well-
defined images. As already mentioned, in
17
rheumatology diagnostics, most structures
are located relatively superficially, so high-
frequency ultrasound should be used. To be
able to distinguish between two interfaces
lying closely together, a distance of at least
half a wavelength is needed between the two
interfaces.
2.2 Generating ultrasound
waves
Ultrasound waves are generated by a trans-
ducer consisting of a disc with crystals of
lead zirconate titanate. These crystals are
piezoelectric, in other words they transform
electrical potentials into mechanical vibra-
tions and vice versa. Every time an electrical
current is passed through the crystals, the
disc generates an ultrasound pulse; con-
versely, when the disc receives a wave of ul-
trasound, it will deform and a voltage is
generated on the transducer surface. To pro-
duce a well-directed beam, the transducer
disc is mounted at the end of a cylindrical
tube, often called a probe. At the other end
of the tube, damping material is mounted to
damp down the ultrasonic waves generated
at the back of the disc.
2.3 Reflection and
transmission
The emitted waves are reflected at the inter-
face of two different tissues. The greater the
difference in tissue density, the more reflec-
tive the boundary will be, while with similar
densities waves pass easily through the tis-
sues.
18 2 FUNDAMENTALS OF MUSCULOSKELETAL ULTRASOUND
The mathematical equation determining the
amount of reflection and transmission is
given by the speed of sound c and the spe-
cific acoustic impedance Z of the tissue. The
impedance of sound in air is low; in muscle
is it 10,000 times higher than in air and in
bone the impedance is so high - about 50,000
times higher than in air - that the sound
beam does not penetrate bone at all.
The boundary between two different tissues
is called the acoustic interface. As there is an
interface between air and skin, we have to
apply a coupling medium on the transducer,
such as a gel with an impedance similar to
human tissue, otherwise only 0.1% of the ul-
trasound pulse would be transmitted into the
skin tissue and 99.9% would be reflected off
the skin surface. Similarly, almost 99% of
the sound beam is reflected at the interface
of air and muscle, while liquids - such as
blood or synovial fluid - do not reflect sound
waves.
When the surface of an object is flat and no
air is present between the source and the ob-
ject, almost all the ultrasound waves will be
reflected from the object at right angles; the
returning echoes are then detected by the
transducer. The crystal reconverts the retur-
ning ultrasound wave, which has the same
wavelength as the emitted wave, into an
electronic potential. Subsequently, the elec-
tronic potential is converted by a computer
into an ultrasound image. The transducer
acts as the receiver of ultrasound echoes for
about 99.9% of the time, and it only emits
sound waves in the very small amount of
time remaining.
2.4 Attenuation
Ultrasound loses its energy as it propagates
through a tissue. This loss of energy is called
attenuation. There are three causes of atten-
uation: diffraction, scattering, and absorp-
tion. Attenuation results in echoes from deep
body tissues being displayed less intensely
than those returning from superficial struc-
tures. A function of the ultrasound system,
called time-gain control (or swept-gain), will
correct the attenuation, and intensifies the
echoes returning from deeper structures.
2.5 A glossary of ultrasound
It is handy to be familiar with a number of
ultrasound concepts or nomenclatures.
B-mode or grayscale ultrasonography.
B (=brightness)-mode is the precursor
of grayscale ultrasound and is limited
to defining boundaries of structures
and differentiating fluid from solid.
Grayscale ultrasound includes the
whole range of possible intensities of
the gray, black and white dynamic
images. However, it cannot differenti-
ate between fibrous tissue and active
synovitis.
Doppler ultrasonography. Doppler
ultrasound relies on the Doppler
principle, which states that sound
waves increase in frequency when they
reflect from objects (e.g., red blood
cells) moving towards the transducer
and decrease when they reflect from
objects moving away. This information
is transferred into sound. Furthermore,
it is possible to delineate flow curves
and to determinate the direction of
blood flow.
Color Doppler ultrasonography. In
color Doppler ultrasound, the Doppler
effect is combined with real-time
imaging. The real-time image is created
by rapid movement of the ultrasound
beam. The information from Doppler
ultrasound is integrated in the gray-
scale image as a color signal. This
signal indicates the direction of blood
flow. Red signals indicate flow that is
directed towards the ultrasound probe,
while blue signals indicate flow direc-
ted away from the probe.
 FUNDAMENTALS OF MUSCULOSKELETAL ULTRASOUND
Duplex ultrasonography. Duplex
ultrasound combines the color Doppler
image with Doppler ultrasound. It
depicts the anatomical image with
color signals and Doppler curves and
makes it possible to estimate the
velocity of flow in combination with
correction of the beam angle.
Power Doppler ultrasonography.
Power Doppler ultrasound displays the
total integrated Doppler power in color.
It increases the sensitivity of the
machine, particularly for small vessels
and for slow blood flow. Some ul-
trasound equipment provides unidirec-
tional images with only one color,
independent of the direction of blood
flow. Other equipment provides bi-
directional information as described for
color Doppler ultrasound. Power
Doppler shows hyperemia in inflamed
tissues. It also differentiates between
cysts and blood vessels, and in this
way can help in ultrasound-guided
aspirations, by avoiding blood vessels
and correctly picking the site of biopsy.
Transducer or probe. The transducer is
the heart of the ultrasound machine. It
generates the sound waves in terms of
millions per second and receives the
echoes. The frequency of the sound
wave determines how deeply it will
penetrate the tissue. The frequency also
determines the resolution, so the higher
the frequency, the greater the resolu-
tion, and the lesser the penetration.
Anisotropy. Anisotropy is a typical
ultrasound artifact, usually occurring
in sonograms of tendons. The tendon
may appear hyporeflexive, thus simula-
ting disease. However, this is not due to
pathology but to scattering of a beam
which is not perpendicular to the
surface. Scattered sound waves are not
captured by the probe and so the
tendon appears dark.
Resolution. Resolution is the optical
2 19
ability to distinguish detail, such as the
separation of closely adjacent objects.
Axial resolution distinguishes two
objects lying in the same line of the
beam at different depths. It is deter-
mined by the frequency of the ul-
trasound signal. Lateral or horizontal
resolution refers to the ability to
distinguish two objects when they lie
side by side. The modern transducers
used for musculoskeletal ultrasound
reach an axial resolution of 0.1 mm
and a horizontal resolution of 0.2 mm.
20 MHz transducers reach an axial
resolution power of 0.04 mm.
Time or B-mode gain. Time or B-mode
gain corrects the attenuation of the
ultrasound beam due to scattering and
tissue absorption. Time gain compensa-
tion amplifies the echoes returning to
the transducer using an exponential
function based on the time of flight.
The examiner can modify the time gain
from his control panel.
Refraction. Refraction is an artifact
depicting real structures in the wrong
position, caused by the bending of an
ultrasound wave at the interface of two
materials; we can minimize this
phenomenon by keeping the incident
beam as close to 90° as possible.
Reverberation. Reverberation is the
phenomenon of the beam bouncing
back and forth between the transducer
and the object, giving rise to multiple
echoes. It causes repetition echoes below
a structure, e.g. below a metal object,
such as a prosthesis or needle. This can
be seen for example when a needle is
introduced in the tissue.
Edge shadows. In ultrasound, edge
shadow refers to the shadows behind the
edge of spherical, fluid-filled structures.
Comet tail. A comet tail is an artifact
caused by reverberation. It creates
characteristic bands of increased
echogenicity distal to the object.
 2 FUNDAMENTALS OF MUSCULOSKELETAL ULTRASOUND
Acoustic shadowing. Acoustic shadow-
ing means that almost all of the beam
is reflected when it hits a highly
reflective surface, such as bone, air,
calcifications and calculi. It produces a
dark shadow below the highly reflec-
tive surface.
Echogenicity (echotexture). A structure
may appear anechoic (black), hypo-
echoic (dark-gray), midechoic (gray,
akin to soft tissue), a mixture of
hyperechoic and hypoechoic, and
hyperechoic (white). Bone sharply
reflects ultrasound waves and the bony
edge appears white. Cartilage appears
as an anechoic or hypoechoic band
overlying the bone. Fluid collections
are hypoechoic or anechoic structures
that may exhibit acoustic enhance-
ment, demonstrated by brighter echoes
behind the structure.
Aliasing. Aliasing is a Doppler artifact
occurring when velocities of red blood
cells are higher than the pulse repeti-
tion frequency (PRF). This occurs for
example in areas of stenosis, where the
reduced lumen of the vessel is seen
with a red to blue shift. Red represents
flow towards the transducer, within the
range of the PRF, and blue velocities
beyond the range of the PRF, not
reversed flow.
Harmonic imaging. Harmonic imaging
transmits signals at a low frequency
and uses the second harmonic signal at
a higher frequency, by filtering out the
first returning echoes from the received
signal to produce an image.
Three-dimensional (3D) ultrasound
has several advantages over conven-
tional 2D ultrasound, because it is
composed of multiple 2D images and
unlike 2D ultrasound, it is not depen-
dent on the angle of scanning to the
body. Microbubble contrast agents
remain in the circulation for a few
minutes and result in a marked incre-
ase of the ultrasound image.

3 Choosing an ultrasound system
Ultrasound offers the rheumatologist sub-
stantial support in diagnosing and monitor-
ing a variety of musculoskeletal conditions.
Thus, when choosing the right system for the
office, take plenty of time to research what
equipment is available. A list of requirements
should usually include the following as-
pects.
First, images should be of high quality so
that the operator can be confident of his di-
agnosis. During scanning, the machine as-
signs different grades of gray to the return-
ing echo signals. The number of shades of
gray depends on how many bits of informa-
tion can be stored for each horizontal and
vertical point of image memory. The quality
of the images therefore depends on the fea-
tures of the system's software and hardware.
Some manufacturers market "upgraded mod-
els" which are more expensive than the older
models, yet they contain in essence the same
chips and electronics. When considering
which system to purchase, a rule of thumb is
to look at the images that appear on the
screen while you scan your own wrist. Ana-
tomic details such as the median nerve should
be outlined clearly on the system monitor.
The monitor should not be too small, but on
the other hand the device should also be easy
to use. The keyboard is used for entering the
patient's data, such as name and date of birth.
Additional information can be typed on the
image using the "Write" function button.
Scanned structures can be measured on the
monitor, using digital caliper cursors. These
calipers can also be used for measuring the
area, circumference or volume of a structure,
for instance the median nerve. The keyboard
should have a logical positioning of the but-
tons for easy navigation.
21
Second, careful attention should to be paid
to the choice of probes. A variety of trans-
ducers are available. An ultrasound machine
designed for the rheumatology office should
come with a linear array probe centered on 7
to 10 MHz with a bandwidth of 30°/o, so that
all frequencies between 5 and 12 MHz will
be covered. This means that in the near field
the scanner electronically filters out the low
frequencies resulting in higher resolution,
whereas in the far field the device lets the
lower frequencies pass through, giving bet-
ter penetration. A 10 MHz linear array probe
can be applied to practically all large joints
except the hip. To scan down the femoral
head in an adult patient, either a curved ar-
ray or a linear array probe of about 5 MHz
can be used. Curved array probes that are
commonly employed for abdominal ultra-
sound may also be used for scanning hip
joints in obese patients. For larger joints, the
width of the transducer should be taken into
account, which is usually about 50 mm. For
scanning small finger joints, toe joints, and
Figure 3-1 Two examples of transducers. The left
transducer shows a 5 MHz curved array transducer, the
right transducer a 7-12 MHz linear array broadband
transducer
22 3 CHOOSING AN ULTRASOUND SYSTEM

tendons, a small foot print probe such as the Other components include extras such as ex-
hockey stick (surface area 26 mm x 10 mm), tended panorama view, a biopsy guidance
with a high frequency of up to 15 MHz, may facility, patient records and registration,
be used. In conclusion, it is a comfortable connection possibilities with the hospital
feeling to have two or three probes, but one picture archiving and communication sys-
ultra wideband linear array probe with a fre- tems (PACS) and ergonomic design. An in-
quency range of 4 to 14 MHz may adequately terface with the hospital PACS allows images
serve a rheumatologist too. to be shared on the hospital network.
Many modern machines have a unit capable Prices for an average complete ultrasound
of visualizing the vascular system. The vas- system vary between € 30,000 and 70,000,
cular imaging unit includes color and power although lower and higher priced systems
Doppler technology. Color Doppler examina- are available. There are handheld devices
tion is now the non-invasive method of which are less expensive. Handheld devices
choice for the evaluation of patients with significantly improve the availability of ul-
clinically suspected deep vein thrombosis. trasound in the physician's office and at the
Another application of color Doppler ultra- bedside.
sonography is the assessment of blood flow High-end equipment may include modalities
in arteries, for instance of the temporal ar- such as harmonic imaging, 3D imaging, and
tery or carotid arteries. Standard examina- microbubble contrast agent ultrasound im-
tion of arteries is done with a high-resolu- aging.
tion transducer of >8 MHz. Three modalities
are needed: grayscale imaging, color flow
Doppler, both on transverse and longitudinal
planes, and spectral Doppler velocities on
longitudinal planes. The two most commonly
used imaging techniques to evaluate flow in
vessels are color flow mapping and 2D sector
scanning. Flow mapping produces a static
image of the blood flow within the vessel.
Two-dimensional sector scanning produces
a sectional image of the vessel's anatomy
which is updated many times per second.
True simultaneous duplex scanners allow the
2D image to remain in real time while the
Doppler beam provides flow information.
Power Doppler ultrasound is useful for the
detection of hyperemia in joints, tendon
sheaths, and entheses and is thus potentially
capable of assessing inflammation.
Other relevant aspects are data storage and
pricing. The frozen image or sequential real-
time images can be recorded and stored in
the machine's data storage system, a CD-
ROM or DVD for example. Older machines
carry a floppy-disk system. Newer machines
have a USB port. Prints can be made using a
connected black and white thermal printer. Figure 3-2 Modern ultrasound system showing
monitor, keyboard and scanner.
 23

4 General ultrasonographic anatomy

Ultrasound is a tomographic imaging method

such as CT and MRI. These imaging methods
generate anatomic slices. For CT and MRI,
the distance between the slices is variable ac-
cording to indication and anatomic region. It
may be 1 mm, 2 mm, or 4 mm, for instance.
For ultrasound, slices are produced continu-
ously, rather like a movie. An anatomic slice
provides an overview of only a limited ana-
tomic region. This makes the interpretation
of ultrasound images more difficult. Further-
more, ultrasound only depicts the anatomic
area between probe and bone surface.
In general, there are two types of scans, the Figure 4-1 Transverse slice of a cucumber. Upper part
transverse (cross-sectional) scan and the of image: anterior (proximal to probe), lower part of
longitudinal scan. Before starting to perform image: posterior (distal to probe), left side of image: left
ultrasound, it is essential to become orien- side seen from the sonographer.
tated with the localization of anatomic struc-
tures on an ultrasound image.

The transverse view is similar to that of a CT

and MRI. Normally, the patient lies on the
right side of the sonographer (Figure 3-2).
The sonographer looks at the patient from
the caudal aspect. The images can be com-
pared with a transverse cut of a cucumber
(Figure 4-1). The upper part of the image is
the anatomic area close to the probe. This is
anterior (ventral) if the patient is supine. The
lower part is the area distal to the probe. This
is posterior (dorsal) if the patient is supine.
The left side of the image is the left side from Figure 4-2 Longitudinal slice of a cucumber. Upper
the sonographer's perspective. This is the part of image: anterior (proximal to probe), lower part of
right side of the body if the patient is supine. image: posterior (distal to probe), left side of image: left
Some sonographers prefer to always localize side seen from the sonographer. Thus this side represents
the medial (ulnar, tibial) anatomic area on the proximal (cranial) anatomic structures.
the left side of the image and the lateral (ra-
dial, fibular) anatomic area on the right side The longitudinal view generates an image
of the image to be better able to compare that is like a cucumber cut lengthways (Fi-
findings of both extremities. gure 4-2). Again, the upper side of the im-
24 4 GENERAL ULTRASONOGRAPHIC ANATOMY
Figure 4-3 Transverse view of the region proximal to a
left MCP 2 joint that explains the localization of
anatomic structures in a standardized ultrasound image.
Figure 4-4 The volar anatomic structures proximal to
a left MCP 2 joint.
age depicts the area that is close to the probe,
and the lower part of the image depicts the
area that is distal to the probe. The left side
of the image displays the cranial (proximal)
anatomic structures, and the right side the
caudal (distal) anatomic structures.
When starting to learn how to perform ultra-
sound, it is important to acquire this "cu-
Figure 4-5 tongitudinal view of an MCP 2 joint that
explains the localization of anatomic structures in a
standardized ultrasound image.
Figure 4-6 The volar anatomic structures of an MCP 2
joint.
cumber view". Translated into the image of a
tendon, this view is shown in Figures 4-3
and 4-4 for a transverse plane and in Figu-
res 4-5 and 4-6 for a longitudinal plane.
Figure 4-5 also shows the sonographic ap-
pearance of the most important anatomic
structures. Figure 4-6 explains the anat-
omy.

4.1 Distinguishing between
the anatomic structures
Bright structures such as bone are referred to
as hyperechoic, dark structures as synovium
are hypoechoic, and black structures includ-
ing fluid and cartilage are anechoic. Subcu-
taneous fat is referred to as midechoic.
Bone surface. Bone surface is hyper-
echoic with posterior acoustic shadow-
ing. Ultrasound does not provide any
information on anatomic structures
that are localized below an intact bone
surface.
Cartilage. Hyaline cartilage is anechoic.
It is localized directly adjacent to the
bone surface. Its surface is regular.
Degenerated cartilage may become
hypoechoic or midechoic with an
irregular surface. Fibrocartilage or
meniscal cartilage is slightly hyper-
echoic.
Synovium. Synovium is midechoic
tissue within a joint. In the joints of
healthy persons, it does not usually
exhibit Doppler signals. Nevertheless,
ultrasound equipment with a high
sensitivity for flow signals may also
show minor flow in the joints of
healthy individuals.
Synovial fluid. Synovial fluid is
anechoic material within a joint. It is
displaceable and compressible but does
not exhibit Doppler signals.
Joint capsule. The joint capsule is the
area that forms the frontier between
the hypoechoic synovium, anechoic
synovial fluid, or anechoic cartilage
and periarticular structures, this last-
mentioned often consisting of mid-
echoic connective tissue.
Connective tissue. Connective tissue is
midechoic and slightly irregular.
GENERAL ULTRASONOGRAPHIC ANATOMY 4 25
Subcutaneous fat. Subcutaneous fat is
also midechoic and slightly irregular. It
usually appears slightly less echoic, i.e.
hypoechoic, than the surrounding
connective tissue.
Tendons. Tendons are characterized by
a fine internal fibrillar pattern. They
are slightly hyperechoic if localized
parallel to the probe. If the tendon is
not parallel to the probe, the tendon
becomes hypoechoic or anechoic as the
ultrasound waves are not reflected to
the probe (anisotropy).
Nerves. Nerves are similar to tendons
but they are slightly hypoechoic, and
their structure is more dotted and less
fibrillar (see under Wrist, Standard
Scans 7-6 and 7-8).
Muscles. Muscles are usually hypo-
echoic but sometimes midechoic or
hyperechoic according to the transdu-
cer orientation. Fine intramuscular
hyperechoic lines represent the epi-
and para-mysium, while thicker
hyperechoic lines represent septae and
investing fascia.
Bursae. Bursae are hypoechoic or
anechoic depending on the structures
that prevail in the bursae.
Ligaments. Ligaments are similar to
tendons. However, if they consist of
several layers, the fibrillar pattern may
run in different directions.
In Chapters 5 to 10, scans relevant for mus-
culoskeletal ultrasound are presented, orga-
nized into the different anatomic locations.
In each chapter Standard Scans show the
normal anatomy, and scanning techniques
are described in detail. These are followed by
pathologies. Chapter 11 and 12 give detailed
information on the use of ultrasound in vas-
culitis and connective tissue diseases.
 5 Shoulder

5.1 Standard Scans of the

shoulder

5.1.1 Transverse view of the biceps

tendon (Standard Scan 5-1)

The patient is seated upright on a low re-

volving stool. For a right-handed ultraso-
nographer, the machine is placed directly in
front of him and the patient is slightly to his
right. For examining the right shoulder, the
patient is facing the examiner and the pa-
tient's back is directed towards the ultra-
sound machine, for the left shoulder the pa-
tient is looking towards the machine.
Alternatively, the examiner may sit or stand
behind the seated patient while the patient is
facing the ultrasound machine.
The patient's arm rests on the thigh with the
palm of the hand facing upward (supination)
and elbow flexed at 90°. The probe is placed
transversely and anteriorly over the shoul-
der. Both shoulders are examined routinely.
The long head of the biceps tendon is the
landmark of anterior shoulder scans. The
transverse sonogram locates the biceps ten-
don within the bony bicipital groove of the
humerus. The tendon has a bright appear-
ance on normal ultrasound. The transverse
humeral ligament is located anterior to the
tendon and straps the tendon down. Medial
to the biceps tendon, the subscapularis mus-
cle is localized, whereas the supraspinatus
muscle is lateral to it.

What is normal?
The mean transverse diameter of the biceps
tendon is 5.0 mm (2.9-7.1 mm). A minimum
amount of fluid may physiologically occur
around the tendon. It is not circumferential.
More distally, at the musculo-tendinous
junction, there may be a halo artifact, be-
cause the muscle is relatively hypoechoic to
the tendon.
28 5 SHOULDER

5.1.2 Longitudinal view of the

biceps tendon (Standard Scan
5-2)

The longitudinal view of the biceps tendon is

obtained by rotating the probe 90°. The posi-
tion of the patient and the examiner remains
the same compared with the first standard
scan of the transverse bicipital view, Stan-
dard Scan 5-1. The tendon should be de-
picted parallel to the probe because of an-
isotropy. This is achieved by applying more
pressure on the distal end of the probe.
Then, the probe should be moved slowly
downwards towards the musculotendinous
junction. The parallel arrangement of the fi-
brillar pattern of the biceps tendon, located
within the bony bicipital groove, is easily vi-
sualized.

What is normal?
The mean sagittal diameter of the long bi-
ceps tendon measured at the end of the rota-
tor cuff is 2.6 mm (1.2-4.0 mm).
 SHOULDER 5 29

5.1.3 Anterior transverse view of

the shoulder (Standard Scan
5-3)
This scan is performed with the shoulder in a
neutral position and the lower arm supi-
nated, with elbow flexed.
The scan is intended to examine the sub-
scapularis and the supraspinatus tendon. The
biceps tendon is identified within the bicipi-
tal groove. At the medial side, the subscapu-
laris tendon is seen.
Rotate the arm externally first to investigate
the entire subscapularis muscle. Then the ex-
amination is continued while rotating the
arm internally. Thus, the supraspinatus ten-
don can be identified. Overlying the rotator
cuff a thin hypoechoic line between two hy-
perechoic lines represents the subacromio-
subdeltoid bursa. In addition, the probe
should be moved slowly upwards and down-
wards in order to view the full subscapularis
tendon.
Anteflexion of the shoulder results in a
smaller window to delineate the rotator cuff
with the anterior scans. Anteflexion or scan-
ning below the rotator cuff may lead to a
false diagnosis of a rotator cuff tear or a
thinned rotator cuff.

What is normal?
The normal sagittal diameter of the subscap-
ularis tendon is 4.2 mm (2.6-5.8 mm).
30 5 SHOULDER

5.1.4 Anterior longitudinal view of

the shoulder (Standard Scan
5-4)

The subscapularis and the supraspinatus ten-

don should be investigated in transverse
(Standard Scan 5-3) and in longitudinal
planes, as is depicted here. This is important
to identify suspected structures as abnormal,
e.g., rotator cuff tears and calcifications.
Tears or calcifications should be visible in
both planes.
At the start of the examination the arm is
held in a neutral position, with flexed elbow
and palm directed upwards. Medial to the bi-
ceps tendon, the subscapularis muscle is
identified. Its tendon inserts at the lesser tu-
bercle.
In order to have a complete view of the sub-
scapularis tendon, the arm of the patient is
then externally rotated.

What is normal?
A normal subscapularis tendon does not
show calcifications. The insertion is
beakshaped. Some fibers run across the bi-
cipital groove forming the transverse hu-
meral ligament in conjunction with fibers of
the supraspinatus tendon. The tendon moves
smoothly in relation with the surrounding
anatomical structures in dynamic examina-
tion.
 SHOULDER 5 I 31

5.1.5 Lateral transverse view of the

shoulder (Standard Scan 5-5)
This scan starts with the shoulder in a neu-
tral position. The transducer is positioned
laterally and posteriorly to the position of
that in Standard Scan 5-4. Lateral to the bi-
ceps tendon, the supraspinatus tendon is
identified.
Then the examination is continued while
maximally rotating the arm internally. This
maneuver is carried out by asking the pa-
tient to hold his hand behind his back.
The sonogram shows a transverse view of
the supraspinatus muscle. Overlying the su-
praspinatus tendon, the subacromio-subdel-
toid bursa is visible as a thin hypoechoic
layer between two parallel curvilinear hy-
perechoic lines, representing the bursal-
muscle interfaces.
The examination is performed starting with
the biceps tendon at the medial side and
gradually moving laterally and upwards and
downwards in order to view the full supra-
spinatus tendon. As mentioned before, the
examination should not be performed too
inferiorly and with internal rotation adduc-
tion of the shoulder to allow an optimal view
of the supraspinatus tendon.

What is normal?
The supraspinatus tendon looks like a regu-
lar arc. The mean transverse diameter of the
supraspinatus tendon measured 2 cm lateral
of the biceps tendon is 4.6 mm (2.7-6.5
mm).
32 5 SHOULDER

5.1.6 Lateral longitudinal view of

the shoulder (Standard Scan
5-6)

The transducer is placed identically to the

previous position but turned 90°, so that the
supraspinatus tendon is visualized as it at-
taches to the greater tuberosity. The arm
should be rotated internally, by asking the
patient to hold his arm behind the back.
This scan, together with the previous scan, is
important for identifying pathology. Rotator
cuff tears should be visualized in two planes.
Furthermore, calcifications can be present in
distal areas of the rotator cuff and have
sometimes larger diameters in the longitudi-
nal plane than in the transverse plane.
With this scan it is also possible to test for
impingement. By passively abducting the
60° internally rotated arm with 90° flexion
of the elbow, the rotator cuff should com-
pletely disappear under the acromion.

What is normal?
The supraspinatus tendon is seen as a beaked
shaped structure protruding from under the
acromion and attaching to the greater tuber-
osity.
 SHOULDER 5 33

5.1.7 Posterior transverse view of

the shoulder (Standard Scan
5-7)

Ultrasound examination of the posterior part

of the shoulder visualizes the posterior as-
pect of the glenohumeral joint, the posterior
glenoid labrum, the hyaline cartilage on top
of the humeral head, the bone underlying
the cartilage and the infraspinatus muscle
and tendon inserting at the greater tubercle.
When moving the probe downwards, the
teres minor tendon and muscle become vis-
ible although it is sonographically impossi-
ble to differentiate the teres minor from the
infraspinatus tendon and muscle.
The fibrocartilaginous posterior labrum is
easily identified as a sharply triangular
shaped hyperechoic structure partly capping
the anechoic hyaline cartilage of the gle-
noid.
The transverse axis view also allows scan-
ning for erosions of the humeral head. Larger
irregular cortical defects, such as Hill-Sachs
lesion, are the result of trauma or recurring
dislocation of the humeral head. Small effu-
sions are also detected with the transverse
scan, sometimes only when rotating the arm
externally. It is also important to move the
probe from cranial to caudal (or vice versa)
for picking up effusions.
The posterior joint space and the glenoid la-
brum may be located quite a long way away
from the probe in obese patients. Depending
on whether the patient is obese or not, fre-
quencies from 5 MHz to 12 MHz are used,
with the lower frequencies better suited to
obese patients.

What is normal?
Just proximal to the insertion on the greater
tuberosity, the sagittal diameter of the infra-
spinatus measures 3.8 mm (2.0-5.6 mm).
34 5 SHOULDER

5.1.8 Posterior longitudinal view of

the shoulder (Standard Scan
5-8)

The longitudinal view of the posterior part of

the shoulder is conducted in the same way as
the transverse view, with the probe rotated
90°. Maneuvering the arm externally and in-
ternally allows visualization of erosions of
the humeral head. It also makes it possible to
depict effusions in the distal posterior recess
and synovitis of the posterior region of the
glenohumeral joint.
More distally, the teres minor muscle be-
comes visible. Although the transverse pos-
terior scan is more important than the longi-
tudinal posterior scan, both scans should be
performed to assess all structures in two
planes.

What is normal?
In general, the infraspinatus muscle cannot
be differentiated from the teres minor mus-
cle.
 SHOULDER 5 35

5.1.9 Transverse view of the acro-

mioclavicular joint (Standard
Scan 5-9)

The acromioclavicular (AC) joint is one of

the two synovial articulations of the shoul-
der. The end of the clavicle rides higher than
the acromion and is readily palpated. The AC
joint is best scanned from above in the lon-
gitudinal plane along the long axis of the
distal clavicle. Inflammation of the acromio-
clavicular joint can mimic rotator cuff dis-
ease, because the supraspinatus tendon and
subacromial bursa run directly underneath.
Effusion of the acromioclavicular joint,
which produces the "geyser" phenomenon,
may be caused by a tear in the underlying
bursa and inferior capsule of the acromio-
clavicular joint, or by synovitis of the acro-
mioclavicular joint itself. The most common
pathology of the acromioclavicular joint,
however, is osteoarthritis. Sonographic signs
of osteoarthritis are joint space narrowing,
hypertrophic spurs and synovial thickening.
The acromioclavicular joint can sublux by
trauma or by severe osteoarthritis. The joint
space is widened and usually a step-off sign
is present between acromion and clavicle,
with the clavicle lower than the edge of the
acromion.

What is normal?
The mean intra articular distance between
bone and joint capsule is at the medial side
1.7 mm (0.9-3.1 mm) and at the lateral side
2.5 mm (0.8-4.2 mm). The width of the acro-
mioclavicular joint space is 5.2 mm (1.9-8.5
mm).
Osteophytes are common in subjects aged
>50 years.
36 5 SHOULDER

5.1.10 Axillary longitudinal view of

the glenohumeral joint
(Standard Scan 5-10)
The capsule of the glenohumeral joint is re-
inforced on the superior, anterior and poste-
rior parts by the glenohumeral ligaments
and the tendons of the supraspinatus, sub-
scapularis, infraspinatus and teres minor
muscles. The capsule is, therefore, relatively
tight, allowing only minor swelling in case
of effusion.
The axillary view gives information on the
presence of fluid in the glenohumeral joint.
With the posterior transverse view with ex-
ternal rotation, the axillary scan is the most
sensitive maneuver to detect effusion or sy-
novitis of the glenohumeral joint. The pa-
tient is asked to lift his arm to about 90° and
place his hand across his chest on top of the
opposite shoulder for comfort. The probe is
positioned in the longitudinal axis in the ax-
illa. The ultrasound image shows a longitu-
dinal view of the humeral head and the joint
capsule.
This scan may not be possible with a frozen
shoulder. If elevation is impaired, the patient
can try to lift his arm with 60° internal rota-
tion (arm in front of chest) to reach enough
elevation of the arm to perform this scan.
Pathologies should be depicted in a corres-
ponding transverse scan.

What is normal?
The mean distance between humerus and
joint capsule at the middle of the concavity
of the humeral head and neck is 2.2 mm
(0.6-3.8 mm).
 SHOULDER 5 37

5.1.11 View of the sternoclavicular

joint (Standard Scan 5-11)
Strictly speaking, the sternoclavicular (SC)
joint is not part of the shoulder. However,
pathology of this joint may sometimes mimic
shoulder disease.
The patient may either sit or lie down. The
scan is about 45° oblique with the proximal
position of the lateral end of the probe.
Pathologies should be depicted in a plane of
90° to this scan.

What is normal?
The mean sternoclavicular joint, bone-cap-
sule distance measured at the lateral end of
the sternum is 0.9 mm (0-2.2 mm). The mean
sternoclavicular joint bone-capsule distance
at the medial end of clavicle is 1.5 mm (0-3.1
mm). The mean width of the sternoclavicular
joint space is 8.2 mm (2.9-13.5 mm).
The surface of the clavicle and sternum is
normally regular.
38 5 SHOULDER

5.2 Pathology of the shoul-

der

5.2.1 Tenosynovitis and calcifica-

tions of the long biceps
tendon
Best Scans: Standard Scans 5-1 and 5-2

In Figure 5-1, a hypoechoic rim, producing

what is known as a halo sign, is visible
around the biceps tendon in the transverse
scan. The fluid distends the sheath of the bi-
ceps tendon (see also Figure 5-2); as a result
the transverse ligament becomes visible. This
may present as either synovial fluid from the
joint or a genuine biceps tenosynovitis.
Compression can be used to make the dis-
tinction between sheath synovitis and syno-
vial fluid spilling over from the glenohu-
meral joint: synovium is not compressible
whereas synovial fluid is; the ballottement
effect can be achieved by probe pressure.

Figure 5-2 depicts a longitudinal ultrasound

scan through the long axis of the biceps ten-
don, showing an anechoic partly hypoechoic
fluid collection surrounding the tendon as a
sign of tenosynovitis or an extension of a
synovitis from the glenohumeral joint.

Figure 5-3 shows a hyperechoic structure

Figure 5-1 and 5-2 Tenosynovitis long biceps tendon.
Figure 5-3 Calcification of tendon sheath of the long
biceps tendon.
(=>) within the biceps tendon sheath adja-
cent to the long head. This is a calcium hy-
droxy-apatite deposition. When the deposi-
tions are loose, they represent intra-articular
bodies that have been lodged in the bicipital
sheath.
 SHOULDER 5 39

5.2.2 Dislocation and rupture of

the long biceps tendon

Best Scans: Standard Scans 5-1 and 5-2

Figure 5-4 is a transverse scan showing the

long head of the biceps tendon (=> <s= ) me-
dial to the bicipital groove. The empty
midechoic groove (^) appears to be filled
with a slightly echogenic material corre-
sponding to granulomatous tissue. Most dis-
locations of the long head of the biceps ten-
don occur medially.

Figure 5-5 is a longitudinal scan showing

anechoic fluid (^) within the bicipital sheath
due to a tear in the long head. There is an
associated effusion of the subdeltoid bursa
(^) containing small echogenic material par-
ticles.

Figure 5-6 is a longitudinal scan of the long

head of the biceps muscle near the musculo-
tendinous junction showing a full-thickness
tear. There is a central discontinuity of the
muscle and a hematoma filling the gap. The
two retracted muscle margins are also visible

Figure 5-4 Dislocation of long biceps tendon.

Figure 5-5 Long biceps tendon rupture and subdeltoid
bursitis in RA.
Figure 5-6 Rupture of the long head of biceps muscle.
40 5 SHOULDER

5.2.3 Bursitis of the subdeltoid

bursa
Best Scans: Standard Scans 5-1 to 5-8

Figure 5-7 is a longitudinal sonogram show-

ing both fluid in the subdeltoid bursa (v) and
a small quantity of fluid surrounding the
long head of the biceps tendon. The bursa is
anterior to the tendon.

Figure 5-8 is a transverse scan, showing the

supraspinatus tendon and the fluid-distended
bursa (v), with a well-defined synovial layer.
Minute midechoic particles are present
within the collected fluid.

Figure 5-9 shows the characteristic tear drop

sign (v), due to a fluid-distended subdeltoid
bursa. The fluid in the bursa arises from a
full-thickness rupture of the underlying su-
praspinatus tendon, the cleft is clearly visi-
ble. Furthermore, there is a small calcifica-
tion of the supraspinatus tendon.

Figure 5-7 Subdeltoid bursitis and tenosynovitis of

long biceps tendon.
Figure 5-8 Subdeltoid bursitis (transverse anterior
plane).
Figure 5-9 Herniation of synovitis into subdeltoid
bursitis because of complete supraspinatus tendon tear.
Bursa shows similarities to a tear drop (longitudinal
view).
 SHOULDER 5 41

5.2.4 Tears of the rotator cuff

Best Scans: Standard Scans 5-3 to 5-8

In the normal situation, the supraspinatus

tendon is found as a tendon deep to the del-
toid muscle. Figure 5-10 shows the humeral
head and deltoid muscle, with a complete
absence of the supraspinatus tendon, leaving
a "bald" humerus, due to a complete retrac-
tion below the acromion process of the su-
praspinatus tendon. Rotator cuff tears are
sonographically hypoechoic or anechoic, be-
cause generally fluid, e.g., synovial fluid or
blood, will fill up the lesion. Large tears as
seen in this scan, have the characteristic ap-
pearance of a complete absence of the supra-
spinatus tendon layer.

Figure 5-11 shows a transverse sonogram of

the supraspinatus tendon, demonstrating a
focal depression (v) in the outer convex layer
and a discontinuity of the tendon fibers with
fluid, corresponding to a full-thickness tear.

In Figure 5-12, an anechoic area represent-

ing fluid (<==>) is present within the supra-
spinatus tendon, while a communicative
channel with a distended bursa (v) lying an-
terior of the tendon is visible. This represents
a partial thickness tear of the supraspinatus
tendon.

Figure 5-10 Complete tear of supraspinatus tendon

with "bald" humerus.
Figure 5-11 Full-thickness tear of supraspinatus
tendon.
Figure 5-12 Partial thickness tear of supraspinatus
tendon and subdeltoid bursitis.
42 5 SHOULDER
Figure 5-13 Anterior longitudinal view. The supraspi-
natus tendon and a humeral head erosion is visible.
Figure 5-14 Thickened and partially ruptured
supraspinatus tendon in anterior transverse view.
Figure 5-15 Calcification of the subscapularis tendon
in an anterior longitudinal view. Hyaline cartilage is
clearly visible covering the humeral head.
5.2.5 Calcifications and inflamma-
tion of the rotator cuff
Best Scans: Standard Scans 5-3 to 5-8
Figure 5-13 shows an erosion with irregular
floor of the humeral head (^)), there is a small
depression in the convex superficial surface
of the supraspinatus tendon because of a
partial thickness tear.
Figure 5-14 shows hypoechoic material that
may represent fluid (v) around the humeral
head extending into a partial tear of the su-
praspinatus tendon; the tear does not reach
the deltoid border of the tendon. Further-
more, the tendon is inhomogeneous and
thickened because of tendinitis. The sagittal
diameter is 10.3 mm (normal <6.5 mm).
The sonogram of Figure 5-15 shows a sharp
hyperechoic calcification (<==>) with an
acoustic shadow below in the subscapularis
tendon. The shadow must not be confused
with a rotator cuff tear; however, a tear with
a hyperechoic appearance is rare as most
tears show up as hypoechoic foci. Calcifica-
tions occur most frequently in supraspinatus
tendons, but may also be found in subscapu-
laris and infraspinatus tendons. They may
cause acute inflammation with a frozen
shoulder when part of the calcification pen-
etrates into the subdeltoid bursa.

Figure 5-16 Posterior transverse scan showing
synovitis of the glenohumeral joint.
Figure 5-17 Anterior transverse scan of the supraspi-
natus tendon with both effusion of the glenohumeral
joint (below supraspinatus tendon) and subdeltoid
bursitis (anechoic fluid above suprapinatus tendon).
Figure 5-18 Synovitis of the axillary recess with
calcification and humeral spur.
SHOULDER 5 43
5.2.6 Synovitis/effusion of the
glenohumoral joint
Best Scans: Standard Scans 5-3, 5-7, 5-8 and 5-
10
Sonographically, there are two accessible re-
gions for the detection of glenohumeral joint
effusion or synovitis. In the transverse and
longitudinal scans of the posterior joint
space, fluid or synovitis can be observed (Fi-
gure 5-16). Elevation of the infraspinatus
tendon or muscle more than 2 mm from the
glenoid labium is a strong indication for ef-
fusion (v). It is important to rotate the arm in
order to detect small effusions, which appear
only in external rotation. The glenoid labium
remains in place while fluid lifts the infra-
spinatus muscle.
In Figure 5-17, anechoic fluid is seen both
in the subdeltoid bursa (large effusion, v)
and in the glenohumeral joint around the
humeral head (^) .
Figure 5-18 shows hypoechoic structures in
the axillary recess that represent synovitis
along with a hyperechoic area that leads to
partial posterior shadowing. This may repre-
sent a calcific deposit (ff). Calcific deposits
are usually found at the insertion of the su-
praspinatus tendon on the tuberosity, rarely
in the other three tendons of the rotator cuff,
and sometimes within the tendon or sheath
of the long head of the biceps muscle.
In addition, it is possible to evaluate bony
irregularities such as spurs (v) and erosions
in the axillary region.
44 5 SHOULDER

5.2.7 Synovitis and luxation of the

acromioclavicular and sterno-
clavicular joints

Best Scans: Standard Scans 5-9 and 5-11

Figure 5-19 shows a marked elevation of

the superior joint capsule of the right acro-
mioclavicularjoint, with thickened synovium
in the lower part of the joint. This entity is
called the "geyser" phenomenon. There is
also an irregular cortex at acromion (^) rep-
resenting minor osteoarthritis.

Figure 5-20 shows the relationship between

the rotator cuff and the acromioclavicular
joint. The distance between the distal mar-
gins of the acromion and the clavicle is
markedly increased due to a rupture of the
weak acriomioclavicular ligament. An effu-
sion is present around the humeral head,
which is located directly posterior to the ac-
romioclavicular joint here, due to a complete
rupture of the rotator cuff. The surface of the
adjacent three bones is irregular.

The sternoclavicular joint is often inflamed

in SAPHO syndrome. Synovitis may also oc-
cur in other rheumatic diseases. Figure 5-21
shows a markedly elevated capsule of the
right sternoclavicular joint due to synovitis.
In chronic synovitis of the sternoclavicular
joint the bone surface is usually more irregu-
lar.

Figure 5-19 Synovitis of the acromioclavicular (AC)

joint.
Figure 5-20 Luxation of the acromioclavicular joint
with rupture of the acromioclavicular ligament, bony
irregularities of clavicula, acromion, and humerus,
effusion of the glenohumeral joint and complete rupture
of the supraspinatus tendon.
Figure 5-21 Synovitis of the left sternoclavicular
joint. The clavicula is on the right side. The sternum is on
the leftside.
 45

6 Elbow

6.1 Standard Scans of the

elbow
6.1.1 Anterior longitudinal view of
the humeroulnar joint (Stan-
dard Scan 6-1)

The sonographic examination of the elbow

starts with the long-axis view of the anterior
side of the ulnar, holding the probe longitu-
dinally (coronal view).
The patient is sitting on a stool or is supine
with the elbow completely extended.
At the cranial side of the image, the humeral
trochlea covered by hyaline cartilage is ob-
served; at the distal pole of the articulation
the coronoid process is visualized. Anterior
to the joint, the brachialis muscle runs down-
wards to its insertion on the tuberosity of the
radius. Just cranial to the trochlea, the coro-
noid fossa containing fat tissue is visible.

What is normal?
Distance between the bone of the coronoid
fossa (a) and the capsule: 1.8 mm (0-3.7
mm).
46 6 ELBOW

6.1.2 Anterior longitudinal view of

the humeroradial joint (Stan-
dard Scan 6-2)

The second long-axis view of the elbow

shows the capitulum humeri and head of the
radius. The position of the patient and the
examiner remain the same as with the previ-
ous view. The anterior side should be well
exposed by full extension of the elbow.
The second longitudinal view shows the ca-
pitulum humeri and the head of the radius.
Joint capsule and cartilage extend far along
the capitulum humeri (to the very end (left)
of the ultrasound image and anatomic draw-
ing and only a short distance distal to the
capitulum humeri). Between the humerus
and the radius, we can detect the capsule, fat
tissue and fibrous tissue. On top of the joint
the brachioradialis muscle is visible. Directly
on top of the radial shaft, the supinator mus-
cle can be visualized.

What is normal?
The hyaline cartilage covering the capitulum
should be easily recognized. There also is an
extensive fibrous capsule connected to fat
tissue visible in this image.
 ELBOW 6 I 47

6.1.3 Anterior transverse view of

the elbow (Standard Scan
6-3)

The position of the patient and examiner re-

main the same as in Standard Scan 6-2; the
probe is rotated 90°. Ultrasound reflections
bounce off the bright bony edge of the hu-
merus. On the left side of the screen, the ca-
pitulum humeri is observed, while the right
of the screen displays the trochlea. The hya-
line cartilage is depicted as a bright dark
band.

What is normal?
The capsule follows the contours of the hya-
line cartilage. Bone capsule distance at the
most anterior point of the ulna (a): 1.0 mm
(0.5-1.5 mm). In cases of effusion, hy-
poechoic fluid will elevate the capsule.
The distal biceps muscle tendon can also be
examined in this scan.
48 6 ELBOW

6.1.4 Posterior longitudinal view of

the elbow (Standard Scan
6-4)

The longitudinal posterior standard scan is

suitable for examination of the triceps mus-
cle, the triceps muscle tendon, the olecranon
fossa, and the posterior joint space. Muscu-
loskeletal pathology seen on this standard
scan includes joint space effusion. Olecranon
bursitis can be visualized superficially when
moving the probe more distally. The long-
axis view is performed with the elbow flexed
90°, in order to obtain an optimal exposure
of the joint space, perhaps with the hand flat
on the examination couch. The elbow can be
flexed and extended in order to detect small
amounts of fluid in the joint.
The humerus and the olecranon fossa with
its fat pad are visualized. Posterior to the hu-
merus a long-axis view of the triceps muscle
is obtained, running down towards its inser-
tion on the olecranon. The bony olecranon is
easily identified.

What is normal?
In the normal situation, no fluid is present in
the posterior olecranon fossa. An effusion
causes a posterior displacement of the fat
pad. Sonography allows identification of as
little as 1-3 ml of fluid posteriorly with the
elbow flexed. Bone-joint capsule distance at
the bottom of the olecranon fossa (a): 1.9
mm (0-3.9 mm).
 ELBOW 6 49

6.1.5 Posterior transverse view of

the elbow (Standard Scan
6-5)

Rotating the probe 90deg yields the short-axis

posterior view. The position of the patient
and the elbow remain the same as with the
long-axis view.
In the short-axis view, the two epicondyles
are distinguished on both sides of the screen.
In the middle, the olecranon fossa is filled
with fat tissue. Posterior to the fossa, the tri-
ceps muscle or its tendon is identified.
This standard scan can be extended to the
examination of the ulnar nerve, which runs
in the ulnar groove next to the medial epi-
condyle (Standard Scan 6-8).

What is normal?
No fluid is present under the posterior fat
pad.
50 I 6 ELBOW

6.1.6 Lateral longitudinal view of

the elbow (Standard Scan
6-6)
The long-axis view of the lateral side is, to-
gether with Standard Scan 6-2, the standard
position for the examination of the origin of
the common extensor tendon at the lateral
epicondyle, the humeroradial joint and the
lateral collateral ligament. The patient is
seated with the elbow extended.

What is normal?
The common extensor tendon is composed
of different muscle slips, which cannot al-
ways be reliably separated. The common ex-
tensor origin is identified as a triangular
shaped, hyperechoic structure comprising of
four superficial extensor muscles, i.e., the
extensor carpi ulnaris, the extensor digiti
minimi, the extensor digitorum, and the ex-
tensor carpi brevis. The lateral collateral
ligament lies deep to the common extensor
tendon.
The extensor insertion may become inflamed
in conditions such as tennis elbow and the
spondylarthropathies. A hypoechoic origin
correlates to edema, and power Doppler
shows increased perfusion in case of enthesi-
tis.
 ELBOW 6 1 51

6.1.7 Medial longitudinal view of

the elbow (Standard Scan
6-7)

Standard Scan 6-7 is the medial mirror im-

age of the Standard Scan 6-6. The position
of the patient is identical in these scans. The
medial longitudinal view gives information
about the medial epicondyle, which is the
humeral site where the common flexor ten-
don originates.
The standard scan also visualizes the ulnar
collateral ligament. The ulnar collateral liga-
ment is identified as a band-like structure
that attaches to the medial epicondyle and
the tubercular portion of the coronoid pro-
cess.
The common flexor tendon origin has an
echogenic appearance similar to its mirror
image on the lateral side. The origin is prone
to enthesitis, giving rise to what is known as
golfer's elbow.

What is normal?
The ulnar collateral ligament attaches to the
coronoid process; the ligament comprises
three bands: anterior (the most important),
posterior and transverse band. The superfi-
cial surface of the ligament is outlined as a
hyperechoic straight line.
6.1.8 Transverse view of the ulnar
nerve in the elbow (Standard
Scan 6-8)
The ulnar nerve is normally positioned in the
cubital tunnel along the posteromedial as-
pect of the distal humerus, in a groove adja-
cent to the medial epicondyle
From the position in Standard Scan 6-5 the
probe is turned more distally and medially to
the point that the ulnar nerve appears at the
posterior side of the medial epicondyle.
In the transverse plane, peripheral nerves
have a honeycomb-like appearance, with
hypoechoic, rounded areas embedded in a
hyperechoic background. The hypoechoic
structures correspond to the neuronal fasci-
cles that run longitudinally within the nerve,
and the hyperechoic background relates to
the interfascicular epineurium. The outer
boundaries of the ulnar nerve are ill defined,
because of the similar hyperechoic appear-
ance of the superficial epineurium and the
surrounding soft tissue and fat tissue.

What is normal?
A square area of <7 mm 2 is normal, >9 mm2
is pathologic and 8 mm2 is borderline. There
is no difference between the dominant and
the non-dominant arm.
 ELBOW 6 53

6.1.9 Longitudinal view of the ulnar

nerve in the elbow (Standard
Scan 6-9)

The position of the arm is the same as in

Standard Scan 6-8. The probe is turned 90°.
In the longitudinal sonographic plane, all
peripheral nerves show a peculiar arrange-
ment made of multiple hypoechoic parallel
linear areas separated by hyperechoic bands.
Generally, the hypoechoic lines dominate the
echo image.
The ulnar nerve passes through the cubital
tunnel, which is a bony passage way be-
tween the medial epicondyle and the olecra-
non. Then, the ulnar nerve curls around the
medial humeral condyle at the elbow and
passes down the proximal forearm between
the two heads of the flexor carpi ulnaris
muscle. Finally, it descends deep into the
muscle of the flexor carpi ulnaris on the sur-
face of the flexor digitorum profundus mus-
cle.

What is normal?
The diameter of the ulnar nerve at the level
of the medial epicondyle, measured in a lon-
gitudinal view between the two borders,
should be no more than 2.5 mm.
54 6 ELBOW

6.2 Pathology of the elbow

6.2.1 Synovitis of the elbow

Best Scans: Standard Scans 6-1 to 6-5

Figure 6-1 shows a longitudinal sonogram

at the anterior ulnar side of the elbow joint.
There is a synovitis with very small areas of
effusion extending from the joint space into
the coronoid fossa. The capsule is pushed up
by the synovitis at the proximal end of the
coronoid fossa (v).

Figure 6-2 shows an anterior transverse

scan, with elevation of the synovial capsule,
due to an effusion of the right elbow joint
(^). The trochlea of the humerus is observed
at the left side of the screen. The hyperechoic
line above the bone represents cartilage (v).

Figure 6-3 is a posterior longitudinal scan

showing an effusion (v) of the posterior fossa
with elevation of the posterior fat pad. The
amount of effusion can be estimated by the
amount of fluid in the olecranon fossa is. In
this case, the fossa is completely filled.

Figure 6-1 Anterior longitudinal view: synovitis in the

coronoid fossa.
Figure 6-2 Anterior transverse view of effusion.
Figure 6-3 Posterior longitudinal view showing
effusion in the olecranon fossa.

Figure 6-4 Longitudinal scan showing calcifying
enthesopathy at the radial humeral epicondyle (tennis
elbow).
Figure 6-5 Enthesopathy without calcification at the
ulnar humeral epicondyle (golfer's elbow) (longitudinal
view).
Figure 6-6 Olecranon bursitis (longitudinal view).
ELBOW 6 55
6.2.2 Enthesopathy of the elbow
Best Scans: Standard Scans 6-6 and 6-7
Figure 6-4 is a longitudinal sonogram of the
antero-lateral region of the elbow. There is
an irregular surface to the lateral epicondyle
of the humerus (^). There also is a calcific
deposit adjacent to the lateral epicondyle. It
is sometimes difficult to make the distinction
between tendon calcification, hyperostosis
of the bone and loose bodies. With hyperos-
tosis it is possible to find a connection be-
tween bone and hyperostosis. A loose body
is usually intra-articular. On the other hand
a similar image is seen if trauma has caused
a dislocation of bone at the tendon insertion.
Therefore, the image may only be evaluated
in connection with history and clinical as-
sessment. In lateral epicondylitis, the deep
fibers of the common extensor tendon are
involved, which belong to the extensor carpi
radialis brevis.
Figure 6-5 shows a hypoechoic, dark, inho-
mogeneous common flexor tendon because
of enthesopathy. Color Doppler US would
show increased blood flow in this region to
distinguish acute from chronic enthesitis.
Figure 6-6 shows a longitudinal sonogram
of the olecranon bursa that is filled with hy-
poechoic material which may represent cell
debris, hematoma, fibrin clots, pus, or other
material. It is probably not possible to punc-
ture this bursa, because there is no anechoic
material.
56 6 ELBOW
Figure 6-7 Hypoechoic swelling of the ulnar nerve in
primary cubital tunnel syndrome (longitudinal scan).
Figure 6-8 Hypoechoic swelling of the ulnar nerve in
cubital tunnel syndrome because of synovitis of the
elbow in RA (see dark area on the right side of the ulnar
nerve).
Figure 6-9 Rheumatic nodule at typical localization
on the extensor posterior ulnar side of the forearm close
to the elbow.
6.2.3 Cubital tunnel syndrome and
rheumatoid nodules
Best Scans: Standard Scans 6-8 and 6-9
Figure 6-7 is a longitudinal sonogram show-
ing a hypoechoic swollen ulnar nerve in the
cubital fossa between the medial epicondyle
and the olecranon (^v).
Figure 6-8 shows a transverse scan with a
hypoechoic swollen ulnar nerve. The square
area is 10 mm2 (7 mm 2 on the healthy side).
The ulnar nerve (=>) in this patient is affected
because of a large synovitis with effusion of
the elbow that extends to the medial poste-
rior areas of the joint (<=). Cubital tunnel
syndrome is a result of inflammation of the
ulnar nerve manifested by an enlarged, hy-
poechoic appearance on sonography because
of edema. Dynamic imaging during flexion
of the elbow can reveal medial subluxation
of the ulnar nerve in 20% of normal persons,
without signs of ulnar neuropathy. Repeated
periods of subluxation may cause neuritis.
Figure 6-9 Rheumatoid nodules are a classic
extra-articular feature of rheumatoid arthri-
tis overlying the posterior aspects of proxi-
mal ulna and other pressure locations such
as the occiput, sacrum, knee, and Achilles
tendon. Sonographically, rheumatoid no-
dules appear as hypoechoic oval structures,
with clear demarcation from the surrounding
tissue. Power Doppler usually reveals minor
blood flow.
 7 Wrist and fingers

7.1 Standard Scans of the

wrist and the fingers

7.1.1 Dorsal radial longitudinal

view of the wrist (Standard
Scan 7-1)

During examination of the wrist and hand,

the examiner sits opposite the patient. The
hand is placed in a neutral position on a flat
surface. It may be extended and flexed for
dynamic examination of the wrist and the
tendons. The examination of the wrist starts
with a longitudinal scan of the dorsal radial
side of the wrist.
The thin extensor retinaculum extends
obliquely across the dorsum of the wrist. The
retinaculum defines six separate extensor
compartments, each of which contains a sy-
novial sheath for the tendons that pass
through it.
The dorsal radial side of the hand locates the
first extensor compartment, which contains
the tendons of the abductor pollicis longus
and the extensor pollicis brevis muscles. Me-
dial to these tendons, the second compart-
ment is located, which comprises the tendons
of the extensor carpi radialis longus and bre-
vis muscles. These tendons lie radially to the
dorsal tubercle (also called Lister's tubercle)
of the distal radius. Medial to Lister's tuber- What is normal?
cle, the third compartment is found, com- Tendons show a fibrillar pattern. The bone
prising the tendon of the extensor pollicus capsule distance at the scaphoid is 1.7 mm
longus muscle. The fourth synovial compart- (0-3.4 mm).
ment contains the four tendons of the exten-
sor digitorum muscle with deep to them the
tendon of the extensor indicis muscle.
58 7 WRIST AND FINGERS

7.1.2 Dorsal ulnar longitudinal view

of the wrist (Standard Scan
7-2)

The position of patient and sonographer and

dynamic examination is identical to that in
Standard Scan 7-1. The probe is moved con-
tinuously in an ulnar direction.
This scan provides information on the ulno-
carpal aspect of the wrist. Synovitis may oc-
cur more at the radial or ulnar side of the
wrist. Therefore all areas should be studied.
This scan is also useful to detect erosions at
the caput ulnae.
The dorsal ulnar side of the wrist accommo-
dates the fifth and sixth compartments of the
extensor tendons. The probe is moved con-
tinuously from the first scan to this position.
The wrist may be extended and flexed for
dynamic examination of the wrist and the
tendons.
The dorsal ulnar side of the wrist houses the
fifth compartment, which is anterior to the
distal radio-ulnar joint. Since the tendon of
the extensor digiti minimi muscle passes di-
rectly over the distal radio-ulnar joint, it is
prone to rupture in patients with rheumatoid
arthritis.
The sixth compartment is mentioned in the
next scan.

What is normal?
The distance between ulna and joint capsule
at the most dorsal point of the ulna is 0.8 mm
(0-1.6 mm).
 WRIST AND FINGERS 7 59

7.1.3 Ulnar longitudinal view of the

wrist (Standard Scan 7-3)
The position of the arm and hand is the same
as in that in Standard Scans 7-1 and 7-2.
The probe is moved continuously from the
position in Standard Scan 7-2 to the ulnar
side. The extensor carpi ulnaris tendon oc-
cupies the sixth extensor compartment and
is located in a groove adjacent to the styloid
process of the ulna. The fibrillar hyperechoic
appearance of the tendon is clearly visible
on the longitudinal ultrasound scan. It over-
lies the ulnar side of the ulnocarpal joint
space. Therefore, the tendon is often involved
in the inflammatory process of rheumatic
diseases.
The extensor carpi ulnaris tendon usually
changes its direction at the wrist. Therefore
one has to be aware of anisotropy and small
physiologic hypoechoic areas around the
tendon. It is important to investigate the full
length of the tendon.
The triangular fibrocartilage complex (TFCC)
can also be examined in this longitudinal
plane. It originates from a groove at the base
of the ulnar styloid process and inserts by a
broad base along the medial portion of the
end of the radius. The fibrocartilage is inter-
posed between the ulna and the carpus,
forming an intra-articular disc.

What is normal?
The TFCC appears as a triangular structure
with a mixed echogenicity.
60 7 WRIST AND FINGERS

7.1.4 Dorsal transverse view of the

wrist (Standard Scan 7-4)
The positions of patient and sonographer are
identical to the previous scans. The probe is
rotated 90° transverse to the position in
Standard Scans 7-1 and 7-2. It is moved
from the radial and ulnar area distally to the
midcarpal region.
The transverse dorsal scan gives the best
view of all the compartments of the extensor
tendons. The sonogram shows, from radius
to ulna, the second, third, fourth and fifth
compartments.
The dorsal radial side of the hand locates the
first compartment, which contains the ten-
dons of the abductor pollicis longus and the
extensor pollicis brevis muscles. These two
tendons are inflamed in the condition known
as De Quervain's tenosynovitis. The second
compartment comprises the tendons of the
extensor carpi radialis longus and brevis
muscles. These tendons run radially to the
dorsal tubercle (also called Lister's tubercle)
of the distal radius. The third compartment
contains the tendon of the extensor pollicis
longus muscle, the fourth compartment the
tendons of the extensor digitorum and ex-
tensor indicis muscles, and in the fifth com-
partment the tendon of the extensor digiti
minimi muscle is found. Compartment three
lies directly medial to the distal tubercle of
the radius, compartment five overlies the ul-
noradial joint space.

What is normal?
A small hypoechoic rim may occur around
the extensor tendons. Anechoic, compress-
ible structures represent veins.
 WRIST AND FINGERS 7 61

7.1.5 Ulnar transverse view of the

wrist (Standard Scan 7-5)

This scan is the transverse homologue of

Standard Scan 7-3. The position of the arm
and hand is similar to the position of the
previous scans. The probe is moved along
the extensor carpi ulnaris tendon from an
area proximal of the caput ulnae to an area
distal to it.
This scan is used to evaluate the extensor
carpi ulnaris tendon which is frequently in-
volved in inflammatory rheumatic diseases.
Also it is used to investigate any erosion of
the ulnar head.
The tendon of the extensor carpi ulnaris
muscle is located at the ulnar side of the ulna
in a groove.

What is normal?
A subtle hypoechoic layer around the tendon
corresponds to synovial fluid. The normal
diameters directly distal to the head of the
ulna are as follows: transverse diameter of
the extensor carpi ulnaris tendon 5.4 mm
(2.8-8.0 mm), sagittal diameter 2.7 mm (0.6-
4.8 mm) and hypoechoic rim 1.2 mm (0.2-
2.2 mm).
62 7 WRIST AND FINGERS

7.1.6 Volar radial longitudinal view

of the wrist (Standard Scan
7-6)
The forearm should rest on a flat surface, the
wrist should be in supination. The wrist may
be dynamically examined by flexion and ex-
tension maneuvers. The probe is moved from
radial to ulnar or vice versa.
The scaphoid and the lunate bones articulate
with the distal radius. The tendon of the
flexor pollicis longus muscle passes through
the radial side of the carpal tunnel. This ten-
don has a long separate synovial sheath. All
eight flexor digitorum tendons are invagi-
nated by a common sheath. The third and
fourth superficialis tendons lie superficially
to the second and fifth superficialis tendons,
and the four profundus tendons lie side by
side, deep to the second and fifth superficia-
lis tendons. The median nerve passes super-
ficial to the flexor tendons through the car-
pal tunnel.

What is normal?
In the longitudinal plane, the nerve runs
parallel and anterior to the tendons. It is de-
lineated as a hypoechoic, less fibrillar struc-
ture and has continuous hyperechoic ante-
rior and posterior borders, that represent the
nerve sheath. Finger tendons, on the other
hand, appear as tightly packed echogenic
structures with fine parallel internal linear
echoes, separated by hypoechoic lines.
 WRIST AND FINGERS 7 63

7.1.7 Volar ulnar longitudinal view

of the wrist (Standard Scan
7-7)

The probe is moved continuously from the

previous scan to this position. The wrist may
be extended and flexed for dynamic exami-
nation of the wrist and the tendons. At the
ulnar volar side, the bony landmark is the
ulnar head and more distally, the pisiform.
The longitudinal scan shows the flexor carpi
ulnaris tendon, running to the pisiform bone.
Below and lateral to the flexor tendon the
ulnar artery can be visualised. The ulnar
nerve runs between the artery and the ten-
don. The tendon is hyperechoic compared
with the nerve, but if the scan head is not in
a plane perpendicular to the tendon surface,
the tendon will appear hypoechoic due to the
anisotropic effect. It is more difficult to visu-
alize the ulnar nerve than the median nerve.
The tendon of the flexor carpi ulnaris muscle
is the only wrist tendon not provided with a
synovial sheath. The ulnar nerve and ulnar
artery are lateral to this flexor tendon in a
separate canal. The nerve enters the canal of
Guyon medial to the artery.

What is normal?
The distance between ulna and joint capsule
1 cm proximal of the wrist joint is 1.1 mm
(0.1-2.1 mm).
64 7 WRIST AND FINGERS

7.1.8 Volar transverse view of the

wrist (Standard Scan 7-8)
The probe is turned 90° from the positions in
Standard Scans 7-6 and 7-7 and than moved
from an area proximal to the wrist to an area
distal to the wrist.
The volar transverse view is the best scan to
assess the carpal tunnel. At the proximal
carpal tunnel, the radial landmark is the tu-
bercle of scaphoid, whereas the medial land-
mark is formed by the ulnar artery and the
pisiform. The distal carpal tunnel landmark
is formed radially by the trapezium and ul-
nar by the hamulus (hook) of the hamate
bone. The flexor retinaculum is stretched out
between these four points.
The median nerve passes through the carpal
tunnel to the radial side of the superficial
flexor digitorum tendons and below the
flexor retinaculum.
The flexor carpi radialis tendon does not
pass through the carpal tunnel whereas the
tendons of the superficial and deep finger
flexors muscles, the tendon of the flexor pol-
licis longus muscle and the median nerve do
pass through the tunnel. The flexor pollicis
longus tendon passes through the radial side
of the tunnel in a separate synovial sheath.

What is normal?
The median nerve is oval or rounded at the
entrance of the carpal tunnel. The nerve flat-
tens progressively as it courses through the
tunnel. Nerve enlargement can be assessed
in the transverse plane at the inlet and the
outlet of the carpal tunnel, where the median
nerve is considered enlarged if the cross-sec-
tional area is >10 mm2 and 11 mm2, respec-
tively. A normal nerve is hypoechoic. A
pathologic nerve is swollen and moves more
hypoechoic.
 WRIST AND FINGERS 7 I 65

7.1.9 Volar longitudinal view of the

MCP joints (Standard Scan
7-9)

The patient is sitting in front of the sonogra-

pher and rests his hand on a table or on his
thighs. The fingers can be flexed or extended
for dynamic examination. The probe is
moved as far as possible around the joint.
The probe may be moved proximally from
the first MCP joint to evaluate the first car-
pometaphalangeal joint.
This longitudinal scan shows the flexor ten-
don of the second finger but can be applied
to all the fingers. It clearly shows the joint
space, the thin layer of hypoechoic cartilage,
the subcapsular fat and the capsule. The pro-
fundus tendon lies deep to the superficialis
tendon until the superficialis tendon divides
and passes around the profundus tendon at
the level of the proximal third of the proxi-
mal phalanx. It is often difficult to distin-
guish the normal superficialis flexor tendon
from the normal profundus tendon, particu-
larly in a longitudinal scan It is easiest to
separate the superficialis and the profundus
flexor tendons on a transverse scan at the
level of the MCP joint. It is important to
move the probe more proximally to the pal-
mar region and distally to the PIP joint, par-
ticularly when searching for tenosynovitis.

What is normal?
The cartilage rim covering the metacarpal
heads should be clearly visible in a normal
situation. The mean thickness between the
proximal phalanx and the joint capsule is
0.9 mm (0-1.9 mm). Normal values are simi-
lar for other MCP joints.
66 7 WRIST AND FINGERS

7.1.10 Volar transverse view of the

MCP joints (Standard Sean
7-10)

The position of the hand is the same as that

in Standard Scan 7-9. Then the probe is
turned 90" with respect to the previous
scan.
The superficial and deep flexor tendons can
be differentiated from each other at the dis-
tal palm but the distinction is difficult to
make in the finger when they enter the flexor
tendon sheath. The insertion for the superfi-
cialis tendon splits into two slips. One slip
passes medially to the profundus while the
other passes laterally before they insert to-
gether again into the base of the middle pha-
lanx.
The flexor tendons of the thumb and the
small finger have separate synovial sheaths.
They emerge from the wrist and continue to
the insertion of the tendon at the distal pha-
lanx. The sheaths for the flexor tendons of
the second, third and fourth digits start at
the level of the metacarpal heads and con-
tinue over the pairs of tendons to the base of
the distal phalanges of digits two, three, and
four.

What is normal?
The tendon sheath contains some hypoechoic
material that is also visible in normal ten-
dons. The mean diameter of a normal tendon
sheath 1 cm proximal to the second MCP
joint is 0.9 mm (0.1-1.7 mm). Diameters are
similar for other finger tendons. Transverse
diameter of finger flexor tendons is 6.4 mm
(3.7-9.1 mm) and sagittal diameter is 3.6 mm
(1.4-5.8 mm).
 WRIST AND FINGERS 7 67

7.1.11 Dorsal longitudinal view of

the MCP joints (Standard
Scan 7-11)

This scan also applies to the other fingers as

mentioned for the previous scans. The hand
is in pronation. As with the previous scans
the probe should also be moved to the radial
and ulnar aspects as far as possible, and it
may be extended proximally and distally.
Joint flexion and extension is part of the dy-
namic examination.
This longitudinal scan shows the MCP joints
with their subcapsular fat and joint capsule
from the dorsal side. On top, the hyperechoic
parallel lines of the second extensor tendon
can be seen.
In contrast to the flexor opponents, the ex-
tensor tendons lack a synovial sheath.

What is normal?
The bone surface is regular, osteophytes may
occur particularly in the second and third
MCP joints in older patients caused by os-
teoarthritis.
68 I 7 WRIST AND FINGERS

7.1.12 Volar longitudinal view of the

PIP joints (Standard Scan
7-12)
The position of the hand is the same as that
in Standard Scan 7-9. The probe is then
moved distally to evaluate the PIP joints and
the IP joint of the thumb as well as the flexor
tendons. The probe can be moved around the
joint in search of erosions.
At this level the two slips of the superficialis
tendon reunite and insert along the proximal
half of the middle phalanx. The PIP joint is
visible, together with its cartilage, joint cap-
sule and subcapsular fat.

What is normal?
Parts of the flexor tendon appear dark be-
cause of anisotropy, particularly in the areas
proximal and distal to the PIP joint. A cer-
tain amount of synovial material may occur
in the proximal recess in healthy subjects.
The mean distance between the proximal
phalanx and the joint capsule is 0.8 mm (0-
1.6 mm). The bone surface is regular.
 WRIST AND FINGERS 7 69

7.1.13 Volar transverse view of the

PIP joints (Standard Scan
7-13)

The probe is turned 90° with respect to the

previous scan to visualize the PIP joint,
flexor tendons, and other soft tissue struc-
tures in a second plane.
On the transverse scan, at the level of the PIP
joint, the deep flexor tendon can be seen in
the middle, as it runs all the way to its inser-
tion at the distal phalanx. On both sides the
two slips of the superficialis flexor tendon
are distinguished before they insert into the
proximal one third of the middle phalanx

What is normal?
The flexor tendon may have a very small hy-
poechoic rim as described in Standard Scan
7-2, but it is smaller than it is at the MCP
joint. The probe should always be parallel to
the tendon to avoid anisotropy. The finger
arteries may be evaluated with color Doppler
ultrasound (see Chapter 11).
70 7 WRIST AND FINGERS

7.1.14 Dorsal longitudinal view of

the PIP joints (Standard Scan
7-14)
The probe is moved directly from Standard
Scan 7-11 to evaluate the PIP joint from the
dorsal aspect. Bony spurs may be visualized
more frequently than with the volar scans.
The ultrasound image shows the second PIP
joint, which is clearly marginated from its
surroundings. The proximal phalanx is lo-
calized on the left side. The middle phalanx
is localized on the right side. The hyaline
cartilage covering the head of the PIP is
clearly visible as an anechoic band. The
midechoic structure filling the joint space is
composed of subcapsular fat and synovial
capsule. The extensor tendon is midechoic
with hyperechoic boundaries. It may be
missed with older low-frequency probes.

What is normal?
The bone surface is regular. Osteophytes oc-
cur frequently in older patients due to osteo-
arthritis.
 WRIST AND FINGERS 7 71

7.1.15 Volar longitudinal view of the

DIP joints (Standard Sean
7-15)

The probe is moved distally from the posi-

tion in Standard Scan 7-12 to evaluate the
DIP joint and the soft tissues in this region.
The probe may be moved around the joint.
Pathologies should also be examined in a
transverse plane. This region is difficult to
evaluate with low-frequency and low-qual-
ity probes.
The profundus flexor tendon passes through
the divided superficialis tendon slips and in-
serts at the base of the distal phalanx, as this
longitudinal palmar scan of the distal pha-
lanx shows. Again, parts of the tendon are
dark because of anisotropy.
The bone surface is regular in a normal DIP
joint. Osteophytes are more clearly visible in
the dorsal scan of the DIP joint.

What is normal?
The bone capsule distance at the volar level
of de DIP joints is 0.8 mm (0.1-2.3 mm).
72 7 WRIST AND FINGERS

7.1.16 Dorsal longitudinal view of

the DIP joints (Standard Scan
7-16)

The probe is moved distally from the posi-

tion in Standard Scan 7-14. The probe may
be moved around the joint. Abnormalities
should also be examined in a second, trans-
verse plane.
The dorsal longitudinal scan gives informa-
tion about the insertion of the extensor ten-
don. In addition, the DIP joint is visible. The
nail bed can be seen at the top right.

What is normal?
The extensor tendon inserts at the base of
the distal phalanx close to the DIP joint and
just distal to the insertion of the joint cap-
sule.
 WRIST AND FINGERS 7 73

7.2 Pathology of the wrist

and the fingers

7.2.1 Synovitis of the wrist I

Best Scans: Standard Scans 7-1, 7-2, 7-4, 7-6,
7-7 and 7-8

Synovitis of the wrist (v) is typically located

between the radius at the very far left side
and the carpal bones (Figure 7-1), for in-
stance the scaphoid or the carpal joints with
extension to dorsal and palmar sides. Syno-
vitis of the wrist is often associated with sy-
novitis of the midcarpal joints (^). Usually
both compartments are separate.

Power Doppler studies are able to show the

inflammatory nature of active synovitis (Fi-
gure 7-2). After steroid treatment, a dra-
matic reduction in the power Doppler signal
can be detected.

Figure 7-3 shows the wrist synovitis (v) in a

dorsal transverse plane (another patient).

Figure 7-1 Synovitis of the wrist and the midcarpal

joints (dorsal longitudinal scan).
Figure 7-2 Power Doppler dorsal longitudinal
sonogram of a patient demonstrating synovitis at wrist
and midcarpal joints (perfusion grade 2).
Figure 7-3 Dorsal transverse view of the wrist
showing synovitis.
 74 7 WRIST AND FINGERS

7.2.2 Synovitis of the wrist II

Best Scans: Standard Scans 7-1, 7-2 and 7-4

Figure 7-4 shows a longitudinal sonogram

at the level of the joint space between radius
and scaphoid showing synovial thickening.
There is a clear associated power Doppler
signal, corresponding to synovial hyperemia
(grade 3) at the midearpal joints (v). At the
radiocarpal (wrist) joint, there is synovitis
with much weaker signal (grade 1).

Figure 7-5 shows a longitudinal image of a

wrist of a patient, with synovitis of the ulno-
earpal joint, extending both proximally over
the ulnar head (^) and distally to the trique-
trum. There are irregularities but no erosions
of the ulnar bone surface.

In Figure 7-6 there is a tenosynovitis of a

finger flexor tendon and a synovitis of the
radio-carpal joint (v). Synovial material ex-
tends proximally to the radius. The longitu-
dinal image shows diffuse hypoechogenicity
around the tendon with free mobility of the
tendon within the sheath on dynamic ex-
Figure 7-4 Power Doppler dorsal longitudinal amination.
sonogram showing synovitis of wrist and midearpal
joints.
Figure 7-5 Synovitis of the ulnoearpal joint and bony
irregularities of the ulna in a dorsal longitudinal scan of
the wrist at the ulna.
Figure 7-6 Wrist synovitis and flexor tenosynovitis in
a volar longitudinal scan.
 WRIST AND FINGERS 7 I 75

7.2.3 Tenosynovitis of the wrist I

Best Scans: Standard Scans 7-1 to 7-8

In Figure 7-7, a longitudinal sonogram

shows hypoechoic material at the dorsal ra-
dial-carpal joint and the midcarpal joints
representing synovitis. In addition there is a
large amount of hypoechoic material around
the extensor digitorum tendons representing
tenosynovitis (^v).

Figure 7-8 shows a transverse sonogram of

the extensor tendons of the fingers. The so-
nogram shows the third (v) and fourth (=>)
compartments. Adjacent to the ulnar side is
the fifth compartment, which comprises the
extensor digiti minimi tendon (ft). The ex-
tensor tendons are much more clearly dem-
onstrated than normal because of the hy-
poechogenicity of the surrounding material,
which enhances the normal echogenicity of
the tendons. Particularly in transverse scans,
this improves the visibility of the extensor
tendons.

Figure 7-9 shows a transverse plane of the

sixth compartment, i.e., the tendon of the
extensor carpi ulnaris muscle. This sonogram
Figure 7-7 Synovitis of wrist and midcarpal joints and demonstrates a tenosynovitis with anechoic
tenosynovitis of extensor tendons (dorsal longitudinal fluid (v) surrounding the tendon.
scan).
Figure 7-8 Tenosynovitis of extensor tendons (dorsal
transverse scan).
Figure 7-9 Tenosynovitis of the extensor carpi ulnaris
tendon close to the ulnar head (transverse view).
 76 7 WRIST AND FINGERS

7.2.4 Tenosynovitis of the wrist II

Best Scans: Standard Scans 7-1 to 7-8

This longitudinal scan of Figure 7-10 shows

a tenosynovitis of the extensor carpi ulnaris
tendon. The hyperechoic fibrillar echotex-
ture of the tendon is readily recognized. The
tendon courses over the ulna, ulnar head and
ulnocarpal joint (ft) and triquetrum. Small
pockets of synovial fluid are visualized (v).

In Figure 7-11, a volar longitudinal scan

showing tenosynovitis of both the superfi-
cial (v) and deep (^) tendons of the flexor
digitorum muscles. In addition there is a sy-
novitis of the radio-carpal joint that extends
over the radial head (=>).

The transverse sonogram of Figure 7-12

shows the double rows of superficial and
deep flexor tendons separated by fluid (hy-
poechoic regions) because of tenosynovitis.
Superficial to the flexor tendons, the median
nerve is visible (=> <=), showing an anatomic
variation. Anterior to the double barrel me-
dian nerve, the fibrous flexor retinaculum
appears as a hyperechoic band (v).

Figure 7-10 Tenosynovitis of the extensor carpi

ulnaris tendon at the wrist (longitudinal view).
Figure 7-11 Tenosynovitis of flexor tendons and
synovitis of the wrist, volar longitudinal scan at the wrist
and proximal of the wrist.
Figure 7-12 Tenosynovitis of the flexor tendons in the
carpal tunnel and double median nerve.

Figures 7-13 Hypoechoic and swollen median nerve
(arrow), anterior to the flexor tendons in a transverse
plane.
Figure 7-14 Hypoechoic and swollen median nerve
(arrow), anterior to the flexor tendons in a longitudinal
plane.
Figure 7-1 5 Transverse volar image of a ganglion
(arrows).
WRIST AND FINGERS 7 77
7.2.5 Carpal tunnel syndrome
Best Scans: Standard Scans 7-6 and 7-8
Ultrasound may distinguish between primary
and secondary carpal tunnel syndrome. In
primary carpal tunnel syndrome the flexor
retinaculum is thickened (about 1.0 mm or
more). Secondary carpal tunnel syndrome
occurs because of tenosynovitis of the flexor
digitorum tendons, wrist synovitis, or gan-
glia. Furthermore, sonographic findings in
carpal tunnel syndrome can be divided into
qualitative and quantitative, subjective and
objective.
Subjective findings are hypoechoic enlarge-
ment of the nerve as it enters the carpal tun-
nel, perhaps with flattening of the nerve,
especially at the level of the hamate bone;
volar bulging of the flexor retinaculum;
large fluid or fat layer surrounding the ten-
dons; decreased mobility of the median nerve
on flexion and extension of the fingers, hand
and wrist.
Objective criteria are the mean cross sec-
tional area of the median nerve >10 mm2 at
the level of the pisiform, a flattening ratio of
the nerve, i.e., transverse diameter divided
by an anterior-posterior diameter >4 at the
level of the hamate, and volar bulging of the
flexor retinaculum >3.1 mm.
Figure 7-13 depicts a hypoechoic, swollen
nerve in carpal tunnel syndrome in a trans-
verse view, figure 7-14 in a longitudinal
view.
Figure 7-15 shows a ganglion, which ap-
pears as an anechoic mass. It may be local-
ized either on the volar or dorsal side of the
wrist.
 78 7 WRIST AND FINGERS

7.2.6 Erosions of the MCP. CMC

and DIP joints

Best Scans: Standard Scans 7-11, 7-13, 7-14 and

7-16

Several studies have shown that ultrasonog-

raphy is able to detect erosions in rheuma-
toid arthritis (RA) reliably and in an early
stage. Bone erosions, such as the one in Fi-
gure 7-16 (^), are characterized by a cortical
defect with sharp margins and few osteo-
phyte bone changes. The majority of ero-
sions in RA occur at the radial side of MCP
joints adjacent to the radial collateral liga-
ment, as a result of a predilection of synovi-
tis at this site. Power Doppler is able to de-
tect active pannus within the erosion,
similarly to the way dynamic gadolinium-
enhanced MR1 is able to discriminate be-
tween active and inactive RA.
In contrast to the erosions of RA, osteoar-
thritic changes typically appear as osteo-
phyte bony spurs (Figures 7-17 and 7-18,
v) Osteoarthritis may occur with or without
effusion or synovitis that usually do not
show positive power Doppler signals.

Figure 7-16 Erosion at the radial aspect of the

metacarpal bone proximal to the second MCP joint in
early RA, longitudinal scan at the radial aspect of the
joint.
Figure 7-1 7 Volar longitudinal scan demonstrating
osteoarthritis of the first carpometacarpal joint with
synovitis.
Figure 7-18 Dorsal longitudinal scan showing
osteoarthritis with effusion of the second DIP joint.
 WRIST AND FINGERS 7 1 79

7.2.7 Synovitis/effusion of the MCP

and PIP joints

Best Scans: Standard Scans 7-9, 7-11, 7-12 and

7-14
Additional scans: Standard Scans 7-10 and 7-13

Synovitis or effusion may be detected both

on the volar and the dorsal side or only on
one side. Dorsally localized effusion or syno-
vitis can be found clinically in most cases,
whereas capsular distension is very difficult
to detect clinically at the volar side because
of larger and stronger flexor tendons.

Figure 7-19 shows anechoic material (v)) in

the volar proximal recess of an MCP joint,
that represents effusion. It takes the form of
a tear drop. No erosions are visible in this
plane.

Figure 7-20 depicts both anechoic effusion

(v) and hypoechoic synovitis (v) of an MCP
joint.

Figure 7-21 shows a PIP joint filled with hy-

poechoic material compatible with synovitis.
Synovitis again extends in the proximal di-
rection (v|), along the shaft of the proximal
phalanx. The joint capsule is not parallel to
the bone.
Figure 7-19 Volar longitudinal scan showing effusion
of the first MCP joint.
Figure 7-20 Dorsal longitudinal scan showing
effusion and synovitis of the fourth MCP joint.
Figure 7-21 Synovitis of the second PIP joint (volar
longitudinal scan).
 80 7 WRIST AND FINGERS
Figure 7-22 Tenosynovitis of the second finger flexor
tendons proximal to the MCP joint (volar transverse
scan).
Figure 7-23 Tenosynovitis of the third finger flexor
tendons at the MCP joint (volar longitudinal scan).
Figure 7-24 Large tenosynovitis of the second finger
flexor tendons at the PIP and DIP joints (volar longitudi-
nal scan).
7.2.8 Tenosynovitis of the finger
flexor tendons
Best Scans: Standard Scans 7-10 and 7-13
Additional scans: Standard Scans 7-9, 7-12 and
7-15
The sensitivity of ultrasonography in detect-
ing tenosynovitis and tendon abnormalities
is high. A high-frequency transducer of at
least 10 MHZ is required, particularly for the
extensor tendons of the fingers. Figure 7-22
depicts a superficial and deep flexor tendon
(v) at the level of the second MCP joint, sur-
rounded by its synovial sheath. The trans-
verse plane clearly shows tightly packed
echoic dots with homogeneous distribution.
There is an increased amount of fluid visible
within the sheath (=>), which allows a clear
definition of the transverse tendon profile. In
patients with spondyloarthropathy dactyli-
tis, the typical sausage-like fingers are due
to flexor tenosynovitis. In these patients,
peritendinous tissues do not appear to be in-
volved.
Figure 7-23 depicts a longitudinal scan of
the third finger flexor tendon showing teno-
synovitis with a fluid collection resembling a
tear drop (^). The fibrillar pattern of the ten-
don is normal, precluding damage to the
tendon. Loss of the normal fibrillar echotex-
ture is one of the earliest signs of tendon
damage both in inflammatory and degenera-
tive disorders.
Figure 7-24 shows a longitudinal scan of
the superficialis and the deep flexor tendons
inserting at the base of the middle phalanx
and the distal phalanx, respectively. There is
associated widening (^) of the finger flexor
tendon due to effusions and synovitis.
 I 81

8 Hip

8.1 Standard Scans of the

hip

8.1.1 Anterior longitudinal view of

the hip (Standard Scan 8-1)
The patient lies supine with the hip in a neu-
tral position. Place the probe parallel to the
femoral neck. This scan is not completely
longitudinal, but about 20° oblique with the
proximal end of the probe localized medi-
ally. The probe should be moved from medial
to lateral or vice versa. For dynamic exami-
nation, the hip can be rotated both exter-
nally and internally to detect minor effu-
sions.
Short linear probes are unable to depict all
interesting structures in one image. There-
fore larger probes can be used. Convex
probes that are in use for abdominal ultra-
sound are practical as they depict a larger
anatomic area. Depending on the diameter
of fat and muscles anterior to the hip joint, it
is advisable to use lower frequencies than in
other musculoskeletal regions. This ultra-
sound image derives from a convex 5 MHz
probe.
The first scan is by far the most important
scan to assess the hip joint. It depicts the
acetabulum, femoral head, and femoral neck
together with the anterior joint capsule that
extends over the femoral head and neck to
its insertion at the proximal femoral shaft.
The iliofemoral ligament is superior to the
synovium and can be seen closely to the femoral neck (a) is 5.2 mm (2.4-8.0 mm). The
joint capsule. difference between right and left neck should
be <1.5 mm. The joint capsule is parallel to
What is normal? the femoral head and neck.
Average distance between bone and joint
capsule at the middle of the concavity of the
82 8 HIP

8.1.2 Anterior transverse view of

the hip (Standard Scan 8-2)
The patient lies supine with the hip in a neu-
tral position. Rotate the probe 90° with re-
gard to the first standard scan for the hip,
Standard Scan 8-1. Again, this scan is not
completely transverse but about 20° oblique.
The lateral end of the probe is localized
proximally. Move the probe from the acetab-
ulum to the femoral head and neck. The fem-
oral vein may be compressed to exclude
thrombosis. Again, it is possible to use larger
convex probes with frequencies of about 5
MHz as mentioned above.
This scan depicts the structures seen in the
first plane in a second, transverse plane.
Sometimes pathologies such as iliopsoas
bursitis and soft tissue masses may be missed
when using only the longitudinal scan. In
the medial area of the image the femoral
vein and femoral artery can be seen.

What is normal?
No larger amounts of fluid and no soft tissue
masses are found. The femoral vein is com-
pressible.
 HIP 8 I 83

8.1.3 Lateral longitudinal view of

the hip (Standard Scan 8-3)

The patient is supine with the hip in neutral

position. Move the probe longitudinally
along the anterolateral regions of the hip
joint from the position in Standard Scan 8-1
to the lateral areas of the hip joint. Then
move the probe from anterior to posterior. It
is even possible to move the probe com-
pletely to the posterior region of the hip
joint, but usually not much further informa-
tion is obtained on hip joint pathologies in
this posterior region.
Again, a 5 MHz convex probe may be used
for this scan. However, this image is from a
linear 4-13 MHz probe that was adjusted at
8 MHz.
In this scan it is also possible to depict syno-
vitis and effusion of the hip joint, irregulari-
ties of the acetabulum and the femur, and
soft tissue masses.

What is normal?
The joint capsule is parallel to the femoral
head and neck. The maximum normal dis-
tance is about 6 mm. Exact normal values
have not been evaluated in this area.
84 8 HIP

8.1.4 Longitudinal view of the

greater trochanter (Standard
Scan 8-4)

The patient is supine with the hip in neutral

position. This scan is similar to Standard
Scan 8-3 of the hip. The probe is only moved
a little distally and slightly anterior to the
greater trochanter. It should then be moved
slightly up and down.
Depending on the diameter of fat and soft
tissue, frequencies between 10 and 5 MHz,
linear or convex probes can be used. This
ultrasound image was acquired with a linear
probe using a frequency of 10 MHz. This
scan delineates the lateral aspects of the
greater trochanter including the trochanteric
bursa and the tendon insertions. The tendon
insertions may be hypoechoic due to aniso-
tropy. Therefore the sonographer should
change the position of the probe until it is
perpendicular to the tendon fibers.

What is normal?
A hypoechoic rim of <2.2 mm can be found
in the region of the trochanteric bursa.
 HIP 8 I 85

8.1.5 Transverse view of the greater

trochanter (Standard Scan
8-5)
The patient is supine with the hip in neutral
position. Turn the probe 90° from the former
scan to depict the same structures in a sec-
ond plane.
This scan is important for evaluating tendon
structures in case of anisotropy. It provides
the possibility to delineate a trochanteric
bursa in the second plane. Furthermore, the
transverse diameter of a calcification may be
much larger than the longitudinal diameter.
Then it is easier to detect the calcification in
the transverse scan.

What is normal?
A hypoechoic rim of <2.2 mm can be found
in the region of the trochanteric bursa.
 86 8 HIP

8.2 Pathology of the hip

8.2.1 Synovitis/effusion of the hip I

Best Scan: Standard Scan 8-1

Additional scans: Standard Scans 8-2 and 8-3

Synovitis occurs in inflamed hip joints (Fig-

ure 8-1). The synovial material distends the
joint capsule in an anterior direction. Thus it
is no longer parallel to the bone surface. The
distance between bone surface and joint
capsule increases to more than 8 mm. As in-
dividual distances display a greater variabil-
ity, the distances can be compared with the
other side. Unilateral synovitis is probable if
the difference between both sides is > 1.5 mm
and the morphology is different. The dis-
tance between bone and joint capsule in Fig-
ure 8-1 is 10.2 mm, and the joint capsule is
not parallel to the bone because of synovitis.
If findings are ambivalent the hip can be ro-
tated internally and externally to detect
smaller pathologies.

If an effusion is present as depicted in Figure

8-2 the finding is clearer as the anechoic
(black) area which represents fluid (=>) con-
trasts with the iliofemoral ligament (<=) that
is pushed in anterior direction to the joint
capsule.

Linear probes with higher resolution may

show further details (Figure 8-3), but they
fail to provide a good overview. This image
was made with a frequency of 8 MHz (color
frequency 6 MHz). The distance between
bone surface and joint capsule is 11.0 mm.

Figure 8-1 Synovitis of the hip joint, slight irregulari- iliofemoral ligament, irregularities of acetabulum and
ties of the acetabulum in osteoarthritis (longitudinal femoral head in osteoarthritis (longitudinal view).
view). Figure 8-3 Synovitis of hip joint with inflammatory
Figure 8-2 Effusion of the hip joint that lifts up the activity (color) and bony irregularities (longitudinal view).
 HIP 8 I 87

8.2.2 Synovitis/effusion of the hip

II
Best Scan: Standard Scan 8-1
Additional scans: Standard Scans 8-2 and 8-3

More expensive ultrasound machines offer

panorama view options. The name of these
options varies between manufacturers of ul-
trasound technology. When moving the
probe along an anatomic structure, technol-
ogy glues the images to a single image that
provides an overview of a larger anatomic
region. Thus a larger area can be depicted
with a small probe with higher resolution as
shown in Figure 8-4. This figure shows effu-
sion of the hip joint and moderate bony ir-
regularities.

Figures 8-5 and 8-6 show synovitis of a hip

joint in a longitudinal (<=) and transverse
(<=) view directly after injection of triam-
cinolone, which is, together with injected air
bubbles, hyperechoic and localizes between
bone and iliofemoral ligament.
Particularly in case of effusion or synovitis
of the hip joint, the pathologies should not
only be depicted in a longitudinal scan but
also in a transverse scan to evaluate the
amount. Synovitis or effusion may extend
more medially or laterally or into the ilio-
psoas bursa.

Figure 8-4 Panoramic view image of effusion of the

hip joint (longitudinal view).
Figure 8-5 Synovitis of the hip joint with hyperechoic
material after glucocorticoid injection (longitudinal
view).
Figure 8-6 Synovitis of the hip joint with hyperechoic
material after glucocorticoid injection (transverse view).
 88 8 HIP

8.2.3 Iliopsoas bursitis

Best Scan: Standard Scan 8-2

Additional scan: Standard Scan 8-1

The iliopsoas bursa localizes between the il-

iopsoas muscle and the hip joint. It does not
contain visible fluid in healthy subjects. If
bursitis occurs a hypoechoic area (=>) can be
seen between muscle and joint capsule/ilio-
femoral ligament (Figures 8-7 and 8-8). Fi-
gure 8-7 additionally shows hip joint effu-
sion (<=) and slight irregularities of the
acetabulum (^).

It is often difficult to detect bursitis as bursa

and muscle may display similar echogenici-
ties and the bursal fluid may localize either
between an area directly anterior to the hip
joint (Figure 8-8) or an area much further
medially, close to the femoral artery (^) and
vein (v) (Figure 8-9).

Just as in a Baker's cyst of the knee, ilio-

psoas bursitis is often a consequence of an
increased amount of fluid in the adjacent
joint. Bursitis can occur both with and with-
out hip joint effusion or synovitis. It is often
possible to sonographically delineate the
communication between hip joint and bursa
(Figures 8-8 and 8-9; <=)•

Figure 8-7 Iliopsoas bursitis, hip joint effusion, and

slight irregularities of the acetabulum, (longitudinal
view).
Figure 8-8 Iliopsoas bursitis with connection to hip
joint effusion, (transverse view).
Figure 8-9 Iliopsoas bursitis localized close to the
femoral artery and vein, (transverse view).
 HIP 8 89

8.2.4 Osteoarthritis/osteonecrosis
of the hip
Best Scans: Standard Scans 8-1 and 8-3
Additional scan: Standard Scan 8-2

Radiography is the imaging method of choice

to diagnose osteoarthritis. Nevertheless, ul-
trasound delineates typical pathologies in
osteoarthritis, too. Ultrasound is very sensi-
tive for the detection of osteophytes that
may occur at the acetabulum and/or the fe-
mur. It is more difficult to detect joint space
narrowing with ultrasound as this imaging
modality provides less information about
this area.

Figure 8-10 shows osteophytes both of the

acetabulum and the femoral head (^). In this
image it is difficult to determine if synovitis
is present. The capsule is not completely par-
allel to the joint space, and the distance be-
tween bone and joint capsule is 8.2 mm. In
fact there is a small amount of synovitis.

Figure 8-11 shows osteophytes only at the

acetabulum (^). The surface of the femoral
head including the cartilage is smooth. There
is no effusion.

Figure 8-12 The appearance of an erosion

(=>) is entirely different. It may occur in os-
teonecrosis (this case) or in rheumatoid ar-
thritis. Synovitis/effusion (<=) which lifts up
Figure 8-10 Major irregularities of acetabulum and the iliofemoral ligament (v) may be seen in
femur in osteoarthritis, (longitudinal view). both conditions.
Figure 8-11 Major irregularities of acetabulum in
osteoarthritis, (longitudinal view).
Figure 8-12 Large erosion of femoral head in
osteonecrosis, hip joint synovitis, that lifts up the
iliofemoral ligament, (longitudinal view).
90 HIP

8.2.5 Loose bodies and arthroplasty

of the hip
Best Scans: Standard Scans 8-1 to 8-3

Ultrasound can detect loose bodies if they

localize in an area that is accessible to ultra-
sound. The loose body has no direct contact
to the underlying bone (Figure 8-13; =>).
Metal is as hyperechoic as bone. Further-
more, ultrasound that is applied in frequen-
cies between 5 and 15 MHz does not pene-
trate either bone or metal surfaces. Metal
surface is more homogeneous than bone.

In case of total hip joint arthroplasty the sur-

face of the prosthesis can be depicted (Figure
8-14; ^). Months after surgery a pseudo-
capsule develops (v) which is usually local-
ized 5-6 mm anterior to the prosthesis. The
distance is 12 mm in Figure 8-14 indicating
that there is more material than normal in
the joint. The pseudo-capsule does not nor-
mally appear as hyperechoic and as thick as
the original joint capsule. As in this patient
it can be only assumed in the area where the
hypoechoic intra-articular material is adja-
cent to the more echogenic fibers of the ilio-
psoas muscle.

Figure 8-15 depicts osteosynthetic material

(^) at the femoral head with a large effusion
proximal to it (=>).
Figure 8-13 Loose body close to the joint space of the
hip joint (longitudinal view).
Figure 8-14 Total hip joint arthroplasty, with pseudo-
capsule, (longitudinal view).
Figure 8-1 5 Osteosynthesis of femoral head and
effusion, (longitudinal view).
 HIP 8 1 91

8.2.6 Greater trochanter patholo-

gies
Best Scans: Standard Scans 8-4 and 8-5

Patients with pain in the hip region often

display pathologies at the greater trochanter.
The trochanteric bursa usually contains very
little fluid. Inflammatory diseases such as
polymyalgia rheumatica may occur with
bursitis. Bursitis may also be purulent. Ultra-
sound helps to detect areas with fluid for
puncture. Trochanteric bursitis may contain
midechoic material. In this case it is often
difficult to differentiate the bursitis from the
surrounding tissue. The tendons that insert
at the trochanter may be inhomogeneous
and hypoechoic because of anisotropy.
Therefore it is necessary to look carefully in
two planes for a dark structure with defined
borders (Figure 8-16; =>) in this region if a
patient complains about pain of the lateral
trochanteric region.

Ultrasound can also delineate calcifications

(Figure 8-17; ^) and inhomogeneous ten-
dons because of enthesopathy particularly in
spondyloarthropathies.

Soft tissue masses in this region, including

hematomas (Figure 8-18; ^), tumors, and
calcifications can be easily depicted by ul-
trasound.

Figure 8-16 Trochanteric bursitis in polymyalgia rheu-

matica (longitudinal view).
Figure 8-17 Calcification of tendons at the greater
trochanter in ankylosing spondylitis (longitudinal view).
Figure 8-18 Hematoma lateral to the greater
trochanter (transverse view).
 9 Knee

9.1 Standard Scans of the knee

9.1.1 Suprapatellar longitudinal

view of the knee (Standard
Scan 9-1)

The patient lies supine with the knee ex-

tended. Place the probe parallel to the femur
directly proximal to the patella. The patient
tightens the quadriceps muscle to visualize
small amounts of fluid in the suprapatellar
recess. Alternatively, the knee may be flexed
and extended. The sonographer can also
press the synovial fluid from the region be-
low the patella to the suprapatellar recess.
Now move the probe continuously to the lat-
eral region and than to the medial region.
This scan is very important when searching
for knee joint effusions and synovial prolif-
eration. It depicts the quadriceps tendon, the
cranial parts of the patella and the femur.

What is normal?
Physiologic fluid in the suprapatellar recess
(a) 2.4 mm (0-4.8 mm midline sagittal), 2.4
mm (0-4.9 mm if the probe is moved to the
lateral aspects of the suprapatellar recess,
sagittal). For measuring, the quadriceps
muscle should be tightened. The amount of
fluid is pathologically increased if fluid is
seen all the way between midline and lateral.
Synovial proliferations (Standard Scan 9-2)
are in general pathologic. The amount of
fluid in the figure on the right side is border-
line to pathologic.
94 9 KNEE

9.1.2 Suprapatellar transverse view

of the knee (Standard Scan
9-2)
The patient lies supine. At first, the knee is
extended. Place the probe transversely in the
area proximal to the patella. With this posi-
tion, it is possible to visualize the quadriceps
tendon and the suprapatellar recess. The su-
prapatellar recess can also be seen if the
probe is moved more medially or laterally
When the patient flexes his knee to 90° or
more, it is possible to visualize, in part, tis-
sue that is localized under the patella includ-
ing the intercondylar cartilage.
This scan is used to see knee joint effusions
in a second plane, to depict synovial prolif-
eration and, if the knee joint is flexed, to
evaluate the intercondylar cartilage.

What is normal?
Cartilage (a) is 3.5 mm (1.7-4.5 mm), in fe-
males 2.7 mm (1.4-4.0 mm) and in males 3.5
mm (2.1-4.9 mm). Normal cartilage is an-
echoic or very hypoechoic. Small physiologic
amounts of fluid can be seen in the suprapa-
tellar recess as described above (Standard
Scan 9-1).
 KNEE 9 95

9.1.3 Lateral longitudinal view of

the knee (Standard Scan 9-3)

The patient lies supine with the knee ex-

tended. Move the probe continuously from
the position in Standard Scan 9-1 via the
anterolateral suprapatellar region to the po-
sition in Standard Scan 9-3 at the lateral
joint space. Move the probe from anterior to
posterior or vice versa. By moving the probe
more distally, the fibula can be seen.
With this scan it is possible to assess the in-
flammatory activity of synovitis. Standard
Scans 9-3 and 9-4 are the favorable scans to
evaluate color Doppler signals.
Erosions are seen in inflammatory arthritis.
Standard Scans 9-3 and 9-4 are best to de-
pict osteophytes in osteoarthritis. Ganglia or
calcifications can be detected in the lateral
meniscus. Nevertheless, ultrasound should
not be used when searching for meniscal
tears. Otherwise, it is possible to investigate
the lateral collateral ligament, iliotibial band,
biceps femoris and popliteal tendons. They
can be torn or damaged after trauma, and
they may be hypoechoic, thickened, and in-
homogeneous in case of enthesopathy.

What is normal?
The bone surface is regular. The lateral col-
lateral ligament is homogeneous. A little
amount of intraarticular fluid is normal
(Standard Scan 9-1), particularly at the an-
terolateral region of the suprapatellar re-
cess.
96 9 KNEE

9.1.4 Medial longitudinal view of

the knee (Standard Scan 9-4)
The patient is supine with the knee extended.
Place the probe parallel to the femur at the
medial joint space. The probe can also be
moved continuously from the position in
Standard Scan 9-1 via the anteromedial su-
prapatellar region to the position in Stan-
dard Scan 9-4 at the medial joint space. At
the medial joint space, move the probe from
anterior to posterior or vice versa.
Indications are similar to Standard Scan 9-3.
Ultrasound should not be used when search-
ing for meniscal tears.

What is normal?
The bone surface is regular. The medial col-
lateral ligament is hyperechoic and homoge-
neous.
 KNEE 9 I 97

9.1.5 Infrapatellar longitudinal

view of the knee (Standard
Scan 9-5)

The patient is supine with the knee extended.

Place the probe longitudinally at the midline
below the patella. For the investigation of
the patellar tendon the quadriceps muscle
should be tightened or the knee should be
flexed. Otherwise the tendon may look ir-
regular. Also move the probe to the more lat-
eral and medial infrapatellar region. It is also
possible to move the probe continuously
from the position in Standard Scan 9-3 or
9-4 via the lateral or medial infrapatellar re-
gion to this scan. The deep infrapatellar
bursa may be filled with fluid on the medial
or lateral side of the distal patellar tendon. It
may often only be detected with contraction
of the quadriceps muscle.
With this scan it is possible to see anterior
bursae, to evaluate the patellar tendon, to
see knee joint synovitis or effusion that is
localized distally to the patella, and irregu-
larities of the femoral and tibial surface, such
as in Osgood-Schlatter disease.

What is normal?
The standard diameter of the patellar tendon
(a) is 3.2 mm (1.9-4.5 mm); for females 2.9
mm (1.9-3.9 mm) and for males: 3.5 mm
(1.9-5.1 mm). A small amount of fluid may
occur in the deep infrapatellar bursa (b) in
6% of a healthy population. Normally, no
visible synovial fluid occurs in the infrapa-
tellar region.
98 9 KNEE

9.1.6 Infrapatellar transverse view

of the knee (Standard Scan
9-6)
The patient is supine with the knee extended.
Turn the probe 90° from the previous scan
below the patella at midline. For the investi-
gation of the patellar tendon the quadriceps
muscle should be tightened or the knee
should be flexed. Move the probe from prox-
imal to distal or vice versa to see all parts of
the tendon and continue further distally to
assess the infrapatellar bursa and the tibial
bone surface.
Just as with the previous scan, this scan en-
ables the sonographer to assess the patellar
tendon, anterior bursae, synovitis, effusion,
and infrapatellar bone surfaces. It is difficult
to see the anterior cruciate ligaments as they
are not parallel to the probe.

What is normal?
See normal values for the patellar tendon on
Standard Scan 9-5. A small amount of fluid
may occur in the deep infrapatellar bursa,
also in healthy individuals.
 KNEE 9 99

9.1.7 Posterior transverse view of

the knee (Standard Scan 9-7)

The patient is prone with the knee extended.

Start at the medial area and move the probe
from the femoral region down to the tibial
region. This is the best area to detect a Ba-
ker's cyst. Then continue to midline to visu-
alize the popliteal artery and the popliteal
vein and to the lateral region. It is important
to look at the medial areas of the lower leg,
particularly if the leg is swollen, when
searching for a ruptured Baker's cyst that
sometimes extends rather medially.
This scan is useful not only to look for pos-
terior bursitis but also to evaluate the popli-
teal vein which may be compressed as in the
ultrasound image at this page, for soft-tissue
masses, and for bony irregularities.

What is normal?
A small amount of fluid in the popliteal
bursa occurs in 16% of healthy individuals.
The popliteal vein is compressible.
9.1.8 Posterior longitudinal view of
the knee (Standard Scan 9-8)
The patient is prone. The knee is extended.
Start at the medial area and move the probe
to the lateral area or vice versa. In midline,
the popliteal vein and artery can be seen.
This scan is used to depict posterior struc-
tures in a second plane.
The first ultrasound image and the corre-
sponding drawing depict the medial aspects.
The second ultrasound shows the lateral as-
pects with a fabella (*).

What is normal?
A small amount of fluid in the popliteal
bursa may occur in healthy individuals. The
popliteal vein is compressible. A fabella (*),
which is a sesamoid bone of the lateral gas-
trocnemius tendon, occurs in 10-20% of
normal persons.
 KNEE 9 101

9.2 Pathology of the knee

9.2.1 Synovitis/effusion of the knee

I

Best Scans: Standard Scans 9-1 and 9-2

Additional scans: Standard Scans 9-3 to 9-8

Effusion (echo-free, compressible material)

is found in most inflamed knees (Figures 9-
1 and 9-2; < ) . It is impossible to determine
the exact amount of synovial fluid by ultra-
sound. Nevertheless, the longitudinal and
sagittal diameters of the suprapatellar recess
can be measured to compare findings in fol-
low-up investigations.

The intra-articular material may be midechoic

and inhomogeneous. This may be fibrin, he-
matoma, cell debris, or synovial prolifera-
tion. Synovial proliferation (Figure 9-2; =>)
is found in most inflamed knees. It becomes
smaller with a straight surface after surgical
synovectomy or radiosynovectomy. It may
exhibit color signals in correlation with the
inflammatory activity. Synovial prolifera-
tion can best be detected in the lateral area
of the suprapatellar recess where it can be
seen in longitudinal and transverse scans.

The best area to visualize synovitis and its

perfusion is the medial and lateral joint space
(Figure 9-3). This figure shows synovitis
with active inflammation (perfusion grade
2). In addition the figure displays slight bony
irregularities, a small osteophyte (v) indicat-
ing mild osteoarthritis and small calcifica-
tions of the lateral meniscus (^).

Figure 9-1 Effusion in the suprapatellar recess in a

longitudinal view.
Figure 9-2 Effusion and synovial proliferation in the
suprapatellar recess (transverse view).
Figure 9-3 Longitudinal view of active inflammatory
synovitis at the lateral joint space.
 102 9 KNEE

9.2.2 Synovitis/effusion of the knee

II

Best Scans: Standard Scans 9-1 and 9-2

Additional scans: Standard Scans 9-3 to 9-8

Although effusion is most often detected in

the suprapatellar recess, it may also occur in
any other anatomic region of the knee.
Therefore it is mandatory to perform a com-
plete ultrasound examination of the whole
knee in search for effusion.

In the infrapatellar region, effusion may

emerge into the Hoffa's fat pad close to the
tibia (Figure 9-4; <=).

In patients with total knee joint arthroplasty

effusions are frequently localized in the in-
frapatellar region (Figure 9-5; <=)• In the
first weeks after surgery, hypoechoic mate-
rial regularly occurs close to the prosthesis
due to hematoma. In contrast to effusions,
hematomas are not completely echo-free,
and they are poorly compressible. A prosthe-
sis is depicted as a hyperechoic, straight line
(^). In this figure, the patellar tendon is post-
operatively inhomogeneous (=>). Further-
more, a prepatellar bursitis can be seen (v).

Figure 9-6 shows synovitis in the posterior

compartment of the knee joint at the medial
femoral condyle. Ultrasound displays hy-
poechoic, but no anechoic material (=>).
Thus, this material cannot be punctured suc-
cessfully. The echo-free region close to the
surface of the medial femoral condyle (<=)
represents cartilage.
Figure 9-4 Knee joint effusion in the infrapatellar
region (longitudinal view).
Figure 9-5 Knee joint effusion in the infrapatellar
region, total knee joint prosthesis, thickening of patellar
tendon, and prepatellar bursitis (longitudinal view).
Figure 9-6 Synovitis at the posterior region of the
medial femoral condyle (longitudinal view).

Figure 9-7 Enthesopathy of the quadriceps tendon
with an osteophyte of the patella (longitudinal view).
Figure 9-8 Tendinitis of the patellar tendon (longitu-
dinal view).
Figure 9-9 Enthesitis of the lateral biceps femoris
tendon at its insertion at the fibula (longitudinal view).
KNEE 9 103
9.2.3 Enthesitis/tendinitis of the
knee
Best Scans quadriceps tendon: Standard Scans 9-1
and 9-2
Best Scans patellar tendon: Standard Scans 9-5
and 9-6
Best Scans medial and lateral tendon, and liga-
ment insertions: Standard Scans 9-3 and 9-4
Especially patients with spondyloarthropa-
thies often report pain at tendon insertions.
Radiography may depict calcifications or
erosions. Ultrasound is particularly useful to
localize these abnormalities at the insertions
of tendons or ligaments together with ten-
don or ligament swelling. An inflamed ten-
don or ligament is thickened, hypoechoic
and inhomogeneous.
Figure 9-7 depicts the quadriceps tendon
with an osteophyte close to its insertion at
the patella (^). This may be due to enthe-
sopathy. Nevertheless, these osteophytes also
occur frequently in patients with osteoar-
thritis of the knee joint.
Figure 9-8 shows the patellar tendon. It is
hypoechoic compared with the surrounding
soft tissue and inhomogeneous. It is also
thickened (>4.5 mm), particularly in its mid-
dle part (v). This is a mild but clearly patho-
logic finding.
Figure 9-9 shows a hypoechoic, thickened
and inhomogeneous distal biceps femoris
tendon at its insertion at the fibula as a sign
of enthesitis in this region (v). The bone sur-
face of the femoral epicondyle (left), the tibia
(center) and the fibula (right) is straight in
this case, but it may also become irregular
with erosions in chronic enthesopathy (see
Figure 10-13).
104 9 KNEE

9.2.4 Prepatellar and infrapatellar

bursitis
Best Scans: Standard Scans 9-5 and 9-6

Three types of bursitis occur in the prepatel-

lar and infrapatellar region: both prepatellar
bursitis (Figure 9-10) and deep infrapatellar
bursitis (Figures 9-11 and 9-12) are com-
mon. Superficial infrapatellar bursitis is a
rare condition. It is localized anteriorly to
the distal part of the patellar tendon. This
alteration is not depicted. In case of bursitis,
the bursae should be depicted and measured
in all three directions (longitudinal, trans-
verse, and sagittal).

Prepatellar bursitis can be diagnosed clini-

cally. Usually it is important to know the
cause of prepatellar bursitis. Ultrasound can
differentiate if there is fluid in the bursitis as
shown in Figures 9-10 to 9-12. Often non-
fluid material is found which may not be
punctured. Ultrasound can find areas of fluid
that may be punctured to diagnose gout or
septic arthritis. In gout, specific hyperechoic
structures with posterior shadowing may be
found as delineated in Figure 9-23. In Figure
9-10 the soft tissue around the bursitis is
thickened and homogeneous due to general-
ized amyloidosis in a patient with plasmacy-
toma.

Infrapatellar bursitis as depicted in Figure 9-

Figure 9-10 Prepatellar bursitis and amyloidosis of
subcutaneous tissue in a longitudinal view.
Figure 9-11 Deep infrapatellar bursitis in a longitudi-
nal view.
Figure 9-12 Deep infrapatellar bursitis in a transverse
view.
11 (longitudinal scan) and in Figure 9-12
(transverse scan) is often combined with an
effusion of the knee. Sometimes, infrapatel-
lar bursitis is the only sign of inflammation
in the knee region. It may be better seen
when the quadriceps muscle is tightened. It
is often localized at the distal lateral or me-
dial edges of the patellar tendon.
 KNEE 9 I 105

9.2.5 Baker's cyst

Best Scans: Standard Scans 9-7 and 9-8

The first indication for musculoskeletal ul-

trasound in the 1970s was the detection of
popliteal Baker's cysts. A ruptured Baker's
cyst is a frequent cause of a swollen leg in
patients with rheumatic diseases. Ultrasound
can easily differentiate between Baker's cysts
and deep vein thrombosis. Baker's cysts may
consist of fluid, midechoic or hyperechoic
material, or even calcifications.
To start the search for a Baker's cyst, use a
transverse scan of the medial posterior side
of the knee, where more than 80°/o of Baker's
cysts are found, and continue distally to the
posterior and medial areas of the lower legs.

A Baker's cyst is typically localized adjacent

to the medial head of the gastrocnemius
muscle and may consist of three compart-
ments that communicate with each other
and with the knee joint (Figure 9-13). The
popliteal bursa (v) is most commonly in-
volved together with the medial gastrocne-
mius bursa (<=). The semimembranosus bursa
(=>) that is localized posterior to the medial
femoral condyle (^) is less frequently in-
volved.

A Baker's cyst should be displayed and mea-

sured in transverse and longitudinal views.
Figure 9-14 shows an intact popliteal cyst
in a longitudinal view.

A Baker's cyst may extend to the lower parts

of the lower legs with a length of >20 cm or
rupture. The distal end of a ruptured (=>)
Figure 9-13 Baker's cyst with fluid in the popliteal Baker's cyst becomes pointed with fluid in
bursa, medial gastrocnemius bursa and semimembrano- its surroundings (v) (Figure 9-15).
sus bursa.
Figure 9-14 Longitudinal view of a Baker's cyst
(popliteal region).
Figure 9-15 Longitudinal view of a ruptured Baker's
cyst (popliteal region).
 106 9 KNEE

9.2.6 Osteophytes, erosions and

loose bodies of the knee
Best Scans: Standard Scans 9-3 and 9-4
Additional scans: Standard Scans 9-1, 9-2, 9-5, 9-
6, 9-7 and 9-8

Ultrasound is an excellent method to de-

scribe the bone surface, also at the knee
joint.

Figure 9-16 shows both osteophytes (^) and

joint space narrowing (between the osteo-
phytes) of the lateral joint space. A small sy-
novitis with mild inflammation (grade 1
color signal) is seen. The iliotibial band is
dislocated to the lateral side (v) by the syno-
vial swelling and the osteophytes.

Figure 9-17 shows a large erosion in a pa-

tient with RA at the lateral femoral condyle
(=>). The detection of erosions helps to dif-
ferentiate between RA and osteoarthritis as a
cause of knee pain. Nevertheless, erosions at
the knee joint are not specific for RA. They
also occur in other chronic inflammatory
diseases such as chronic reactive arthritis.

Figure 9-18 shows a loose body (^) that is

localized next to the lateral aspect of the
tibia in a patient with osteochondritis disse-
cans. The bone on the left is the femur. The
bone on the right is the fibula. When the
probe is moved to the ends of the loose body
in both a longitudinal and a transverse plane,
it is impossible to delineate a connection be-
Figure 9-16 Osteophytes and small synovitis with tween the loose body and the tibia.
mild inflammation in osteoarthritis (longitudinal lateral
view).
Figure 9-17 Erosion of the lateral femoral condyle in
RA (longitudinal lateral view).
Figure 9-18 Loose body lateral of the tibia in
osteochondrosis dissecans (longitudinal lateral view).
 KNEE 9 I 107

9.2.7 Osgood Schlatter disease and

paratenonitis

Best Scans Osgood-Schlatter disease: Standard

Scans 9-5 and 9-6
Best Scans paratenonitis of the semitendinosus
tendon: Standard Scans 9-7 and 9-8

Figure 9-19 depicts a patient who had Os-

good-Schlatter disease. Severe irregularities
of the tibia (^) can be seen at the insertion of
the patellar tendon and calcifications (v) in
the patellar tendon. The distal end of the pa-
tellar tendon is hypoechoic. This may be due
to either mild tendinitis or anisotropy. Pa-
tients with acute Osgood-Schlatter disease
appear with patellar tendon tendinitis, ir-
regularities of the epiphysial cartilage and at
the tibia.

Figure 9-20 shows a longitudinal view of a

paratenonitis (^, v) of the semitendinosus
tendon. This patient presents with a painful,
slightly reddened longitudinal area at the
medial posterior region proximal to the knee
joint. Clinically, this appears to resemble a
thrombophlebitis. The ultrasound image is
similar to tenosynovitis, but this condition
cannot be called tenosynovitis because the
semitendinosus tendon has no tendon sheath.
The tissue around the tendon is inflamed.
The patient can be treated with an ultra-
sound-guided corticosteroid injection.

Figure 9-21 shows the same patient with

paratenonitis of the semitendinosus tendon
in a transverse scan. The semimembranosus
tendon can also exhibit a paratenonitis.

Figure 9-19 Tibial irregularities and calcifications of

the patellar tendon in Osgood-Schlatter disease
(longitudinal view).
Figure 9-20 Longitudinal view of a paratenonitis of
the semitendinosus tendon.
Figure 9-21 Transverse view of a paratenonitis of the
semitendinosus tendon.
 108 9 KNEE
Figure 9-22 Transverse superpatellar view with 90'
flexion of knee of the intercondylar cartilage with
chondrocalcinosis.
Figure 9-23 Intra-articular tophus close to the medial
femoral condyle, there is a shadow that partially
extinguishes the signal of the bone surface.
Figure 9-24 Longitudinal suprapatellar view of a
ruptured quadriceps tendon with synovitis, effusion and
knee joint prosthesis.
9.2.8 Chondrocalcinosis, tophus and
tendon rupture of the knee
Best Scans chondrocalcinosis: Standard Scans 9-2,
9-6, 9-7 and 9-8
Best Scans tophus: Standard Scans 9-3, 9-4, 9-5
and 9-6
Best Scans tendon rupture: Standard Scans 9-1,
9-2, 9-5 and 9-6
Chondrocalcinosis is diagnosed clinically
and radiographically (Figure 9-22). The di-
agnosis can also be confirmed by ultrasound
as it depicts specific midechoic or hypere-
choic dots and lines within the cartilage (^).
Ultrasound also provides typical images of
gout tophi (Figure 9-23). A tophus has a hy-
perechoic appearance. It is slightly irregular
(v) with a shadow (=>,<=) that only partially
extinguishes the signal of the bone surface
(^). Calcifications or bone, in contrast, com-
pletely extinguish the signal of the bone sur-
face. The tophus may be intra-articular as in
this patient where it localizes within the knee
joint close to the medial condyle or extra-
articular. Furthermore, ultrasound helps to
find an area of fluid for puncture to perform
microscopy for the diagnosis of gout.
Tendon rupture with or even without trauma
is a common complication of rheumatic dis-
eases. This patient presents with a rupture of
the quadriceps tendon. Ultrasound depicts
both ends of the tendon (Figure 9-24, v).
With dynamic examination, the parts can be
even moved further apart from each other
while flexing the knee. Furthermore, in this
patient ultrasound depicts effusion (=>), sy-
novitis (<=), and a knee joint prosthesis that
is hyperechoic, straight, and horizontal (^).
 109

10 Ankle, foot and toes

10.1 Standard Scans of the

ankle, foot and toes

10.1.1 Anterior longitudinal view of

the ankle (Standard Scan 10-
1)
The patient is in a supine position. There are
two possibilities: either the knee is extended
with the ankle in a neutral position, or the
knee is 45° flexed with the foot resting on
the bed. Place the probe longitudinally, mid-
line of the ankle. Then move the probe to the
medial and lateral areas. Short probes (<4.5
cm) delineate either the ankle joint or the
talonavicular joint. Make sure both joints are
examined. For dynamic examination have
the patient flex and extend his ankle to de-
tect minor amounts of fluid. Note that the
talonavicular joint is not at the deepest point
of the talus but more distal.
This scan is useful to evaluate the ankle and
the talonavicular joints as well as to detect
tenosynovitis of the extensor tendons.

What is normal?
The distance between talus and joint capsule
1 cm distal of the ankle joint midline sagittal
(a) is 1.1 mm (0.1-2.1 mm) The maximum
sagittal distance between bone and joint
capsule at the talonavicular joint (b) is 1.4
mm (0.2-2.6 mm).
110 10 ANKLE, FOOT AND TOES

10.1.2 Anterior transverse view of

the ankle (Standard Sean
10-2)

The patient's position is identical to that in

Standard Scan 10-1. Place the probe in a
transverse way in the region of the ankle
joint and move it from tibia to talus and cal-
caneus or vice versa. This scan is important
for investigating the structures seen in Stan-
dard Scan 10-1 in a second plane. In healthy
subjects it is difficult to differentiate the an-
atomic structures, in particular tendons, un-
less there is a certain amount of fluid in the
tendon sheaths.

What is normal?
Normal sagittal diameter of the tibialis ante-
rior tendon (a) is 2.5 mm (1.2-3.8 mm). The
normal transverse diameter (b) is 8.2 mm
(4.7-11.7 mm). The physiologic hypoechoic
rim (c) is 0.8 mm (0-1.7 mm). The maximum
diameter of the tendon sheath of any exten-
sor tendon at any location should be <3
mm.
 ANKLE, FOOT AND TOES 10 111

10.1.3 Medial transverse view of the

ankle (Standard Scan 10-3)

The patient's position is identical to that in

Standard Scans 10-1 and 10-2. The patient
only rotates the leg externally. Thus it is eas-
ier to assess this region. Start directly distal
to the malleolus. Then move the probe dis-
tally to the insertions of the flexor tendons.
Afterwards move the probe along the mal-
leolus up to an area 10 cm cranial of the
malleolus as the tendon sheath extends that
far.
The aim of this scan is to look for tenosyno-
vitis of the flexor tendons. The tibialis poste-
rior tendon localizes most anteriorly fol-
lowed by the flexor digitorum longus tendon
and the flexor hallucis longus tendon. The
tibialis posterior tendon is markedly thicker
than the flexor digitorum longus tendon. In
addition, the neurovascular bundle includes
the tibial posterior artery and the two tibial
posterior veins which are normally com-
pressible. The tibialis posterior nerve is lo-
calized between the posterior tibialis vein
and the flexor hallucis longus tendon. The
neurovascular bundle passes below the flexor
retinaculum of the ankle.

What is normal?
The normal sagittal diameter of the tibialis
posterior tendon directly distal of the mal-
leolus (a) is 2.8 mm (1.0-4.6 mm), the trans-
verse diameter (b) is 8.4 mm (4.2-12.6 mm).
The normal diameter of the physiologic hy-
poechoic rim (c) is 1.2 mm (0-2.8 mm). The
maximum diameter of the tendon sheath of
any flexor tendon at any location should be
<3.5 mm.
10.1.4 Medial longitudinal view of
the ankle (Standard Scan
10-4)
The patient's position is identical to that in
Standard Scans 10-1 to 10-3. The patient
only rotates the leg externally as in Standard
Scan 10-3 to improve the assessment of this
region.
Again start at the region distal to the malle-
olus and move the probe distally to the in-
sertions of the flexor tendons. Also move the
probe proximally behind the malleolus up to
an area 10 cm cranial of the malleolus to
completely visualize the area in which the
tendons are surrounded by a tendon sheath.
This scan displays the flexor tendons, the
posterior tibial artery and veins, and the tib-
ial nerve in the second plane.

What is normal?
The tendons are slightly hyperechoic or
isoechoic and homogeneous. They can be
hypoechoic because of anisotropy in the re-
gion of their insertions. Sometimes it is dif-
ficult to visualize the tibialis posterior ten-
don near its insertion at the navicular.
 ANKLE, FOOT AND TOES 10 113

10.1.5 Lateral transverse view of the

ankle (Standard Scan 10-5)
The patient's position is identical to that in
Standard Scans 10-1 to 10-4. The patient
only rotates the leg internally to improve the
assessment of this region. Start again in the
area directly distal to the malleolus. Then
move the probe distally to the insertions of
the peroneus tendons and also proximally,
up to an area 10 cm cranial of the malleolus
as the tendon sheath extends that far.
This scan is to look for tenosynovitis of the
paired peroneal tendons. On the transverse
scan the peroneus brevis tendon localizes
medially and closer to the bone than the
peroneuslongus tendon.

What is normal?
The normal sagittal diameter of the peroneus
longus tendon directly distal of the malleo-
lus (a) is 3.0 mm (1.4-4.6 mm). The trans-
verse diameter (b) is 6.0 mm (2.3-9.7 mm).
The normal diameter of the physiologic hy-
poechic rim (c) is 1.1 mm (0-2.3 mm).
The normal sagittal diameter of the peroneus
brevis tendon directly distal of the malleolus
(d) is 2.5 mm (1.2-3.8 mm). The transverse
diameter (e) is 4.3 mm (1.3-7.3 mm). The
normal diameter of physiologic hypoechoic
rim (f) is 0.9 mm (0.1-1.7 mm). The maxi-
mum diameter of the tendon sheath of any
peroneus tendon at any location should be
<3 mm.
114 10 ANKLE, FOOT AND TOES

10.1.6 Lateral longitudinal view of

the ankle (Standard Scan
10-6)
The patient's position is identical to that in
Standard Scans 10-1 to 10-5. The patient
only rotates the leg internally as in Standard
Scan 10-5 to improve assessment of this re-
gion. Again start in the region distal to the
malleolus and move the probe distally to the
insertions of the peroneal tendons. Also
move the probe proximally behind the mal-
leolus up to an area 10 cm cranial of the
malleolus to completely visualize the area in
which the tendons are surrounded by a ten-
don sheath. This scan displays the paired pe-
roneal tendons in the second plane.

What is normal?
The normal ultrasound appearance is of a
hyperechoic structure with a typical fibrillar
structure as found in other tendons.
 ANKLE, FOOT AND TOES 10 115

10.1.7 Posterior longitudinal view of

the ankle (Standard Scan
10-7)

The patient is in prone position with his feet

hanging over the end of the edge of the ex-
amination table. Alternatively, the patient
can rest his toes on the bed with extension of
the ankle. For dynamic assessment the so-
nographer can hold the foot and flex and
extend the ankle.
First concentrate on superficial structures,
such as the Achilles tendon, retrocalcaneal
bursa, and posterior area of the calcaneus.
Then move the probe to the proximal areas
of the Achilles tendon until the gastrocne-
mius and soleus muscles can be seen.
Furthermore, this scan should be used to in-
vestigate more profound structures, particu-
larly for the assessment of the posterior re-
cess of the tibiotalar (ankle) joint. Sometimes
effusion or synovitis of the ankle joint occur
only in the posterior area of the joint. Small
effusions can be detected while extending
and flexing the ankle joint when performing
ultrasound.

What is normal?
The sagittal diameter of the Achilles tendon,
2 cm proximal of calcaneus (a) is 4.3 mm
(2.7-5.9 mm). In females this is 4.1 mm (2.7-
5.5 mm) and in males: 4.6 mm (3.0-6.2 mm).
A small amount of fluid occurs in 24% of
retrocalcaneal bursae (b). The sagittal dia-
meter should be <2.7 mm. The posterior re-
cess of the ankle joint is 1.2 mm (0.1-2.3
mm) (c).
10.1.8 Posterior transverse view of
the ankle (Standard Scan
10-8)
The patient's position is identical to that in
Standard Scan 10-7. Again look at all areas
of the Achilles tendon, at the posterior as-
pect of the calcaneus and the ankle joint.
This scan displays the anatomic structures in
the second plane in search for Achilles ten-
dinitis, paratenonitis, enthesitis, calcaneal
spurs, and effusions of the posterior recess of
the ankle joint.

What is normal?
The echogenicity of the Achilles tendon
should be identical to the surrounding tissue.
It takes the form of an ellipse with multiple
hyperechoic dots corresponding to collagen
bundles. Two cm proximal of its insertion in
the calcaneus, the tendon has a transverse
diameter (a) of 14.3 mm (10.2-18.4 mm). In
females this is 13.3 mm (9.9-16.7 mm) and
in males 15.4 mm (11.5-19.3 mm). A hy-
poechoic rim around the Achilles tendon oc-
curs in 13% of normal scans. The diameter
of this rim should be <3.3 mm. It corresponds
to the paratenon.
 ANKLE, FOOT AND TOES 10 117

10.1.9 Plantar proximal longitudinal

view of the foot (Standard
Scan 10-9)

The patient's position is identical to that in

Standard Scans 10-7 and 10-8 for the ankle.
The patient lies prone with his feet hanging
over the end of the examination table.
Place the probe midline at the plantar area of
the calcaneus. The distal end of the probe is
directed to the first toe. Therefore, this scan
is not completely longitudinal but 10-20%
oblique with the distal end of the probe
pointing medially. Move the probe slightly
to medial and lateral side to be sure to get
the central area of the plantar fascia and to
assess the calcaneus for the existence of
spurs.
As the skin is slightly thicker in this region it
is necessary to apply more pressure with the
probe and maybe also increase the gain, as
structures often appear rather dark.

What is normal?
The plantar fascia is hyperechoic and homo-
geneous just as most other tendons. The sag-
ittal diameter of the plantar fascia at the dis-
tal plantar end of the calcaneus (a) is 3.4 mm
(2.1-4.7 mm).
1 1 8 I 10 ANKLE, FOOT AND TOES

10.1.10 Anterior longitudinal view of

the midfoot (Standard Scan
10-10)
The patient's position is identical to that in
Standard Scans 10-1 and 10-2 of the ankle.
Start midline distal to the ankle and talona-
vicular joints to depict the naviculocunei-
form joint and the third tarsometatarsal
joint. Then move the probe medially to as-
sess the medial aspects of the naviculocu-
neiform joint and the first and second tarso-
metatarsal joints. Also move the probe
laterally to assess the lateral aspects of the
naviculocuneiform joint and the fourth, and
fifth tarsometatarsal joints.
This scan is important to detect effusion, sy-
novitis and bony irregularities (e.g. in osteo-
arthritis) of the midfoot.

What is normal?
The distance between bone and joint capsule
is minimal in these joints. Normal values
have not yet been determined.
 ANKLE, FOOT AND TOES 10 I 1 1 9

10.1.11 Anterior longitudinal view of

the toes (Standard Scan 10-
11)
The patient's position is identical to that in
Standard Scans 10-1 and 10-2 of the foot.
For dynamic examination the sonographer
can ask the patient to flex and extend his
toes. Place the probe midline at the anterior
aspect of each MTP joint. This scan offers the
fastest possibility to detect effusions or sy-
novitis of the toes. As synovitis may occur
more medially or laterally, the probe should
be moved slightly in these directions. The
MTP I and the MTP V joints can also be as-
sessed at their medial or lateral region, partic-
ularly to detect bony irregularities or erosions.
Then move the probe semi-circumferentially
around the joints.
All joints can also be assessed from the plan-
tar side. Findings should be re-evaluated in a
transverse plane. A further option is to ex-
tend the anterior scan to the PIP and DIP
joints of the toes.

What is normal?
Maximum sagittal anterior distance between
bone and joint capsule for an MTP 1 joint (a)
is 1.7 mm (0-3.5 mm). For an MTP II joint
this is 1.6 mm (0.1-3.1 mm). The ultrasound
figure displays physiologic synovial material
in an MTP joint.
120 10 ANKLE, FOOT AND TOES
Figure 10-1 Effusion of the ankle joint and tenosyno-
vitis of the extensor hallueis longus tendon (longitudinal
view).
Figure 10-2 Effusion of the ankle joint and synovitis
of the talonavicular joint (longitudinal view).
Figure 10-3 Effusion of the ankle joint and tenosyno-
vitis of the extensor tendons (transverse view).
10.2 Pathology of the ankle,
foot and toes
10.2.1 Synovitis/effusion of the
ankle and talonavicular joint
Best Scans: Standard Scans 10-1, 10-2, 10-7 and
10-8
The joint capsule of the tibiotalar (ankle)
joint extends distally and inserts at the talus.
The joint capsule of the talonavicular joint
extends more proximally until its insertion
at the talus. The insertions of both joint cap-
sules are close together. In case of effusion
or synovitis, anechoic or hypoechoic mate-
rial extends between the talus and joint cap-
sule. The joint capsule will no longer be par-
allel to the bone.
Figures 10-1 and 10-2 depict effusions of
the ankle joint (^). In addition Figure 10-1
shows a tenosynovitis of the extensor hal-
lueis longus tendon (=>). This must not be
confused with the dorsalis pedis artery (v).
Figure 10-2 displays additional synovitis of
the talonavicular joint (=>}. In addition, the
surface of the talus is irregular (<=).
Figure 10-3 shows tenosynovitis of the tibi-
alis anterior tendon (=>), the extensor hallu-
eis longus tendon (v), and the extensor digi-
torum longus tendon (^) together with an
effusion of the ankle joint (<=). It is much
easier to visualize the extensor tendons in
case of tenosynovitis.

Figure 10-4 Tenosynovitis of the tibialis posterior and
flexor digitorum longus tendons (transverse view).
Figure 10-5 Tenosynovitis of the peroneal tendons
(longitudinal view).
Figure 10-6 Tenosynovitis of the tibialis posterior
tendon (transverse view).
ANKLE, FOOT AND TOES 10 I 1 2 1
10.2.2 Tenosynovitis of the flexors of
the foot and the peroneal
tendons
Best Scans: 10-3 to 10-6
Tenosynovitis can occur in any region at,
proximal, or distal of the malleolus. The ten-
don is often not localized in the middle of
the effusion or synovitis within the tendon
sheath as shown in Figure 10-4. Therefore
tenosynovitis can be missed if only a longi-
tudinal scan is performed. Again, a tendon
with tenosynovitis is much easier to depict
than a normal tendon. In this figure, there is
a large amount of hypoechoic material
around the tibialis posterior tendon (^) and a
minor tenosynovitis of the flexor digitorum
longus tendon (v). Furthermore, there is
some edema (<=).
Figure 10-5 also displays edema (<=) and
fluid below the peroneal tendons (^) due to
tenosynovitis.
Tenosynovitis may either contain fluid as
shown in Figures 10-4 and 10-5 or hy-
poechoic, non-compressible material as in
synovitis. In RA, this material is usually pan-
nus. In case of severe inflammation major
perfusion of this material can be detected as
shown in Figure 10-6. This image displays
tenosynovitis of the tibialis posterior tendon
with a high inflammatory activity.
 122 10 ANKLE, FOOT AND TOES
Figure 10-7 Tendinitis of the Achilles tendon with
small calcification (longitudinal view).
Figure 10-8 Tendinitis of the Achilles tendon
(transverse view).
Figure 10-9 Tendinitis and paratendinitis of the
Achilles tendon (transverse view).
10.2.3 Tendinitis and paratenonitis
of the Achilles tendon
Best Scans: 10-7 and 10-8
In case of tendinitis, the Achilles tendon is
hypoechoic, i.e. the tendon is darker than the
surrounding soft tissue. Furthermore, it may
be inhomogeneous with increasing sagittal
diameter.
Figure 10-7 shows a longitudinal scan of a
patient with Achilles tendinitis. The sagittal
diameter is 7.5 mm. Tendinitis is not severe
in this case. The deeper areas of the tendon
are rather homogeneous. The superficial re-
gion is darker and more inhomogeneous
with a small calcification (v).
Figure 10-8 displays Achilles tendinitis in a
transverse plane. Again, the tendinitis is not
severe. The sagittal diameter is also 7.5 mm.
There are darker and inhomogeneous areas
within the more superficial areas of the ten-
don.
Figure 10-9 represents a case with both ten-
dinitis and paratenonitis of the Achilles ten-
don. The more profound areas of the tendon
are darker, they are inhomogeneous and dis-
play increased perfusion. The sagittal dia-
meter of the tendon is 9 mm. Furthermore,
there is hypoechoic tissue at the medial side
of the tendon (||.) that displays many color
signals as this tissue is highly inflamed. This
is paratenonitis, but no tenosynovitis as the
Achilles tendon has no tendon sheath.
 ANKLE, FOOT AND TOES 10 123

10.2.4 Achilles tendon rupture and

retrocalcaneal bursitis

Best Scans: 10-7 and 10-8

Ultrasound is an excellent technique to dis-

play Achilles tendon rupture as it allows
both static and dynamic examination.

In Figure 10-10 the fibers of the tendon are

not straight as seen on the left side of image.
Furthermore there is a hypoechoic region (v)
that represents the ruptured area. If the ankle
is extended, the gap increases as the two
pieces of ruptured tendon move away from
each other.

Figure 10-11 shows both Achilles tendinitis

with a dark, inhomogeneous structure and
an increased sagittal diameter of 10 mm and
a retrocalcaneal bursitis with fluid (=>). Small
amounts of bursal fluid can be found by
flexing and extending the ankle during ul-
trasound examination in this area.

Retrocalcaneal bursitis can also occur with-

out Achilles tendinitis as shown in Figure
10-12. In both cases, ultrasound-guided
bursal puncture and glucocorticoid injection
is a promising therapeutic option.

Figure 10-10 Rupture of the Achilles tendon

(longitudinal view).
Figure 10-11 Tendinitis of the Achilles tendon and
retrocalcaneal bursitis (longitudinal view).
Figure 10-12 Retrocalcaneal bursitis producing a
tear-drop appearance without Achilles tendinitis
(longitudinal view).
124 10 ANKLE, FOOT AND TOES

10.2.5 Heel pain: enthesopathy,

calcaneal spur and effusion
Best Scans: 10-7 and 10-8

Heel pain is common in spondyloarthropa-

thy. In these patients Achilles tendinitis fre-
quently occurs. Furthermore, bony changes
can often be seen that are typical for enthe-
sopathy.

As shown in Figure 10-13, the posterior sur-

face of the calcaneus is irregular with both
erosions (^) and osteophytes (v). In addition,
this patient has a small retrocalcaneal bursi-
tis (=>).

Posterior calcaneal spurs as shown in Figure

10-14 frequently occur in healthy subjects.
They may not correlate with any symptoms.
They are localized at the very distal end of
the Achilles tendon (^).

In patients with heel pain, it is important not

just to focus on the superficial structures as
the Achilles tendon, retrocalcaneal bursa and
posterior bone surface of the calcaneus, but
also to depict the posterior recess of the an-
kle joint. Figure 10-15 shows a large effu-
sion in the posterior area of the ankle joint
(v). Effusions or synovitis sometimes only
occur on the posterior side of the ankle joint.
Therefore arthritis of the ankle may be missed
if only anterior scans are performed.

Figure 10-13 Enthesopathy with Achilles tendinitis,

erosions of the calcaneus and retrocalcaneal bursitis
(longitudinal view).
Figure 10-14 Posterior calcaneal spur (longitudinal
view).
Figure 10-15 Large effusion in the posterior recess of
the ankle joint (longitudinal view).
 ANKLE, FOOT AND TOES 10 125

10.2.6 Plantar fasciitis and patholo-

gies of the midfoot
Best Scans plantar fascia: Standard Scan 10-9
Best Scans midfoot: Standard Scan 10-10

The plantar fascia becomes hypoechoic, in-

homogeneous, and thickened in case of fas-
ciitis.

Figure 10-16 shows plantar fasciitis. The

sagittal diameter is 6.0 mm. Furthermore,
there is an erosion of the plantar aspect of
the calcaneus (^).

Figure 10-17 also depicts a hypoechoic,

thickened, and inhomogeneous plantar fas-
cia. The sagittal diameter is 6.5 mm. Further-
more, this patient has a plantar calcaneal
spur (^) that looks like a step of the bone
surface in contrast to the continuous line of
the bone which is seen in Figure 10-16.
Plantar calcaneal spurs occur with or with-
out plantar fasciitis. They are more frequent
than erosions of the calcaneus.

Figure 10-18 shows major synovitis of the

naviculocuneiform joint (v) and minor syno-
vitis of the third tarsometatarsal joint (<=) in
a patient with osteoarthritis of the midfoot.
The bony surface at the joint spaces is ir-
regular, and the joint space of the third tar-
sometatarsal joint is narrowed.

Figure 10-16 Plantar fasciitis and calcaneal erosion

(longitudinal view).
Figure 10-1 7 Plantar fasciitis and plantar calcaneal
spur (longitudinal view).
Figure 10-18 Synovitis of the naviculocuneiform and
the third tarsometatarsal joints in osteoarthritis
(longitudinal view).
 126 10 ANKLE, FOOT AND TOES

10.2.7 Synovitis of the MTP joints

Best Scan: Standard Scan 10-11

It is often difficult to decide clinically if sy-

novitis of the MTP joints exists. The easiest
sonographic access is from the anterior side.
The patient should flex and extend the toes
to detect minor amounts of fluid or synovi-
tis. In case of synovitis the sagittal diameter
is increased and the joint capsule is not par-
allel to the bone surface.

Figure 10-19 shows both effusion (anechoic

region) and synovitis (hypoechoic region) of
the first MTP joint.

Figure 10-20 shows synovitis of the second

MTP joint and a small area of effusion to-
gether with perfusion of synovial tissue.
Furthermore, the bone surface is irregular as
in osteoarthritis and the phalanx points an-
teriorly. It is extended because of a hammer
toe. In hammer toes it is often difficult to
place the probe correctly on the anterior side.
To do so, the toe can be flexed to a certain
degree, and liberal ultrasound gel should be
applied, which is seen in the black area on
the top of the figure. If it is still impossible to
visualize the joint correctly, use a smaller
probe if available, or focus on the transverse
scan.

Figure 10-19 Effusion and synovitis of the first MTP
joint (longitudinal view).
Figure 10-20 Synovitis, osteoarthritis and hammer
toe (second MTP joint; longitudinal view).
Figure 10-21 Erosion of the fi^h MTP joint in RA
(longitudinal view).
Figure 10-21 provides a lateral longitudinal
view of the fifth MTP joint with a deep ero-
sion (<=). The joint space in seen on the right
side (=>). Ultrasound is sensitive for the de-
tection of erosions, particularly at the first
and fifth MTP joint.
 127

11 Arterial ultrasound

11.1 Vasculitis At least 30 to 50 normal subjects should be

examined to become familiar with the nor-
Primary vasculitides may involve blood ves- mal anatomy, before trying to diagnose GCA.
sels of different calibers: small vessels, as in Figure 11-1 shows the normal anatomy of
Wegener's granulomatosis, medium-sized the common superficial temporal artery with
arteries as in polyarteritis nodosa, and large its frontal and parietal branch.
arteries as in temporal arteritis (giant-cell ar-
teritis, GCA) and Takayasu arteritis (TAK).
It is possible to establish the diagnosis of
large artery vasculitis by ultrasound in com-
bination with clinical findings. Ultrasound
shows characteristic homogeneous wall
swelling of arteries o^en with stenoses and/
or occlusions.

11.1.1 Temporal arteries (giant cell

arteritis)
Temporal artery ultrasound scans may be
obtained by using linear probes with gray-
scale frequencies of >8 MHz (usually about
10-15 MHz) and color frequencies of about
8-10 MHz. As the temporal artery branches
are small (the lumen is about 0.7 mm) high-
end equipment is favorable. To date, some
medium quality ultrasound machines also
provide reasonable images.
Several machine adjustments are necessary.
The pulse repetition frequency (PRF) should
be set at about 2.5 KHz and the beam steering
of the color box should be maximal as the
temporal artery branches are localized paral-
lel to the probe. Color should completely
cover the artery lumen but should not cover
the artery wall. The investigation includes
the search for stenoses using duplex ultra-
sound. Stenoses are defined as a greater than
twofold increase in maximum systolic blood
flow velocity in the stenosis compared with
an area proximal or distal to the stenosis.
Figure 11-1 Anatomy of the common superficial
temporal artery with its frontal (a) and parietal branch
(b).
A longitudinal scan is started anterior to the
le^ ear (Figure 11-2). Thus the patient is fac-
ing the image on the monitor. Then continue
distally to the parietal branch and return
scanning the parietal branch and the com-
mon superficial artery in transverse planes
(Figure 11-3). When doing this the frontal
branch can be found. Follow the frontal
branch in a longitudinal plane (with regard
to the course of the artery; Figure 11-4) and
return using a transverse plane (Figure 11-5).
Subsequently, the same scans should be per-
128 ARTERIAL ULTRASOUND
Figure 11 -2 Longitudinal scan of the common
superficial temporal artery and the parietal branch.
Figure 11 -4 Longitudinal scan with regard to the
course of the frontal branch of the superficial temporal
artery.
formed on the right side. The temporal arter-
ies should be examined as completely as
possible.
An ultrasound image of a normal temporal
artery consists of the anechoic lumen, which
may be color coded, surrounded by a hyper-
echoic structure that represents the artery
wall and the temporal fascia. The temporal
fascia encloses the distal common superficial
temporal artery and its branches (Figures 11-
6 and 11-7). In case of acute temporal artery
vasculitis a circumferential hypoechoic wall
Figure 11 -3 Transverse scan of the parietal branch of
the superficial temporal artery.
Figure 11 -5 Transverse scan with regard to the course
of the frontal branch of the superficial temporal artery.
swelling is found (Figures 11-8 and 11-9) due
to edema ("halo sign"). This wall swelling
disappears in most patients a^er two to three
weeks of glucocorticoid treatment.
If turbulent flow ("aliasing", i.e. a mixture of
colors because of higher velocities and a
mixture of blood flow directions) is seen,
and if flow in diastole persists, use the Dop-
pler mode to determine flow curves for doc-
umenting stenosis (Figure 11-10).
The overall flow velocities are not important
 ARTERIAL ULTRASOUND 11 129

Figure 11 -7 Ultrasound image of a normal parietal

branch of the superficial temporal artery in a transverse
Figure 11 -6 Color Doppler ultrasound image of a view with regard to the course of the artery.
normal frontal branch of the superficial temporal artery in
a longitudinal view with regard to the course of the artery.

Figure 11 -9 Ultrasound image of a frontal branch of

Figure 11 -8 Ultrasound image of a frontal branch of the superficial temporal artery in acute GCA in a
the superficial temporal artery in acute GCA in a transverse view with regard to the course of the artery
longitudinal view with regard to the course of the artery showing concentric edematous wall swelling ("halo
demonstrating edematous wall swelling. sign").

Figure 11-10 Spectral Doppler ultrasound image of

stenotic flow curves of a frontal branch of the superficial
temporal artery in acute GCA with much higher flow Figure 11-11 Acute occlusion of parietal branch in
velocities at the region of the stenosis (1) than distal to active GCA. On the right side color represents perfusion
it (2). that stops at the border to the hypoechoic (dark) area.

for the diagnosis. The maximum systolic ve- ultrasound image displays hypoechoic intra-
locity may vary between 20 and 100 cm/s in arterial material without color signals (Fig-
healthy subjects. In about 30% of patients ure 11-11).
with acute GCA acute occlusions occur. The The sensitivity of temporal artery duplex ul-
130 11 ARTERIAL ULTRASOUND

trasound (i.e. the combination of color Dop-

pler ultrasound and the investigation of
Doppler curves) is high. It is comparable with
histology (85 to 90% with regard to clinical
diagnosis). The advantage of histology is
that it may reveal minor inflammation, but it
may miss the diagnosis if the biopsy is taken
from a non-inflamed skip lesion. GCA o^en
has a segmental occurrence.
Ultrasound depicts nearly the whole area of Figure 11-12 Longitudinal view of common carotid
the temporal arteries. With experienced so- artery in TAK showing homogenous bright (midechoic to
nographers temporal artery ultrasound may hyperechoic) wall thickening.
replace histology in typical cases of tempo-
ral arteritis because of its high specificity (95
to 100%).

11.1.2 Large-vessel giant cell arteri-

tis and Takayasu arteritis
GCA o^en occurs in the axillary, distal sub-
clavian, and proximal brachial arteries
("large-vessel GCA"). The axillary region
should be examined in suspected GCA in ad-
dition to the temporal arteries. Furthermore,
other arteries such as the occipital arteries,
facial arteries, vertebral arteries, and the ar-
teries of the lower extremities can be inves-
tigated depending on the clinical symptoms.
TAK occurs primarily in young females and
usually involves the subclavian arteries, the
common carotid arteries, and the aorta. The
wall thickening is homogeneous as in GCA
but usually more echogenic as there is less
edema in TAK due to its more chronic course
(Figures 11-12 and 11-13). With therapy, the
wall swelling decreases only slowly within
months.
Figure 11-13 Transverse view of common carotid
artery in TAK showing a circumferential bright (mide-
choic to hyperechoic) wall thickening.
sclerosis and in CREST syndrome or because
of thrombosis or embolism in anti-phospho-
lipid syndrome, vasculitis, or endocarditis.
Digital arteries are comparable in size with
the temporal artery branches. The diameter
of the lumen is comparable with the tempo-
ral arteries, around 0.7 mm. They localize
closely to finger joints that are frequently
investigated with ultrasound. Figure 11-14
displays the anatomy.

Investigation of the digital arteries is per-

11.2 Digital arteries
Several rheumatic diseases cause damage to
digital arteries. Patients with primary Ray-
naud's syndrome demonstrate vasospasm in
cold or wet environments. Secondary Ray-
naud's syndrome can occur because of digi-
tal artery stenosis or occlusion in systemic
formed from the palmar side. All ten proper
palmar digital arteries of one hand, all three
common palmar digital arteries of one hand,
the superficial palmar arch, the ulnar, and
radial arteries are easily accessible by ultra-
sound. Before the procedure, the patient
should put his hand into a water bath of
about 37° C for about five minutes to pre-

Figure 11-14 Anatomy of the distal radial, ulnar
arteries and the palmar and digital arteries. Longitudinal
scan of the 3rd / 4th common palmar digital artery.
vent vasospasm. Equipment and machine
adjustments are comparable with temporal
artery ultrasound, but the PRF should be
lower: about 1.2 KHz instead of 2.5 KHz as
flow velocities are lower in digital arteries.
Figure 11-15 depicts a normal proper palmar
digital artery between the PIP joint and the
DIP joint in a longitudinal scan. It is easier
to follow the digital arteries in longitudinal
scans, but it is also possible to delineate them
in transverse scans. Figure 11-16 shows that
one of the two arteries may be smaller in
healthy individuals. In this case the ulnar
digital artery is smaller than the radial digi-
tal artery.
Figure 11-15 Longitudinal palmar scan of a normal
proper palmar digital artery between PIP and DIP joint.
ARTERIAL ULTRASOUND 11 131
Figure 11-16 Transverse palmar scan of two normal
proper palmar digital arteries between PIP and DIP joint.
Figure 11-17 depicts a narrowed digital ar-
tery in systemic sclerosis. The pulsation is
reduced, and o^en digital arteries are not
detectable. In advanced stages of systemic
sclerosis the ulnar artery and the superficial
palmar arch are occluded. The radial artery
is less frequently occluded. The artery walls
tend to be slightly more echogenic than in
normal scans.
Figure 11-17 Longitudinal palmar scan of a proper
palmar digital artery at the PIP joint in systemic sclerosis.
Figure 11-18 depicts an acutely occluded
digital artery in a patient with vasculitis.
Dark intra-arterial thrombotic material does
not display color. The same image occurs in
embolism and in anti-phospholipid syn-
drome.
Turbulent flow and increased diastolic flow
velocities are typical for arterial stenoses.
Doppler flow displays increased systolic and
diastolic velocities. Normal systolic veloci-
ties vary between 10 and 40 cm/s, normal
diastolic velocities vary between 0 and 20
 132 11 ARTERIAL ULTRASOUND

Figure 11-18 Longitudinal palmar scan of a proper

palmar digital artery proximal to the PIP joint in a
patient with acute digital artery occlusion in Wegener's
granulomatosis. The speckled area represents turbulent
flow at the beginning of the occlusion and stenotic flow
into a collateral vessel.

cm/s. Velocities differ greatly between indi-
viduals. Therefore the appearance of Doppler
curves is only one of the parameters. De-
creased diastolic flow appears with increased
peripheral resistance, for instance, if the
hands are not warmed up enough and on in-
spiration. Figure 11-19 shows Doppler curves
of a digital artery.
Digital artery ultrasound correlates well with
Figure 11-19 Duplex ultrasound image with Doppler
curves of a proper palmar digital artery at the PIP joint.
The curves on the le^ side represent normal flow. The
curves on the right side show increased systolic and
diastolic flow because of stenosis.
angiography. It aids in differentiating pri-
mary from secondary Raynaud's syndrome
and in assessing patients with acute or
chronic ischemia of the fingers.

12 Ultrasound of the salivary glands
Ultrasound of the salivary glands is an easy
to perform and widely available technique
which provides a quick, non-invasive pa-
rameter in the diagnosis of Sjogren's syn-
drome. Sjogren's syndrome is a common
rheumatic disease. Diagnosis includes his-
tory (xerostomia, xerophthalmia), measure-
Figure 12-1 Transverse scan of the left submandibular
gland (a), This figure also shows the localization of the
parotid gland (b).
Figure 12-3 Longitudinal scan of the left parotid
gland.
133
ment of salivary and ocular gland function
as well as the detection of antibodies such as
anti-Ro and anti-La antibodies, and histol-
ogy of glands. Furthermore, the morphology
of the parotid and submandibular glands
changes in the course of the disease. The
glands become fibrotic, and lymphatic tissue
Figure 12-2 Longitudinal scan of the left submandi-
bular gland.
Figure 12-4 Transverse scan of the left parotid gland.
134 12 ULTRASOUND OF THE SALIVARY GLANDS
Figure 12-5 Transverse view of a normal submandi
bular gland.
Figure 12-7 Transverse view of an atrophic, hypoe-
choie, and inhomogeneous submandibular gland in Sjog-
ren's syndrome.
increases within the glands. The parotid
glands are frequently enlarged whereas the
submandibular glands become atrophic.
The submandibular and parotid glands are
easily accessible by ultrasound. All glands
may be assessed by longitudinal and trans-
verse scans (Figures 12-1 to 12-4).
The same linear probes can be used as for
musculoskeletal ultrasound with frequencies
between 7.5 MHz and 15 MHz.
The normal ultrasound appearance of pa-
rotid and submandibular glands is homoge-
neous and hyperechoic, just as thyroid tis-
sue. It can be easily distinguished from the
surrounding tissue.
In Sjogren's syndrome glands become inho-
Figure 12-6 Longitudinal view of a normal parotid
gland.
Figure 12-8 Longitudinal view of an enlarged
inhomogeneous parotid gland with many hypoechoic
(dark) intraglandular lymph nodes in Sjogren's syndrome.
mogeneous and hypoechoic in comparison
with the surrounding so^ tissue. Thyroid tis-
sue looks similar in chronic thyreoiditis. The
sagittal diameter of a submandibular gland
should be >0.8 cm. It should be <2.0 cm for
a parotid gland. Figures 12-5 and 12-6 show
normal salivary glands.
Figures 12-7 and 12-8 show ultrasound im-
ages of pathologic submandibular and pa-
rotid glands in Sjogren's syndrome.
Ultrasound of the salivary glands reveals
changes that occur because of chronic sia-
ladenitis. Causes of sialadenitis other than
Sjogren's syndrome lead to the same ultra-
sound appearance of salivary glands. Never-
theless, the involvement of all four large
salivary glands is rare in other conditions.
 ULTRASOUND OF THE SALIVARY GLANDS 12 135

Therefore, ultrasound images of at least two about 70%. Patients with early or less active
salivary glands as shown above are highly disease, or without anti-Ro antibodies, may
specific for Sjogren's syndrome in a rheuma- display normal salivary glands in an ultra-
tology practice. The sensitivity is lower at sound investigation.

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vasculitis and in systemic sclerosis. Ann
Rheum Dis 2006;65:265-7.
Schmidt WA. Doppler sonography in rheumatology.
Best Pract Res Clin Rheumatol 2004;18:827-
46.
Schmidt WA. Use of imaging studies in the
diagnosis of vasculitis. Curr Rheumatol Rep
2004;6:203-11.
Chapter 12
El Miedany YM, Ahmed I, Mourad HG, et al.
Quantitative ultrasonography and magnetic
resonance imaging of the parotid gland: can
they replace the histopathologic studies in
patients with Sjogren's syndrome? Joint Bone
Spine 2004;71:29-38.
Makula E, Pokorny G, Kiss M, et al. The place of
magnetic resonance and ultrasonographic
examinations of the parotid gland in the
diagnosis and follow-up of primary Sjogren's
syndrome. Rheumatology (Oxford)
2000;39:97-104.
Niemela RK, Takalo R, Paakko E, et al.
Ultrasonography of salivary glands in primary
Sjogren's syndrome. A comparison with
magnetic resonance imaging and magnetic
resonance sialography of parotid glands.
Rheumatology (Oxford) 2004;43:875-9.
Salaffi F, Argalia G, Carotti M, et al. Salivary gland
ultrasonography in the evaluation of primary
Sjogren's syndrome. Comparison with minor
salivary gland biopsy. J Rheumatol
2000;27:1229-36.
 141

About the Authors

George A.W. Bruyn, MD, PhD

Born in Amersfoort, the Netherlands, in 1955
Studied medicine at the Vrije Universiteit Brussel, Belgium, from 1975-1982
Resident in internal medicine at Diakonessenhuis Hilversum and Academisch Zieken-
huis Leiden from 1982-1987
Resident in rheumatology at Academisch Ziekenhuis Utrecht from 1987-1989
Consultant in rheumatology at Medisch Centrum Leeuwarden and Antoniusziekenhuis
Sneek since 1989
PhD thesis "Immunological and clinical studies of pneumococcal infection", University
of Leiden (1990)

Wolfgang A. Schmidt, MD
Born in Berlin, Germany in 1957
Studied medicine at Free University in Berlin from 1977-1983
Residency and specialisation in internal medicine at Krankenhaus Berlin-Zehlendorf in
Berlin, training in abdominal and vascular ultrasound and echocardiography, gastroin-
testinal endoscopy, intensive care and emergency medicine from 1983-1993
Consultant at Rheumaklinik (Medical Centre for Rheumatology) Berlin-Buch since
1993
Dr. med. thesis "Alcohol consumption in the phases of alcoholism" (1995)
Degree as rheumatologist in 1996, deputy director since 1998
PD thesis "Ultrasound in the diagnosis of vasculitis", Humboldt University, Berlin
(2002)
Ultrasound teacher of the DEGUM (German ultrasound society), conducting ultrasound
workshops together with George Bruyn at the annual ACR national meetings since
1999, teacher and speaker at many
national and international ultrasound
courses and congresses, several stays as
visiting professor in various countries
Scientific publications on ultrasound in
vasculitis (in New England Journal of
Medicine, Lancet, Annals of Internal
Medicine, and others), musculoskeletal
ultrasound (in Lancet, Annals of the
Rheumatic Diseases and others) and
clinical rheumatology, and many
review articles on ultrasound and
vasculitis. Reviewer for the main
scientific journals in rheumatology Wolfgang A. Schmidt and George A.W. Bruyn
 Index
A wall swelling, 127, 128
acetabulum
osteoarthritis, 86
Achilles tendinitis, 122
Achilles tendon, 115, 116
diameter, 115, 116
paratenonitis, 122
rupture, 123
acoustic interface, 18
acoustic shadowing, 20
acromioclavicular joint, 35
effusion, 35
inflammation , 35
luxation, 44
osteoarthritis, 35
osteophytes, 35
structure distance, 35
subluxation, 35
synovitis, 44
transverse view, 35
aliasing, 20, 128
anechoic, 20
anisotropy, 19, 85
ankle
anterior longitudinal view, 109
anterior transverse view, 110
dynamic examination, 109
effusion, 115
flexor tendons, 112
lateral longitudinal view, 114
lateral transverse view, 113
medial longitudinal view, 112
medial transverse view, 111
posterior longitudinal view, 115
posterior transverse view, 116
synovitis, 115
ankle joint
effusion, 120
posterior recess, 124
ankylosing spondylitis, 91
arterial ultrasound, 127
artery
turbulent flow, 128
attenuation, 18
audible range sound, 17
axial resolution, 19
axillary recess synovitis, 43
axillary scan, 36
B
B-mode gain, 19
Baker's cyst, 105
bald humerus, 41
beam penetration, 17
biceps sheath
calcium hydroxy-apatite deposition, 38
intra-articular body, 38
biceps tendon
anechoic fluid, 39
calcification, 38
dislocation, 39
longitudinal view, 28
sagittal diameter, 28
tear, 39
tenosynovitis, 38, 40
transverse view, 27
bone surface, image of, 25
broadband probe, 15
bursa, image of, 25
c
calcaneus, 115, 116, 117
osteophytes, 124
spurs, 124
capitulum humeri, 47
carpal tunnel, 64
primary syndrome, 77
secondary syndrome, 77
tenosinovitis, 76
cartilage, image of, 25
CMC joint
osteoarthritis, 78
color Doppler, 18
comet tail, 19
connective tissue, image of, 25
144 INDEX
convex probes, 81
coronoid fossa
synovitis, 54
CREST syndrome, 130
cross-sectional scan, 23
cubital tunnel, 53
cubital tunnel syndrome, 56
cucumber view, 24
D vascular imaging unit, 22
deep vein thrombosis, 22, 105
De Quervain's tenosynovitis, 60
digital artery
longitudinal palmar view, 131
occlusion, 131
stenoses, 131
systemic sclerosis, 131
transverse palmar view, 131
DIP joint
dorsal longitudinal view, 72
osteoarthritis, 78
volar longitudinal view, 71
direct contact scanner, 14
dominant, non-dominant arm, 52
Doppler principle, 18
E artery, 69
early rheumatoid arthritis, 13
echogenicity, 20
echotexture, 20
edge shadow, 19
elbow
anterior transverse view, 47
biceps muscle tendon, 47
edema, 50
effusion, 54
enthesopathy, 55
epicondyles, 49
fibrous capsule, 46
fluid, 48
hyaline cartilage, 46
lateral longitudinal view, 50
medial longitudinal view, 51
posterior fat pad, 49
posterior longitudinal view, 48
posterior transverse view, 49
power Doppler, 56
so^ tissue, 56
spondyloarthropathy, 50
structure distance, 45, 47
synovitis, 54
equipment
monitor, 21
probe, 21
shades of gray, 21
upgraded models, 21
erosion, 126
extensor carpi ulnaris tendon
evaluation, 61
hypoechoic rim, 61
sagittal diameter, 61
tenosynovitis, 75, 76
transverse diameter, 61
extensor hallucis longus tendon
tenosynovitis, 120
F
fabella, 100
feet, 117
femoral vein compression, 82
fibrocartilaginous posterior labrum, 33
finger
effusion, 79
nail bed, 72
sausage-like, 80
synovitis, 79
tenosynovitis, 80
finger flexor tendon
sagittal diameter, 66
sheath diameter, 66
structure, 69
structure appearance, 62
tear drop, 80
transverse diameter, 66
flexor digitorum longus tendon
tenosynovitis, 121
flow mapping, 22
foot
dynamic examination, 119
plantar proximal longitudinal view, 117
frequencies
ultrasonic range, 17

frozen shoulder, 36, 42
G history taking, 13
geyser phenomenon, 35, 44
giant-cell arteritis (GCA), 127
glenohumeral joint
axillary longitudinal view, 36
distal posterior recess, 34
effusion, 36, 43
fluid, 36
structure distance, 36
synovitis, 34, 36, 43
golfer's elbow, 51, 55
gout, 104
greater trochanter
bursa, 85
calcification, 85
longitudinal view, 84
pathology, 91
transverse view, 85
H infrapatellar bursitis, 104
halo sign, 128
biceps tendon, 38
hammer toes, 126
harmonic imaging, 20
heel pain, 124
enthesitis, 124
high-end equipment, 22
Hill-Sachs lesion, 33
hip
anterior longitudinal view, 81
anterior transverse view, 82
arthroplasty, 90
bony irregularity, 87
dynamic examination, 81
effusion, 83, 86
glucocorticoid injection, 87
inflammation, 86
lateral longitudinal view, 83
loose body, 90
osteoarthritis, 89
osteonecrosis, 89
osteosynthetic material, 90
pseudo-capsule, 90
spondyloarthropathy, 91
structure distance, 81, 83
INDEX 145
synovitis, 83, 86
unilateral synovitis, 86
Hoffa's fat pad, 102
humeral head
effusion, 33
erosion, 33, 34, 42
humeral spur
calcification, 43
humero-ulnar joint
anterior longitudinal view, 45
humeroradial joint
anterior longitudinal view, 46
hyperechoic, 20, 25
hypoechoic, 25
I
iliopsoas bursa effusion, 87
iliopsoas bursitis, 88
iliotibial band, 106
impingement, 32
infraspinatus tendon
normal sagittal diameter, 33
K
knee
active inflammation, 101
anterior bursa, 97
bone surface, 106
bursitis, 104
calcification, 95
cartilage, 94
chondrocalcinosis, 108
effusion, 94, 101, 102, 104
enthesopathy, 103
erosion, 95, 106
fibrin, 101
ganglion, 95
hematome, 101
infrapatellar lingitudinal view, 97
infrapatellar transverse view, 98
lateral longitudinal view, 95
loose body, 106
medial joint space, 96
medial longitudinal view, 96
osteophytes, 106
 146 INDEX

posterior longitudinal view, 100 0

posterior transverse view, 99 obesity
suprapatellar longitudinal view, 93 choice of frequency, 33
suprapatellar transverse view, 94 olecranon
synovial proliferation, 93, 101 bursitis, 48, 55
synovitis, 102 effusion, 48, 54
synovitis posterior compartment, 102 fossa, 48, 54
tendinitis, 103 Osgood-Schlatter disease, 97, 107

L P
large-vessel GCA, 130 panorama view, 87
ligament, image of, 25 parotid gland, 134
linear array transducer, 14 patellar tendon
Lister's tubercle, 57, 60 diameter, 97
longitudinal scan, 23 peripheral nerve
structure appearance, 52
M peroneal tendon
M-mode registration, 14 diameter, 113
malleolus, 112, 113, 114 structure appearance, 114
MCP joint tenosynovitis, 121
dorsal longitudinal view, 67 piezoelectric crystals, 17
dynamic examination, 67 PIP joint
effusion, 79 dorsal longitudinal view, 70
erosion, 78 osteophyte, 70
synovitis, 79 volar longitudinal view, 68
volar longitudinal view, 65 volar transverse view, 69
volar transverse view, 66 PIP joints
median nerve structure distance, 68
enlargement, 64 plantar fascia, 117
position in wrist, 62 structure appearance, 117
structure appearance, 64 plantar fasciitis, 125
microbubble contrast agents, 20 polymyalgia rheumatica, 91
midechoic, 20, 25 popliteal vein, 99, 100
midfoot posterior tibial vessel, 112
anterior longitudinal view, 118 power Doppler mode, 15
osteoarthritis, 125 prepatellar bursitis, 104
pathologies, 125 primary vasculitides, 127
structure distance, 118 probe, 17, 19
MTP joint, 119
erosion, 126 Q
structure distance, 119 quadriceps muscle, 98
synovitis, 126
muscle, image of, 25 R
radio-carpal joint
N synovitis, 74
naviculocuneiform joint, 118 tenosynovitis, 76
nerve, image of, 25 Raynaud's syndrome
 primary, 130
secondary, 130
refraction, 19
resolution, 19
horizontal, 19
lateral, 19
retrocalcaneal bursa, 115
fluid, 115
retrocalcaneal bursitis, 123
reverberation, 19
rheumatoid nodule, 56
rotator cuff
calcification, 30, 32
false diagnosis, 29
fluid, 42
tear, 30, 32, 41
s synovium, image of, 25
SAPHO syndrome, 44
semitendinosus tendon
paratenonitis, 107
septic arthritis, 104
shoulder
anterior longitudinal view, 30
anterior transverse view, 29
lateral longitudinal view, 32
lateral transverse view, 31
posterior longitudinal view, 34
posterior transverse view, 33
Sjogren's syndrome, 133, 134
skin thickness, 117
small parts probe, 14
spondyloarthropathy, dactylitis, 80
sternoclavicular joint, 37
structure distance, 37
synovitis, 44
subacromio-subdeltoid bursa, 29, 31
subcutaneous fat, image of, 25
subdeltoid bursitis, 40, 43
submandibular gland, 134
subscapularis tendon
anterior longitudinal view, 30
anterior transverse view, 29
calcification, 42
normal sagittal diameter, 29
suprapatellar recess
physiologic fluid, 93
supraspinatus tendon
absence, 41
anechoic area, 41
anterior longitudinal view, 30
anterior transverse view, 29
insertion, 32
rupture, 42
structure appearance, 32
tear, 40
transverse diameter, 31
swept-gain control, 18
swollen leg, 105
swollen median nerve, 77
swollen ulnar nerve, 56
synovial fluid, image of, 25
synovitis
inflammatory nature, 73
T
Takayasu arteritis (TAK), 127, 130
talonavicular joint, 118
problems, 120
structure distance, 109
tarsometatarsal joint, 118
tear drop sign, 40
temporal artery
anatomy, 127
scan, 128
stenosis, 127
tendon, image of, 25
tennis elbow, 50, 55
thrombophlebitis, 107
thrombosis prevention, 82
tibialis anterior tendon
diameter, 110
tenosynovitis, 120
tibialis posterior tendon, 111
diameter, 111
inflammation, 121
tenosynovitis, 121
tibial nerve, 112
time-gain control, 18
time gain compensation, 19
tissue density, 17
toe
anterior longitudinal view, 119
148 INDEX

tophus, 108 pitfalls, 13

total hip joint arthroplasty, 90 power Doppler, 19
total knee joint arthroplasty, 102 ultrasound
transducer, 17 three-dimensional (3D), 20
curved array, 21 two-dimensional (2D), 20
linear array broadband, 21
transverse scan, 23 W
triangular fibrocartilage complex (TFCC), 59 Wegener's granulomatosis, 127, 132
triceps muscle, 48 wrist
trochanteric bursa active inflammation, 74
hypoechoic rim, 84, 85 dorsal radial longitudinal view, 57
dorsal ulnar longitudinal view, 58
u dynamic examination, 58, 63
ulnar artery, 63 extensor retinaculum, 57
ulnar collateral ligament, 51 ganglion, 77
ulnar nerve power Doppler sonogram, 73
diameter at epicondyle, 53 structure distance, 57
diameter in elbow, 52 synovial compartment, 57
longitudinal view, 53 synovial hyperemia, 74
medial subluxation, 56 synovitis, 73
transverse view, 52 tenosynovitis, 75, 76
ulnocarpal joint synovitis, 74 transverse dorsal view, 60
ultrasonography ulnar longitudinal view, 59
B-mode, 18 ulnar transverse view, 61
color Doppler, 15, 18 volar radial longitudinal view, 62
development, 14 volar transverse view, 64
duplex, 19 volar ulnar longitudinal view, 63
grayscale, 18