Level V Evidence
Use of Ultrasonography as a Diagnostic and Therapeutic Tool in Sports Medicine Bryson P. Lesniak, M.D., Dustin Loveland, M.D., Jean Jose, D.O., Ryan Selley, B.A., Jon A. Jacobson, M.D., and Asheesh Bedi, M.D.
Abstract: Ultrasonography has many important advantages over other imaging modalities and many important applications in sports medicine. This article presents an evidence-based discussion of the use of ultrasound technology to diagnose and treat common musculoskeletal disorders, with emphasis on the shoulder, elbow, hip, knee, and foot and ankle. Topics include basic principles, scan artifacts, the appearance of musculoskeletal structure characteristics and pathologies, and various diagnostic and therapeutic applications in sports medicine.
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he first report of musculoskeletal ultrasonography (US) was published in 1958 by Dussik et al.,1 who measured the acoustic attenuation of articular and periarticular tissues. In 1972 McDonald and Leopold2 described the use of US imaging in differentiating Baker cysts from thrombophlebitis, an application still used in current clinical practice. Interest in US in sports medicine has grown exponentially as image quality has improved in recent years.3 Furthermore, the ability to perform a dynamic examination offers advantages over the static assessments of magnetic resonance imaging (MRI) and computed tomography (CT). Other strengths include cost, portability, decreased artifact from metal hardware, and fast scan time.4 The most notable drawback of musculoskeletal sonography is that physicians are unaware of its usefulness in diagnosis and treatment and are untrained in scanning and image interpretation (Table 1).
From UHealth Sports Medicine, the Department of Orthopaedics (B.P.L., D.L.), and Radiology (J.J.), University of Miami Miller School of Medicine, Miami, Florida; and the Section of Sports Medicine and Shoulder Surgery, Department of Orthopaedic Surgery (R.S., A.B.), and Department of Radiology (J.A.J.), University of Michigan, Ann Arbor, Michigan, U.S.A. The authors report the following potential conflict of interest or source of funding: J.A.J. receives support from American Institute of Ultrasound in Medicine. A.B. receives support from Smith & Nephew. Received September 3, 2013; accepted October 29, 2013. Address correspondence to Asheesh Bedi, M.D., MedSport, University of Michigan, 24 Frank Lloyd Wright Dr, Lobby A, Ann Arbor, MI 48106, U.S.A. E-mail: [email protected] Ó 2014 by the Arthroscopy Association of North America 0749-8063/13640/$36.00 http://dx.doi.org/10.1016/j.arthro.2013.10.011
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Shoulder Diagnostic US of the shoulder can identify abnormalities in the rotator cuff, biceps tendon, glenohumeral joint, and acromioclavicular joint, as well as other periarticular softtissue structures. Static and dynamic evaluation of the rotator cuff has been shown to be highly accurate in diagnosing pathology. In a meta-analysis, de Jesus et al.5 showed that the sensitivity and specificity relative to diagnosis of a full-thickness rotator cuff tear were 92% and 94%, respectively. There was no significant difference in the diagnostic capability of US and MRI for either fullthickness or partial-thickness tears.5 Rutten et al.6 showed increased sensitivity (89% v 67%) but decreased specificity (80% v 86%) with US versus MRI in the diagnosis of partial-thickness tears and showed decreased sensitivity (95% v 100%) and increased specificity (93% v 91%) with US versus MRI in the diagnosis of full-thickness tears in 5,216 patients. Middleton et al.7 had 2 radiologists independently scan patients with shoulder pain, categorizing the rotator cuff as normal, partially torn, or fully torn, and they found low interobserver variability. The radiologists were in agreement in 92% of the patients. In 4 of the 5 discrepant cases, the disagreement was between a full-thickness and partial-thickness tear. They were in agreement concerning which tendons were involved in 80% of the patients in whom a tear was detected by both observers. In all discrepant cases, the disagreement was about whether a tear involved both tendons or was isolated to 1 tendon. Wall et al.8 examined the accuracy of US compared with MRI in identifying fatty degeneration and found that US accuracy was 93% for the supraspinatus and infraspinatus muscles and 88% for the teres minor.
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 30, No 2 (February), 2014: pp 260-270
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ULTRASONOGRAPHY AS A TOOL IN SPORTS MEDICINE Table 1. Recommended Transducers Organized by Body Part According to Authors’ Preferences Scan Subacromial space Glenohumeral joint Elbow Wrist/feet Peritrochanteric Hip Knee Ankle
Probe Straight linear array Straight linear array Straight linear array Straight linear array Straight linear array Curved array Straight linear array Straight linear array
Frequency 12 MHz 12 MHz 12 MHz 15 MHz, small footprint 9 MHz 6 MHZ 12 MHz 12 MHz
The ability to diagnose rotator cuff pathology by use of US has been shown to be user dependent. Goldberg et al.9 showed that only 38% of cuff tears were diagnosed by community radiologists. They concluded that US, for diagnosing rotator cuff tears, may be limited to academic centers with well-trained radiologists. US can also be used to assess rotator cuff repairs postoperatively (Fig 1). A recent study investigated serial US examinations in patients with large rotator cuff tears who underwent arthroscopic repair.10 Of the repaired rotator cuff tears, 9 (41%) showed recurrent tears. This study elegantly showed the appearance of a failing rotator cuff repair on serial US scans. Sonographic evaluation of subscapularis repairs after total shoulder arthroplasty is a unique application and is considered more accurate than clinical examination findings. CT and MRI are difficult in this setting because of metal artifact. One study showed that 87% of patients had an intact repair at follow-up whereas abdominal compression tests had a sensitivity and specificity of 25% and 73%, respectively.11 US can also identify abnormalities affecting the biceps tendon. Such pathology includes effusion within the tendon sheath, tendon subluxation, or dislocation.12 The capacity for dynamic assessment with US has been
Fig 1. Recurrent supraspinatus tendon tear after prior repair. A longitudinal US image shows supraspinatus tendon retraction (white arrows) and discontinuity with the suture anchor (red arrow), reflecting recurrent tear.
Plane of View Transverse Transverse Transverse and axial Transverse and axial Transverse and axial Transverse Transverse and axial Transverse and axial
Body Position Lateral recumbent Lateral recumbent Supine Supine Lateral recumbent Supine Supine, prone, and lateral recumbent Supine and prone
shown to improve the accuracy of identifying biceps tendon instability to 86%.13 MRI with intra-articular gadolinium is the gold standard for diagnosing labral abnormalities. However, studies have shown that the sensitivity of US in the diagnosis of labral tears ranges from 67% to 95%.14,15 Paralabral cysts may also be identified. Evaluation of the periarticular structures should include imaging of the spinoglenoid notch and suprascapular notch because cysts in these regions may cause a suprascapular neuropathy. US of the shoulder is increasingly being used for facilitation of minimally invasive procedures. A randomized, prospective study has shown no statistical difference in accuracy between blind subacromial injections and USguided injections.16 However, other studies have shown 100% accuracy for image-guided subacromial injections versus 72% accuracy for noneimage-guided injections of the subacromial bursa.17 Glenohumeral injections have been shown to be statistically more accurate with image guidance (92.5% to 95%) compared with a freehand technique (72.5% to 79%).17,18 Injections into the acromioclavicular joint have also shown significantly increased accuracy with image guidance (100%) versus blind injection (44%).17 Less commonly performed biceps tendon sheath injections have also been shown to be significantly more accurate with the use of US (87%) compared with blind injection (27%) (Fig 2).19 Calcific tendinosis of the rotator cuff is a common disorder. Both US-guided needle aspiration and extracorporeal shockwave therapy have been shown to improve clinical outcomes (Fig 3). Aspiration combined with shockwave therapy has been compared with shockwave therapy alone, and the combined treatment resulted in significantly improved Constant scores and a decreased progression to surgical debridement.20 A recent randomized, comparative investigation studied US-guided lavage of the calcific lesion and injection versus subacromial injection alone.21 Although both groups showed significant improvement compared with before the procedure, the lavage group had better clinical and radiographic results than the group that underwent injection alone. Symptomatic cysts in the spinoglenoid or suprascapular notch can be aspirated by use of US (Fig 4).22,23
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Fig 2. Long head of biceps tendinosis (A) and tenosynovitis (B) with US-guided injection. (A) A transverse US image at the level of the proximal humerus shows hypoechoic fluid around the long head of the biceps, with hypoechoic echotexture of the long head of the biceps (arrow), reflecting tendinosis and tenosynovitis. (B) The needle tip (arrow) is placed within the long head of the biceps tendon sheath, between the long head of the biceps tendon and the bicipital groove. (C-E) Subdeltoid bursitis, including normal view and subdeltoid bursa injection. Longitudinal US images show the normal peribursal fat stripe in an asymptomatic patient (arrows in C), pronounced synovitis reflecting subdeltoid bursitis in a patient with rheumatoid arthritis (arrows in D), and US-guided injection with the needle tip inside the subdeltoid bursa (arrows in E). (F) US-guided glenohumeral joint injection through posterior approach. A transverse US image of the posterior margin of the glenohumeral joint shows the needle tip (arrow) within the glenohumeral joint capsule deep to the infraspinatus tendon. It should be noted that the needle is away from the glenoid labrum.
In summary, US has shown equal or increased sensitivity and specificity versus MRI in the noninvasive diagnosis of common sports medicine shoulder pathologies, as well as increased accuracy for injections into the acromioclavicular and glenohumeral joints, subacromial bursa, and biceps tendon sheath. Increased accuracy of US-guided injections of all joints, particularly of the shoulder, is independent of the physician’s level of experience.24
Elbow US is an effective imaging modality for the elbow. Abnormal signals in the soft tissues can identify pathology, including partial- and full-thickness tears of tendons, tendinosis, epicondylitis, ligament tears, ulnar nerve entrapment, olecranon bursitis, effusions, and loose bodies.25 Lateral and medial epicondylitis can be diagnosed with US because the involved tendon appears swollen and hypoechoic from degeneration with possible interstitial tears and an absence of inflammation. There is often tenderness with transducer pressure or cortical irregularity of the affected epicondyle.26 In lateral epicondylitis, US has been used to guide injections of corticosteroids or
platelet-rich plasma (PRP) (Fig 5). US-guided injection of PRP compared with whole blood has been described in a recent study.27 Significantly improved visual analog scale (VAS) scores were seen in the PRP group. USguided radiofrequency-based plasma microdebridement has been advocated recently as an effective method to treat recalcitrant lateral epicondylitis. Another treatment option, US-guided radiofrequency thermal lesioning, has shown statistically significant improvements at 6 months’ follow-up with regard to VAS score, grip strength, and Modified Mayo Clinic Performance Index.4 US can also lend insights into the presence and severity of collateral ligament pathology of the elbow (Fig 6). Ligament integrity and competency can be directly observed with dynamic maneuvers that stress the ligament to identify instability of the elbow, including pushing up from a chair or tabletop with a supinated forearm. The size of intrasubstance tears and the presence of a lateral ulnar collateral ligament (UCL) tear on US have been used to assess tendinopathy severity and predict response to treatment.28 Valgus instability of the elbow, including partial and complete tears of the UCL, can be identified on sonography statically by focal hypoechoic areas in the ligament. In addition, dynamic
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different in pitching arms when they compared initial and final US scans, but there were no significant differences in any parameters when they compared asymptomatic elbows with those that underwent subsequent UCL reconstruction. Distal biceps ruptures can also be diagnosed with US. This imaging not only confirms the diagnosis but also can characterize the integrity of the lacertus fibrosis and quantify the degree of retraction superficial to the brachialis.31 Furthermore, US can identify musculotendinous junction injury, which may not benefit from surgical exploration (Fig 7).
Hip
Fig 3. US-guided lavage for supraspinatus calcific tendinitis. (A) A transverse US image shows an echogenic mass within the supraspinatus tendon, reflecting a calcific tendinitis deposit (arrow). (B) A transverse image shows the needle entering the calcific deposit (arrow). (C) A transverse US image shows disbursement of calcification during lavage, now with internal areas of fluid (arrow).
US may be used to identify valgus instability. Medial joint widening to valgus stress should be no more than 0.5 to 1.0 mm when compared with the uninjured side. This is a helpful adjunct to MRI, which cannot provide the dynamic information and often shows chronic changes in the UCL that are of uncertain significance in the overhead athlete.29 Ciccotti et al.30 recently presented data based on dynamic elbow US scans that were performed bilaterally in 368 professional pitchers. The mean amount of stressed joint space, change in joint space, and presence of heterogeneity were significantly
In the past, US as a diagnostic modality for the hip was thought to be anecdotal.32 Recently, however, US has been used in both diagnostic and therapeutic protocols in and around the hip joint. Coxa sultans, or snapping hip, is a common cause of hip discomfort. The syndrome is classified into external, internal, and intra-articular causes. External snapping is typically attributed to the iliotibial band or the gluteus maximus tendons snapping over the greater trochanter. The internal type typically involves the iliopsoas snapping against the superior pubic ramus near the iliopectineal eminence.33 Intra-articular lesions may be due to a variety of causes, including loose bodies, labral tears, osteochondral fractures, or synovial chondromatosis. Recent radiologic advancements have shown great utility of US in sorting through these diagnoses (Fig 8). Pelsser et al.34 showed that a cause of snapping hip could be identified in 24 of 26 cases (92%). An evaluation of 26 ballet dancers with 50 snapping hips showed that US could identify a cause in 63%; intra-articular causes were suspected to account for the remaining one-third.35 Other muscles around the hip can also be evaluated with US, specifically the abductors. US can be used to evaluate partial- and full-thickness tears and tendinosis, all of which are commonly found in athletes.36 These pathologies can be viewed with both MRI and US, and a systematic review of gluteal tendon tear diagnostic accuracy by Westacott et al.37 found US to have a higher sensitivity and positive predictive value. This improved visualization may be combined with therapeutic interventions to offer accurately placed needle fenestration or injections for tendon pathology. Few studies have investigated the role of US in the diagnosis of acetabular labral tears. Troelsen et al.38 reported a sensitivity of 44% and a positive predictive value of 88% and concluded that the use of US in diagnosing labral tears should be developed further. Subsequently, Troelsen et al.39 were able to diagnose labral tears with a sensitivity of 94% and a positive predictive value of 94%, as confirmed by magnetic resonance arthrography. This indicates that a significant learning curve may be associated with diagnosis of
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Fig 4. US-guided cyst aspiration and injection of spinoglenoid notch. (A) A long-axis US image of the spinoglenoid notch shows a hypoechoic paralabral cyst (arrow) compressing the suprascapular nerve. (B) A longitudinal US image shows aspiration of the cyst with a needle (arrow). It should be noted that the cyst is smaller and now contains echogenic internal microbubbles.
intra-articular pathology using US. Most recently, a study evaluated the potential benefit of an intraarticular injection on the ability to diagnose an acetabular labral tear.40 Although the authors were able to show that the accuracy of US diagnosis of labral tears was improved with an intra-articular injection, they also found that the interobserver reliability was poor. Furthermore, they found that CT arthrograms were more accurate than US in this setting. We currently prefer MRI and, specifically, magnetic resonance arthrography to characterize pathology of the hip. Sonographic guidance is commonly used in and around the hip. Injections and arthroscopic portal placement have been described using US.41 Trochanteric bursitis and associated gluteus medius tendinopathy have been treated with US-guided injections. One study found that 72% of patients with US-guided injections of the gluteus medius tendon showed clinically significant improvement as measured by VAS pain score.42 Smith et al.43 showed that sonographically guided intra-articular injections could be placed with 97% accuracy as verified by fluoroscopy. Sonography also allows for paralabral cyst aspirations in patients with hip pain who do not wish to undergo arthroscopic hip surgery. This has allowed for outpatient intraarticular hip injections to be an option without the
risk of the radiation exposure that is associated with fluoroscopically or CT-guided injections.43 US has also proven valuable in the setting of athletic pubalgia. Although this diagnosis is often based on clinical symptoms, a dynamic US evaluation of the abdominal wall musculature and fascia with a Valsalva maneuver has allowed for the identification of potentially reparable lesions. A recent prospective study also investigated the response of US-guided corticosteroid injections as a treatment modality for athletic pubalgia, in which 13 of 18 patients (72%) achieved an ideal outcome based on the Western Ontario and McMaster Universities Arthritis Index score.44
Knee There are many indications for US of the knee. Peripheral meniscus tears, patellar or quadriceps tendinopathy, and bursitis can be confirmed. This is particularly beneficial in claustrophobic patients or patients with implanted devices that preclude the use of MRI. In patients whose body habitus can make blind injections difficult because of loss of the normal anatomic landmarks, US provides a safe and accurate way to provide intra-articular injections. Use of US in patellar tendinopathy (jumper’s knee) has shown benefit with regard to diagnosis and prognosis. In
Fig 5. US-guided trephination and PRP injection of common extensor tendinosis and partial-thickness tear (lateral epicondylitis). (A) A longitudinal US image shows common extensor tendinosis at the origin, with a small partial-thickness tendon tear near the articular surface (arrow). (B) The needle tip is placed at the tear site (arrow) under US guidance. (C) A post-injection long-axis US image of the lateral elbow shows echogenic PRP within the tear.
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Fig 6. (A) Partial-thickness tear of UCL sublime tubercle. The arrow shows discontinuity of the anterior bundle of the UCL at the sublime tubercle attachment. (B) US-guided PRP injection for symptomatic, low-grade, partial-thickness UCL tear. The arrow shows the needle tip placed at the UCL tear site within injection of echogenic PRP.
a study investigating competitive athletes with clinical symptoms of jumper’s knee, 60% of the examined tendons displayed structural tendon changes with neovascularization and increased blood flow whereas 26% had structural changes alone and 14% were normal.45 This neovascularization may indicate that a patient could benefit from recently described therapies, such as US-guided sclerosis of neovessels using polidocanol.46 Cystic abnormalities about the knee can be identified and treated with US as well. Baker cysts represent distention of the semimembranosusemedial gastrocnemius bursa and are a significant source of pain and disability. Ward et al.47 showed that Baker cysts could be diagnosed with 100% accuracy as confirmed by MRI. US can also categorize cysts as either simple or complex. These categories were used to predict treatment outcomes in a prospective study of 32 patients.48 US has also been used in the treatment of Baker cysts by guiding both aspiration and localized corticosteroid injections. Bandinelli et al.49 showed that US-guided direct aspiration of a Baker cyst followed by US injection of steroid directly
Fig 7. Biceps brachii tendon with distal musculotendinous tear. A long-axis US image of the biceps brachii shows a hypoechoic tear (arrow) at the musculotendinous junction (Br, brachialis; H, humerus).
into the cyst resulted in a significantly smaller cyst compared with intra-articular injection. When one is aspirating a Baker cyst, it is critical to also aspirate any knee joint effusion, given potential communication between the Baker cyst and knee joint (Fig 9). Ganglion cysts, though less common than Baker cysts, have also been described in and around the knee. They may be intra-articular or extra-articular and may not have a definable connection with the joint. They can occur in atypical locations, including the proximal tibiofibular joint, tendon sheaths, cruciates, or peripheral nerves.50 Jose et al. have reported success with aspirations of atypical symptomatic ganglion cysts, including an intraneural cyst of the tibial nerve51 and 1 associated with the popliteus tendon.52 Parameniscal cysts can be identified on US when a hypoechoic cyst is in contact with the meniscus.53 Macmahon et al.54 performed US-guided percutaneous drainage of parameniscal cysts in 18 patients. Ten patients reported complete resolution of symptoms and returned to high-level sports, and all had a pain-free interval of at least 1 week. A coexisting meniscal tear is present in approximately 85% of cases and may also be visualized with US.53 Shetty et al.55 performed a prospective study investigating the accuracy of diagnosing meniscal tears by US in comparison with MRI, as confirmed by arthroscopy. For US, there was a sensitivity of 86.4%, a specificity of 69.2%, a positive predictive value of 82.6%, and a negative predictive value of 75%. This compared with a sensitivity of 86.4%, a specificity of 100.0%, a positive predictive value of 100.0%, and a negative predictive value of 81.3% for MRI. The similar sensitivity between modalities implies that US can be applied to confirm the clinical diagnosis but MRI remains the standard of care because US is limited with regard to a comprehensive evaluation of the meniscus. However, in patients who cannot undergo MRI, US is a viable alternative. Intra-articular knee injections are commonly performed in clinical practice. The placement of these injections can be significantly improved with US guidance compared with freehand.56,57 A systematic review by Berkoff et al.56
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Fig 8. Iliopsoas complex with snapping hip syndrome. (A) A short-axis US image of the iliopsoas tendon shows the medial fibers of the iliacus (MFI) with a segment of iliacus muscle (arrow) entrapped between the psoas major tendon (PMT) and superior pubic ramus (SPR) with the hip in abduction, flexion, and external rotation. (B) The entrapped muscle is then released with the hip in a fullextension position, causing an abrupt snapping movement of the psoas major tendon to contact the superior pubic ramus (right side of image is medial).
found that sonography-guided intra-articular knee injections improved accuracy to 95.8% compared with accuracy of 77.8% for anatomic guidance. In addition, it has been found that accurate intra-articular injections have significantly improved clinical outcomes.24
Foot and Ankle Achilles tendon abnormalities that have been diagnosed by US include tendinosis, partial- and full-thickness tears, and Haglund syndrome. Surrounding structures that may also be identified during examination include the plantaris tendon, retrocalcaneal bursa, retro-Achilles bursa, and gastrocnemius musculature and aponeurosis.58 Achilles tendinopathy can be both diagnosed and treated with the use of sonography. US of Achilles tendinopathy has resulted in the development of a grading scheme that has been shown to predict healing times.59 In a placebocontrolled study of US-guided peritendinous steroid
Fig 9. A transverse image shows the needle (arrow) within a Baker cyst, inserted from a posteromedial approach. The patient underwent US imaging in a prone position.
injection in athletes with Achilles tendinopathy, Fredberg and Ostgaard60 found that the steroid group had reduced pain and tendon thickening compared with the placebo group. Koenig et al.61 investigated color Dopplereguided injections of glucocorticoids in 6 tendons. They concluded that color Doppler significantly contributes to Achilles tendonitis diagnosis, location, and follow-up. Early studies of sclerotherapy of neovessels using US-guided polidocanol injections have achieved encouraging results.62-64 One study of polidocanol injections at 3 months’ followup showed significantly reduced tendon pain when compared with controls.64 Clinical follow-up at 2 years showed good results with a significant reduction in the mean tendon thickness, as well as a reduction in the number of neovessels in treated tendons.63 A recent technique has been described for US-guided injection of PRP into the tendon and paratenon in the presence of Achilles tendinopathy.65 Other modalities using US guidance with some degree of success include high-volume saline solution injections,66 electrocoagulation of neovessels,67 intratendinous injection of hyperosmolar dextrose,68 and percutaneous tenotomy.69 US is also valuable in the diagnosis and characterization of traumatic Achilles tendon injuries. US is reliably used to diagnose complete Achilles tendon tears, estimate the severity and location of the abnormality, and assist in preoperative planning by identifying the location of the tear.70 Recent studies have evaluated the use of dynamic US in acute complete Achilles tendon rupture as a method of evaluating the reduction of the tendon gap, as well as better determining whether to recommend operative versus nonoperative management.70,71 Qureshi et al.71 evaluated 125 patients with acute Achilles tendon ruptures with dynamic US. Patients with a gap of 5 mm or more in equinus on US underwent surgery, whereas those with a gap of less than 5 mm received nonoperative treatment. There were 2 reruptures in the nonoperative group and 1 in
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Table 2. Commonly Used Transducers for Musculoskeletal Diagnostic and Interventional Procedures Transducer Linear probe
Image Shape Rectangle
Frequency (MHz) 5-17
Depth of Field (cm) 3-4
Resolution Increased
Curved probe
Pie/sector
1-8
3-12
Decreased
the surgery group, and no significant difference between the groups for any complication was noted. With the ongoing controversy regarding operative versus nonoperative management of Achilles ruptures, sonography in this setting can assist the sports medicine physician to better assess the optimal treatment plan. US is also well suited for the evaluation of other tendons and ligament injuries about the ankle. The resolution of modern US allows for detailed evaluation of tendon architecture (Table 2). Skilled radiologists are able to identify a spectrum of pathology based on findings, including tendinosis, tenosynovitis, and tears. Waitches et al.72 have shown 100% sensitivity and 88% specificity in the diagnosis of tears involving the peroneal, posterior tibial, and flexor digitorum longus tendons. More recently, Grant et al.73 found US to have a sensitivity of 100% and specificity of 85% in diagnosing peroneal tendon tears with surgical correlation. A cadaveric study comparing MRI and US in diagnosing surgically created posterior tibial tendon tears found the 2 imaging modalities to be equally sensitive and accurate, with US being more specific.74 This study suggests that US can be more appropriate than MRI in the evaluation of posterior tibial tendon tears. A preliminary study recently investigated the accuracy of
Fig 10. Peroneal tendons with intrasheath subluxation and peroneus brevis tear. A short-axis US image of the peroneus brevis (PB) and peroneus longus (PL) tendons shows a hypoechoic partial-thickness tear (arrow) of the peroneus brevis. With dynamic imaging, the peroneus brevis and longus tendons snapped against each other within the tendon sheath. The convex posterior border of the fibula (F) should be noted.
Musculoskeletal Uses Small footprint probe (2.5 cm): wrist, hand, foot, and pubic symphysis Traditional footprint probe (5 cm): arm, shoulder, forearm, calf, elbow, wrist, knee, and ankle Obese patients, thigh, hips, greater trochanteric region, pelvis, and piriformis fossa
dynamic US in the diagnosis of ankle syndesmotic injury in professional athletes and found a sensitivity and specificity of 100%, as confirmed by MRI.75 Identification of tendon subluxation is important not only to explain patient symptoms but also to allow prompt treatment. Neustadter et al.76 evaluated 13 consecutive patients in whom peroneal tendon subluxation was clinically suspected with dynamic US. Of the 13 patients, 12 had sonographic findings of peroneal tendon subluxation that was confirmed by subsequent surgery. Sonography showed peroneus brevis tendon tears in 5 patients and a peroneus longus tear in 1 patient; all findings were confirmed at surgery, with no false-positive sonograms. A study of 14 patients with 2 subtypes of intrasheath subluxation yielded results of 100% sonographic accuracy after intraoperative confirmation (Fig 10).77 Plantar fasciitis is a diagnosis commonly encountered in orthopaedics. Studies have proven the diagnostic efficacy of sonography in the evaluation of plantar fasciitis.78,79 Findings included hypoechoic plantar fascia as well as significantly increased fascia thickness in patients with symptomatic heels when compared with patients with asymptomatic heels and a control group. With advances such as power Doppler US, additional information on neovascularity can aid in the diagnosis and treatment. Walther et al.80 compared 20 patients with a diagnosis of unilateral plantar fasciitis and 20 healthy volunteers and found moderate hyperemia in 40% of the symptomatic heels compared with 5% of the asymptomatic heels. McMillan et al.81 randomized 82 patients with plantar fasciitis to US-guided injections of corticosteroid or normal saline solution. At 4 weeks, there was a significant reduction in pain scores in the steroid group. Corticosteroid injections are often used, but palpation-guided injections are not always accurate.82 With inaccurate injections of corticosteroid, the complications can include heel fat pad atrophy and fascia rupture, emphasizing the importance of accurate injection.83 In a study of 4 patients who were unresponsive to palpation-guided injection, Kane et al.82 used US-guided injections and found complete relief at 24 months in 4 of 5 heels. Tsai et al.83 confirmed these findings in a subsequent study of 14 patients with unilateral plantar fasciitis; after US-guided injections, the patients had significantly improved VAS scores, decreases in thickness, and improved echogenicity, as well as no change in the properties of the heel fat pad. A
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subsequent study by Tsai et al.84 showed that although both US-guided and blind injections produced decreases in thickness, improved echogenicity, and improved VAS scores, the US-guided group had a significantly decreased recurrence rate (8%) compared with the palpation-guided group (46%). Other injections of the foot and ankle may also be facilitated by US guidance. Wisniewski et al.85 injected 40 cadaveric ankles, randomizing between US guidance and a blind anterior technique. The accuracy rate for guided tibiotalar joint injections was 100% versus 85% for blind injections. The accuracy rate for sinus tarsi injections was 90% for guided injections versus 35% for blind injections. This shows the accuracy of USguided injections over conventional blind injection techniques using superficial anatomic landmarks alone.
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Conclusions Sonography is an excellent imaging modality for the diagnosis and treatment of common musculoskeletal injuries that avoids the risk of ionizing radiation or contrast material. It is useful in the presence of metallic hardware and offers equal or higher diagnostic sensitivity and specificity compared with MRI in a wide variety of musculoskeletal disorders. It is particularly useful in the identification of pain generators that are evident with dynamic, provocative maneuvers. USguided injection of intra-articular and periarticular structures is reliable and improves accuracy compared with conventional blind techniques. Close communication between the orthopaedic surgeon and the sonographer is essential for a successful and meaningful evaluation, but the combination of clinical examination and dynamic imaging can offer great synergy for improved diagnostic accuracy and clinical outcomes after US-assisted procedures.
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References 1. Dussik KT, Fritch DJ, Kyriazidou M, Sear RS. Measurements of articular tissues with ultrasound. Am J Phys Med 1958;37:160-165. 2. McDonald DG, Leopold GR. Ultrasound B-scanning in the differentiation of Baker’s cyst and thrombophlebitis. Br J Radiol 1972;45:729-732. 3. Erickson SJ. High-resolution imaging of the musculoskeletal system. Radiology 1997;205:593-618. 4. Lin CL, Lee JS, Su WR, Kuo LC, Tai TW, Jou IM. Clinical and ultrasonographic results of ultrasonographically guided percutaneous radiofrequency lesioning in the treatment of recalcitrant lateral epicondylitis. Am J Sports Med 2011;39:2429-2435. 5. de Jesus JO, Parker L, Frangos AJ, Nazarian LN. Accuracy of MRI, MR arthrography, and ultrasound in the diagnosis of rotator cuff tears: A meta-analysis. AJR Am J Roentgenol 2009;192:1701-1707. 6. Rutten MJ, Spaargaren GJ, van Loon T, de Waal Malefijt MC, Kiemeney LA, Jager GJ. Detection of rotator
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cuff tears: The value of MRI following ultrasound. Eur Radiol 2010;20:450-457. Middleton WD, Teefey SA, Yamaguchi K. Sonography of the rotator cuff: Analysis of interobserver variability. AJR Am J Roentgenol 2004;183:1465-1468. Wall LB, Teefey SA, Middleton WD, et al. Diagnostic performance and reliability of ultrasonography for fatty degeneration of the rotator cuff muscles. J Bone Joint Surg Am 2012;12:e831-e839. Goldberg JA, Bruce WJ, Walsh W, Sonnabend DH. Role of community diagnostic ultrasound examination in the diagnosis of full-thickness rotator cuff tears. ANZ J Surg 2003;73:797-799. Miller BS, Downie BK, Kohen RB, et al. When do rotator cuff repairs fail? Serial ultrasound examination after arthroscopic repair of large and massive rotator cuff tears. Am J Sports Med 2011;39:2064-2070. Armstrong A, Lashgari C, Teefey S, Menendez J, Yamaguchi K, Galatz LM. Ultrasound evaluation and clinical correlation of subscapularis repair after total shoulder arthroplasty. J Shoulder Elbow Surg 2006;15:541-548. Middleton WD, Reinus WR, Totty WG, Melson CL, Murphy WA. Ultrasonographic evaluation of the rotator cuff and biceps tendon. J Bone Joint Surg Am 1986;68:440-450. Farin PU, Jaroma H, Harju A, Soimakallio S. Medial displacement of the biceps brachii tendon: Evaluation with dynamic sonography during maximal external shoulder rotation. Radiology 1995;195:845-848. Hammar MV, Wintzell GB, Åstörm KGO, Larsson S, Elvin A. Role of US in the preoperative evaluation of patients with anterior shoulder instability. Radiology 2001;219:29-34. Taljanovic MS, Carlson KL, Kuhn JE, Jacobson JA, Delaney-Sathy LO, Adler RS. Sonography of the glenoid labrum: A cadaveric study with arthroscopic correlation. AJR Am J Roentgenol 2000;174:1717-1722. Dogu B, Yucel SD, Sag SY, Bankaoglu M, Kuran B. Blind or ultrasound-guided corticosteroid injections and shortterm response in subacromial impingement syndrome: A randomized, double-blind, prospective study. Am J Phys Med Rehabil 2012;91:658-665. Daley EL, Bajaj S, Bisson LJ, Cole BJ. Improving injection accuracy of the elbow, knee, and shoulder: Does injection site and imaging make a difference? A systematic review. Am J Sports Med 2011;39:656-662. Patel DN, Nayyar S, Hasan S, Khatib O, Sidash S, Jazrawi LM. Comparison of ultrasound-guided versus blind glenohumeral injections: A cadaveric study. J Shoulder Elbow Surg 2012;21:1664-1668. Hashiuchi T, Sakurai G, Morimoto M, Komei T, Takakura Y, Tanaka Y. Accuracy of the biceps tendon sheath injection: Ultrasound-guided or unguided injection? A randomized controlled trial. J Shoulder Elbow Surg 2011;20:1069-1073. Krasny C, Enenkel M, Aigner N, Wlk M, Landsiedl F. Ultrasound-guided needling combined with shock-wave therapy for the treatment of calcifying tendonitis of the shoulder. J Bone Joint Surg Br 2005;87:501-507. de Witte PB, Selten JW, Navas A, et al. Calcific tendinitis of the rotator cuff: A randomized controlled trial of ultrasoundguided needling and lavage versus subacromial corticosteroids. Am J Sports Med 2013;41:1665-1673.
ULTRASONOGRAPHY AS A TOOL IN SPORTS MEDICINE 22. Lenart MJ, Wong K, Gupta RK, et al. The impact of peripheral nerve techniques on hospital stay following major orthopedic surgery. Pain Med 2012;13:828-834. 23. Loustau O, Sans N, Despeyroux-Ewers ML, ChiavassaGandois H, Vial J, Railhac JJ. Shoulder pain: Image guided management. J Radiol 2007;88:1238-1241 (pt 2). 24. Cunnington J, Marshall N, Hide G, et al. A randomized, doubleblind, controlled study of ultrasound-guided corticosteroid injection into the joint of patients with inflammatory arthritis. Arthritis Rheum 2010;62:1862-1869. 25. Tran N, Chow K. Ultrasonography of the elbow. Semin Musculoskelet Radiol 2007;11:105-116. 26. Connell D, Burke F, Coombes P, et al. Sonographic examination of lateral epicondylitis. AJR Am J Roentgenol 2000;176:777-782. 27. Thanasas C, Papadimitriou G, Charalambidis C, Paraskevopoulos I, Papanikolaou A. Platelet-rich plasma versus autologous whole blood for the treatment of chronic lateral elbow epicondylitis: A randomized controlled clinical trial. Am J Sports Med 2011;39:2130-2134. 28. Clarke AW, Ahmad M, Curtis M, et al. Lateral elbow tendinopathy: Correlation of ultrasound findings with pain and functional disability. Am J Sports Med 2010;38: 1209-1214. 29. De Smet AA, Winter TC, Best TM, Bernhardt DT. Dynamic sonography with valgus stress to assess elbow ulnar collateral ligament injury in baseball pitchers. Skeletal Radiol 2002;31:671-676. 30. Ciccotti MG, Nazarian L, Atanda A, et al. Using dynamic elbow ultrasound to characterize progression of ulnar collateral ligament abnormalities over time in professional baseball pitchers. Presented at the American Orthopaedic Society for Sports Medicine Annual Meeting, Baltimore, MD, July 2012. 31. Miller TT, Adler RS. Sonography of tears of the distal biceps tendon. AJR Am J Roentgenol 2000;175:1081-1086. 32. Allen WC, Cope R. Coxa saltans: The snapping hip revisited. J Am Acad Orthop Surg 1995;3:303-308. 33. Guillin R, Cardinal E, Bureau NJ. Sonographic anatomy and dynamic study of the normal iliopsoas musculotendinous junction. Eur Radiol 2009;19:995-1001. 34. Pelsser V, Cardinal E, Hobden R, Aubin B, Lafortune M. Extraarticular snapping hip: Sonographic findings. AJR Am J Roentgenol 2001;176:67-73. 35. Winston P, Awan R, Cassidy JD, Bleakney RK. Clinical examination and ultrasound of self-reported snapping hip syndrome in elite ballet dancers. Am J Sports Med 2007;35: 118-126. 36. Nelson EN, Kassarjian A, Palmer WE. MR imaging of sports-related groin pain. Magn Reson Imaging Clin N Am 2005;13:727-742. 37. Westacott DJ, Minns JI, Foguet P. The diagnostic accuracy of magnetic resonance imaging and ultrasonography in gluteal tendon tearsdA systematic review. Hip Int 2011;21:637-645. 38. Troelsen A, Jacobsen S, Bolvig L, Gelineck J, Rømer L, Søballe K. Ultra-sound versus magnetic resonance arthrography in acetabular labral tear diagnostics: A prospective comparison in 20 dysplastic hips. Acta Radiol 2007;48:1004-1010.
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39. Troelsen A, Mechlenburg I, Gelineck J, Bolvig L, Jacobsen S, Søballe K. What is the role of clinical tests and ultrasound in acetabular labral tear diagnostics? Acta Orthop 2009;80: 314-318. 40. Jung JY, Kim GU, Lee HJ, Jang EC, Song IS, Ha YC. Diagnostic value of ultrasound and computed tomographic arthrography in diagnosing anterosuperior acetabular labral tears. Arthroscopy 2013;29:1769-1776. 41. Hua Y, Yang Y, Chen S, et al. Ultrasound-guided establishment of hip arthroscopy portals. Arthroscopy 2009;25: 1491-1495. 42. Labrosse JM, Cardinal E, Leduc BE, et al. Effectiveness of ultrasound-guided corticosteroid injection for the treatment of gluteus medius tendinopathy. AJR Am J Roentgenol 2010;194:202-206. 43. Smith J, Hurdle MF, Weingarten TN. Accuracy of sonographically guided intra-articular injections in the native adult hip. J Ultrasound Med 2009;28:329-335. 44. Fokin A, Wodicka R, Jose J, Page C, Lesniak BP. Review of athletic pubalgia and role of ultrasound-guided corticosteroid injections as a treatment modality. Presented at the American College of Sports Medicine Annual Meeting, San Francisco, CA, May 2012. 45. Hoksrud A, Öhberg L, Alfredson H, Bahr R. Color Doppler ultrasound findings in patellar tendinopathy (jumper’s knee). Am J Sports Med 2008;36:1813-1820. 46. Hoksrud A, Öhberg L, Alfredson H, Bahr R. Ultrasoundguided sclerosis of neovessels in painful chronic patellar tendinopathy: A randomized controlled trial. Am J Sports Med 2006;34:1738-1746. 47. Ward EE, Jacobson JA, Fessell DP, et al. Sonographic detection of Baker’s cysts: Comparison with MR imaging. AJR Am J Roentgenol 2001;176:373-380. 48. Koroglu M, Callioglu M, Eris HN, et al. Ultrasound guided percutaneous treatment and follow-up of Baker’s cyst in knee osteoarthritis. Eur J Radiol 2012;81:3466-3471. 49. Bandinelli F, Fedi R, Generini S, et al. Longitudinal ultrasound and clinical follow-up of Baker’s cysts injection with steroids in knee osteoarthritis. Clin Rheumatol 2012;31:727-731. 50. Burk DL Jr, Dalinka MK, Kanal E, et al. Meniscal and ganglion cysts of the knee: MR evaluation. AJR Am J Roentgenol 1998;150:331-336. 51. Jose J, Fourzali R, Lesniak B, Kaplan L. Ultrasoundguided aspiration of symptomatic intraneural ganglion cyst within the tibial nerve. Skeletal Radiol 2011;40: 1473-1478. 52. Jose J, Silverman E, Kaplan L. Symptomatic ganglion cyst of the popliteus tendon treated with ultrasound-guided aspiration and steroid injection: A case report. Sports Health 2011;3:393-395. 53. Rutten MJ, Collins JM, van Kampen A, Jager GJ. Meniscal cysts: Detection with high-resolution sonography. AJR Am J Roentgenol 1998;171:491-496. 54. Macmahon PJ, Brennan DD, Duke D, Forde S, Eustace SJ. Ultrasound-guided percutaneous drainage of meniscal cysts: Preliminary clinical experience. Clin Radiol 2007;62: 683-687. 55. Shetty AA, Tindall AJ, James KD, Relwani J, Fernando KW. Accuracy of hand-held ultrasound
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scanning in detecting meniscal tears. J Bone Joint Surg Br 2008;90:1045-1048. Berkoff DJ, Miller LE, Block JE. Clinical utility of ultrasound guidance for intra-articular knee injections: A review. Clin Interv Aging 2012;7:89-95. Curtiss HM, Finnoff JT, Peck E, Hollman J, Muir J, Smith J. Accuracy of ultrasound-guided and palpation-guided knee injections by an experienced and less-experienced injector using a superolateral approach: A cadaveric study. PM R 2011;3:507-515. Dong Q, Fessell DP. Achilles tendon ultrasound technique. AJR Am J Roentgenol 2009;193:W173. Archambault JM, Wiley JP, Bray RC, Verhoef M, Wiseman DA, Elliott PD. Can sonography predict the outcome in patients with achillodynia? J Clin Ultrasound 1998;26:335-339. Fredberg U, Ostgaard R. Effect of ultrasound-guided, peritendinous injections of adalimumab and anakinra in chronic Achilles tendinopathy: A pilot study. Scand J Med Sci Sports 2009;19:338-344. Koenig MJ, Torp-Pedersen S, Qvistgaard E, Terslev L, Bliddal H. Preliminary results of colour Doppler-guided intratendinous glucocorticoid injection for Achilles tendonitis in five patients. Scand J Med Sci Sports 2004;14: 100-106. Alfredson H, Ohberg L. Sclerosing injections to areas of neo-vascularisation reduce pain in chronic Achilles tendinopathy: A double-blind randomised controlled trial. Knee Surg Sports Traumatol Arthrosc 2005;13:338-344. Lind B, Ohberg L, Alfredson H. Sclerosing polidocanol injections in mid-portion Achilles tendinosis: Remaining good clinical results and decreased tendon thickness at 2-year follow-up. Knee Surg Sports Traumatol Arthrosc 2006;14:1327-1332. Ohberg L, Alfredson H. Sclerosing therapy in chronic Achilles tendon insertional paindResults of a pilot study. Knee Surg Sports Traumatol Arthrosc 2003;11:339-343. Wiegerinck JI, Reilingh ML, de Jonge MC, van Dijk CN, Kerkhoffs GM. Injection techniques of platelet-rich plasma into and around the Achilles tendon: A cadaveric study. Am J Sports Med 2011;39:1681-1686. Chan O, O’Dowd D, Padhiar N, et al. High volume image guided injections in chronic Achilles tendinopathy. Disabil Rehabil 2008;30:1697-1708. Boesen MI, Torp-Pedersen S, Koenig MJ, et al. Ultrasound guided electrocoagulation in patients with chronic noninsertional Achilles tendinopathy: A pilot study. Br J Sports Med 2006;40:761-766. Maxwell NJ, Ryan MB, Taunton JE, Gillies JH, Wong AD. Sonographically guided intratendinous injection of hyperosmolar dextrose to treat chronic tendinosis of the Achilles tendon: A pilot study. AJR Am J Roentgenol 2007;189:W215-W220. Testa V, Capasso G, Benazzo F, Maffulli N. Management of Achilles tendinopathy by ultrasound-guided percutaneous tenotomy. Med Sci Sports Exerc 2002;34:573-580.
70. Hartgerink P, Fessell DP, Jacobson JA, van Holsbeeck MT. Full- versus partial-thickness Achilles tendon tears: Sonographic accuracy and characterization in 26 cases with surgical correlation. Radiology 2001;220:406-412. 71. Qureshi AA, Ibrahim T, Rennie WJ, Furlong A. Dynamic ultrasound assessment of the effects of knee and ankle position on Achilles tendon apposition following acute rupture. J Bone Joint Surg Am 2011;93:2265-2270. 72. Waitches GM, Rockett M, Brage M, Sudakoff G. Ultrasonographic-surgical correlation of ankle tendon tears. J Ultrasound Med 1998;17:249-256. 73. Grant TH, Kelikian AS, Jereb SE, McCarthy RJ. Ultrasound diagnosis of peroneal tendon tears. A surgical correlation. J Bone Joint Surg Am 2005;87:1788-1794. 74. Gerling MC, Pfirrmann CW, Farooki S, et al. Posterior tibialis tendon tears: Comparison of the diagnostic efficacy of magnetic resonance imaging and ultrasonography for the detection of surgically created longitudinal tears in cadavers. Invest Radiol 2003;38:51-56. 75. Mei-Dan O, Kots E, Barchilon V, Massarwe S, Nyska M, Mann G. A dynamic ultrasound examination for the diagnosis of ankle syndesmotic injury in professional athletes: A preliminary study. Am J Sports Med 2009;37:1009-1016. 76. Neustadter J, Raikin SM, Nazarian LN. Dynamic sonographic evaluation of peroneal tendon subluxation. AJR Am J Roentgenol 2004;183:985-988. 77. Raikin SM, Elias I, Nazarian LN. Intrasheath subluxation of the peroneal tendons. J Bone Joint Surg Am 2008;90: 992-999. 78. Cardinal E, Chhem RK, Beauregard CG, Aubin B, Pelletier M. Plantar fasciitis: Sonographic evaluation. Radiology 1996;201:257-259. 79. Gibbon WW, Long G. Ultrasound of the plantar aponeurosis (fascia). Skeletal Radiol 1999;28:21-26. 80. Walther M, Radke S, Kirschner S, Ettl V, Gohlke F. Power Doppler findings in plantar fasciitis. Ultrasound Med Biol 2004;30:435-440. 81. McMillan AM, Landorf KB, Gilheany MF, Bird AR, Morrow AD, Menz HB. Ultrasound guided corticosteroid injection for plantar fasciitis: A randomised controlled trial. BMJ 2012;344:e3260. 82. Kane D, Greaney T, Bresnihan B, Gibney R, FitzGerald O. Ultrasound guided injection of recalcitrant plantar fasciitis. Ann Rheum Dis 1998;57:383-384. 83. Tsai WC, Wang CL, Tang FT, Hsu TC, Hsu KH, Wong MK. Treatment of proximal plantar fasciitis with ultrasoundguided steroid injection. Arch Phys Med Rehabil 2000;81: 1416-1421. 84. Tsai WC, Hsu CC, Chen CP, Chen MJ, Yu TY, Chen YJ. Plantar fasciitis treated with local steroid injection: Comparison between sonographic and palpation guidance. J Clin Ultrasound 2006;34:12-16. 85. Wisniewski SJ, Smith J, Patterson DG, Carmichael SW, Pawlina W. Ultrasound-guided versus nonguided tibiotalar joint and sinus tarsi injections: A cadaveric study. PM R 2010;2:277-281.
Use of Ultrasonography as a Diagnostic and Therapeutic Tool in Sports Medicine Bryson P. Lesniak, M.D., Dustin Loveland, M.D., Jean Jose, D.O., Ryan Selley, B.A., Jon A. Jacobson, M.D., and Asheesh Bedi, M.D.
Abstract: Ultrasonography has many important advantages over other imaging modalities and many important applications in sports medicine. This article presents an evidence-based discussion of the use of ultrasound technology to diagnose and treat common musculoskeletal disorders, with emphasis on the shoulder, elbow, hip, knee, and foot and ankle. Topics include basic principles, scan artifacts, the appearance of musculoskeletal structure characteristics and pathologies, and various diagnostic and therapeutic applications in sports medicine.
T
he first report of musculoskeletal ultrasonography (US) was published in 1958 by Dussik et al.,1 who measured the acoustic attenuation of articular and periarticular tissues. In 1972 McDonald and Leopold2 described the use of US imaging in differentiating Baker cysts from thrombophlebitis, an application still used in current clinical practice. Interest in US in sports medicine has grown exponentially as image quality has improved in recent years.3 Furthermore, the ability to perform a dynamic examination offers advantages over the static assessments of magnetic resonance imaging (MRI) and computed tomography (CT). Other strengths include cost, portability, decreased artifact from metal hardware, and fast scan time.4 The most notable drawback of musculoskeletal sonography is that physicians are unaware of its usefulness in diagnosis and treatment and are untrained in scanning and image interpretation (Table 1).
From UHealth Sports Medicine, the Department of Orthopaedics (B.P.L., D.L.), and Radiology (J.J.), University of Miami Miller School of Medicine, Miami, Florida; and the Section of Sports Medicine and Shoulder Surgery, Department of Orthopaedic Surgery (R.S., A.B.), and Department of Radiology (J.A.J.), University of Michigan, Ann Arbor, Michigan, U.S.A. The authors report the following potential conflict of interest or source of funding: J.A.J. receives support from American Institute of Ultrasound in Medicine. A.B. receives support from Smith & Nephew. Received September 3, 2013; accepted October 29, 2013. Address correspondence to Asheesh Bedi, M.D., MedSport, University of Michigan, 24 Frank Lloyd Wright Dr, Lobby A, Ann Arbor, MI 48106, U.S.A. E-mail: [email protected] Ó 2014 by the Arthroscopy Association of North America 0749-8063/13640/$36.00 http://dx.doi.org/10.1016/j.arthro.2013.10.011
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Shoulder Diagnostic US of the shoulder can identify abnormalities in the rotator cuff, biceps tendon, glenohumeral joint, and acromioclavicular joint, as well as other periarticular softtissue structures. Static and dynamic evaluation of the rotator cuff has been shown to be highly accurate in diagnosing pathology. In a meta-analysis, de Jesus et al.5 showed that the sensitivity and specificity relative to diagnosis of a full-thickness rotator cuff tear were 92% and 94%, respectively. There was no significant difference in the diagnostic capability of US and MRI for either fullthickness or partial-thickness tears.5 Rutten et al.6 showed increased sensitivity (89% v 67%) but decreased specificity (80% v 86%) with US versus MRI in the diagnosis of partial-thickness tears and showed decreased sensitivity (95% v 100%) and increased specificity (93% v 91%) with US versus MRI in the diagnosis of full-thickness tears in 5,216 patients. Middleton et al.7 had 2 radiologists independently scan patients with shoulder pain, categorizing the rotator cuff as normal, partially torn, or fully torn, and they found low interobserver variability. The radiologists were in agreement in 92% of the patients. In 4 of the 5 discrepant cases, the disagreement was between a full-thickness and partial-thickness tear. They were in agreement concerning which tendons were involved in 80% of the patients in whom a tear was detected by both observers. In all discrepant cases, the disagreement was about whether a tear involved both tendons or was isolated to 1 tendon. Wall et al.8 examined the accuracy of US compared with MRI in identifying fatty degeneration and found that US accuracy was 93% for the supraspinatus and infraspinatus muscles and 88% for the teres minor.
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ULTRASONOGRAPHY AS A TOOL IN SPORTS MEDICINE Table 1. Recommended Transducers Organized by Body Part According to Authors’ Preferences Scan Subacromial space Glenohumeral joint Elbow Wrist/feet Peritrochanteric Hip Knee Ankle
Probe Straight linear array Straight linear array Straight linear array Straight linear array Straight linear array Curved array Straight linear array Straight linear array
Frequency 12 MHz 12 MHz 12 MHz 15 MHz, small footprint 9 MHz 6 MHZ 12 MHz 12 MHz
The ability to diagnose rotator cuff pathology by use of US has been shown to be user dependent. Goldberg et al.9 showed that only 38% of cuff tears were diagnosed by community radiologists. They concluded that US, for diagnosing rotator cuff tears, may be limited to academic centers with well-trained radiologists. US can also be used to assess rotator cuff repairs postoperatively (Fig 1). A recent study investigated serial US examinations in patients with large rotator cuff tears who underwent arthroscopic repair.10 Of the repaired rotator cuff tears, 9 (41%) showed recurrent tears. This study elegantly showed the appearance of a failing rotator cuff repair on serial US scans. Sonographic evaluation of subscapularis repairs after total shoulder arthroplasty is a unique application and is considered more accurate than clinical examination findings. CT and MRI are difficult in this setting because of metal artifact. One study showed that 87% of patients had an intact repair at follow-up whereas abdominal compression tests had a sensitivity and specificity of 25% and 73%, respectively.11 US can also identify abnormalities affecting the biceps tendon. Such pathology includes effusion within the tendon sheath, tendon subluxation, or dislocation.12 The capacity for dynamic assessment with US has been
Fig 1. Recurrent supraspinatus tendon tear after prior repair. A longitudinal US image shows supraspinatus tendon retraction (white arrows) and discontinuity with the suture anchor (red arrow), reflecting recurrent tear.
Plane of View Transverse Transverse Transverse and axial Transverse and axial Transverse and axial Transverse Transverse and axial Transverse and axial
Body Position Lateral recumbent Lateral recumbent Supine Supine Lateral recumbent Supine Supine, prone, and lateral recumbent Supine and prone
shown to improve the accuracy of identifying biceps tendon instability to 86%.13 MRI with intra-articular gadolinium is the gold standard for diagnosing labral abnormalities. However, studies have shown that the sensitivity of US in the diagnosis of labral tears ranges from 67% to 95%.14,15 Paralabral cysts may also be identified. Evaluation of the periarticular structures should include imaging of the spinoglenoid notch and suprascapular notch because cysts in these regions may cause a suprascapular neuropathy. US of the shoulder is increasingly being used for facilitation of minimally invasive procedures. A randomized, prospective study has shown no statistical difference in accuracy between blind subacromial injections and USguided injections.16 However, other studies have shown 100% accuracy for image-guided subacromial injections versus 72% accuracy for noneimage-guided injections of the subacromial bursa.17 Glenohumeral injections have been shown to be statistically more accurate with image guidance (92.5% to 95%) compared with a freehand technique (72.5% to 79%).17,18 Injections into the acromioclavicular joint have also shown significantly increased accuracy with image guidance (100%) versus blind injection (44%).17 Less commonly performed biceps tendon sheath injections have also been shown to be significantly more accurate with the use of US (87%) compared with blind injection (27%) (Fig 2).19 Calcific tendinosis of the rotator cuff is a common disorder. Both US-guided needle aspiration and extracorporeal shockwave therapy have been shown to improve clinical outcomes (Fig 3). Aspiration combined with shockwave therapy has been compared with shockwave therapy alone, and the combined treatment resulted in significantly improved Constant scores and a decreased progression to surgical debridement.20 A recent randomized, comparative investigation studied US-guided lavage of the calcific lesion and injection versus subacromial injection alone.21 Although both groups showed significant improvement compared with before the procedure, the lavage group had better clinical and radiographic results than the group that underwent injection alone. Symptomatic cysts in the spinoglenoid or suprascapular notch can be aspirated by use of US (Fig 4).22,23
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Fig 2. Long head of biceps tendinosis (A) and tenosynovitis (B) with US-guided injection. (A) A transverse US image at the level of the proximal humerus shows hypoechoic fluid around the long head of the biceps, with hypoechoic echotexture of the long head of the biceps (arrow), reflecting tendinosis and tenosynovitis. (B) The needle tip (arrow) is placed within the long head of the biceps tendon sheath, between the long head of the biceps tendon and the bicipital groove. (C-E) Subdeltoid bursitis, including normal view and subdeltoid bursa injection. Longitudinal US images show the normal peribursal fat stripe in an asymptomatic patient (arrows in C), pronounced synovitis reflecting subdeltoid bursitis in a patient with rheumatoid arthritis (arrows in D), and US-guided injection with the needle tip inside the subdeltoid bursa (arrows in E). (F) US-guided glenohumeral joint injection through posterior approach. A transverse US image of the posterior margin of the glenohumeral joint shows the needle tip (arrow) within the glenohumeral joint capsule deep to the infraspinatus tendon. It should be noted that the needle is away from the glenoid labrum.
In summary, US has shown equal or increased sensitivity and specificity versus MRI in the noninvasive diagnosis of common sports medicine shoulder pathologies, as well as increased accuracy for injections into the acromioclavicular and glenohumeral joints, subacromial bursa, and biceps tendon sheath. Increased accuracy of US-guided injections of all joints, particularly of the shoulder, is independent of the physician’s level of experience.24
Elbow US is an effective imaging modality for the elbow. Abnormal signals in the soft tissues can identify pathology, including partial- and full-thickness tears of tendons, tendinosis, epicondylitis, ligament tears, ulnar nerve entrapment, olecranon bursitis, effusions, and loose bodies.25 Lateral and medial epicondylitis can be diagnosed with US because the involved tendon appears swollen and hypoechoic from degeneration with possible interstitial tears and an absence of inflammation. There is often tenderness with transducer pressure or cortical irregularity of the affected epicondyle.26 In lateral epicondylitis, US has been used to guide injections of corticosteroids or
platelet-rich plasma (PRP) (Fig 5). US-guided injection of PRP compared with whole blood has been described in a recent study.27 Significantly improved visual analog scale (VAS) scores were seen in the PRP group. USguided radiofrequency-based plasma microdebridement has been advocated recently as an effective method to treat recalcitrant lateral epicondylitis. Another treatment option, US-guided radiofrequency thermal lesioning, has shown statistically significant improvements at 6 months’ follow-up with regard to VAS score, grip strength, and Modified Mayo Clinic Performance Index.4 US can also lend insights into the presence and severity of collateral ligament pathology of the elbow (Fig 6). Ligament integrity and competency can be directly observed with dynamic maneuvers that stress the ligament to identify instability of the elbow, including pushing up from a chair or tabletop with a supinated forearm. The size of intrasubstance tears and the presence of a lateral ulnar collateral ligament (UCL) tear on US have been used to assess tendinopathy severity and predict response to treatment.28 Valgus instability of the elbow, including partial and complete tears of the UCL, can be identified on sonography statically by focal hypoechoic areas in the ligament. In addition, dynamic
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different in pitching arms when they compared initial and final US scans, but there were no significant differences in any parameters when they compared asymptomatic elbows with those that underwent subsequent UCL reconstruction. Distal biceps ruptures can also be diagnosed with US. This imaging not only confirms the diagnosis but also can characterize the integrity of the lacertus fibrosis and quantify the degree of retraction superficial to the brachialis.31 Furthermore, US can identify musculotendinous junction injury, which may not benefit from surgical exploration (Fig 7).
Hip
Fig 3. US-guided lavage for supraspinatus calcific tendinitis. (A) A transverse US image shows an echogenic mass within the supraspinatus tendon, reflecting a calcific tendinitis deposit (arrow). (B) A transverse image shows the needle entering the calcific deposit (arrow). (C) A transverse US image shows disbursement of calcification during lavage, now with internal areas of fluid (arrow).
US may be used to identify valgus instability. Medial joint widening to valgus stress should be no more than 0.5 to 1.0 mm when compared with the uninjured side. This is a helpful adjunct to MRI, which cannot provide the dynamic information and often shows chronic changes in the UCL that are of uncertain significance in the overhead athlete.29 Ciccotti et al.30 recently presented data based on dynamic elbow US scans that were performed bilaterally in 368 professional pitchers. The mean amount of stressed joint space, change in joint space, and presence of heterogeneity were significantly
In the past, US as a diagnostic modality for the hip was thought to be anecdotal.32 Recently, however, US has been used in both diagnostic and therapeutic protocols in and around the hip joint. Coxa sultans, or snapping hip, is a common cause of hip discomfort. The syndrome is classified into external, internal, and intra-articular causes. External snapping is typically attributed to the iliotibial band or the gluteus maximus tendons snapping over the greater trochanter. The internal type typically involves the iliopsoas snapping against the superior pubic ramus near the iliopectineal eminence.33 Intra-articular lesions may be due to a variety of causes, including loose bodies, labral tears, osteochondral fractures, or synovial chondromatosis. Recent radiologic advancements have shown great utility of US in sorting through these diagnoses (Fig 8). Pelsser et al.34 showed that a cause of snapping hip could be identified in 24 of 26 cases (92%). An evaluation of 26 ballet dancers with 50 snapping hips showed that US could identify a cause in 63%; intra-articular causes were suspected to account for the remaining one-third.35 Other muscles around the hip can also be evaluated with US, specifically the abductors. US can be used to evaluate partial- and full-thickness tears and tendinosis, all of which are commonly found in athletes.36 These pathologies can be viewed with both MRI and US, and a systematic review of gluteal tendon tear diagnostic accuracy by Westacott et al.37 found US to have a higher sensitivity and positive predictive value. This improved visualization may be combined with therapeutic interventions to offer accurately placed needle fenestration or injections for tendon pathology. Few studies have investigated the role of US in the diagnosis of acetabular labral tears. Troelsen et al.38 reported a sensitivity of 44% and a positive predictive value of 88% and concluded that the use of US in diagnosing labral tears should be developed further. Subsequently, Troelsen et al.39 were able to diagnose labral tears with a sensitivity of 94% and a positive predictive value of 94%, as confirmed by magnetic resonance arthrography. This indicates that a significant learning curve may be associated with diagnosis of
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Fig 4. US-guided cyst aspiration and injection of spinoglenoid notch. (A) A long-axis US image of the spinoglenoid notch shows a hypoechoic paralabral cyst (arrow) compressing the suprascapular nerve. (B) A longitudinal US image shows aspiration of the cyst with a needle (arrow). It should be noted that the cyst is smaller and now contains echogenic internal microbubbles.
intra-articular pathology using US. Most recently, a study evaluated the potential benefit of an intraarticular injection on the ability to diagnose an acetabular labral tear.40 Although the authors were able to show that the accuracy of US diagnosis of labral tears was improved with an intra-articular injection, they also found that the interobserver reliability was poor. Furthermore, they found that CT arthrograms were more accurate than US in this setting. We currently prefer MRI and, specifically, magnetic resonance arthrography to characterize pathology of the hip. Sonographic guidance is commonly used in and around the hip. Injections and arthroscopic portal placement have been described using US.41 Trochanteric bursitis and associated gluteus medius tendinopathy have been treated with US-guided injections. One study found that 72% of patients with US-guided injections of the gluteus medius tendon showed clinically significant improvement as measured by VAS pain score.42 Smith et al.43 showed that sonographically guided intra-articular injections could be placed with 97% accuracy as verified by fluoroscopy. Sonography also allows for paralabral cyst aspirations in patients with hip pain who do not wish to undergo arthroscopic hip surgery. This has allowed for outpatient intraarticular hip injections to be an option without the
risk of the radiation exposure that is associated with fluoroscopically or CT-guided injections.43 US has also proven valuable in the setting of athletic pubalgia. Although this diagnosis is often based on clinical symptoms, a dynamic US evaluation of the abdominal wall musculature and fascia with a Valsalva maneuver has allowed for the identification of potentially reparable lesions. A recent prospective study also investigated the response of US-guided corticosteroid injections as a treatment modality for athletic pubalgia, in which 13 of 18 patients (72%) achieved an ideal outcome based on the Western Ontario and McMaster Universities Arthritis Index score.44
Knee There are many indications for US of the knee. Peripheral meniscus tears, patellar or quadriceps tendinopathy, and bursitis can be confirmed. This is particularly beneficial in claustrophobic patients or patients with implanted devices that preclude the use of MRI. In patients whose body habitus can make blind injections difficult because of loss of the normal anatomic landmarks, US provides a safe and accurate way to provide intra-articular injections. Use of US in patellar tendinopathy (jumper’s knee) has shown benefit with regard to diagnosis and prognosis. In
Fig 5. US-guided trephination and PRP injection of common extensor tendinosis and partial-thickness tear (lateral epicondylitis). (A) A longitudinal US image shows common extensor tendinosis at the origin, with a small partial-thickness tendon tear near the articular surface (arrow). (B) The needle tip is placed at the tear site (arrow) under US guidance. (C) A post-injection long-axis US image of the lateral elbow shows echogenic PRP within the tear.
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Fig 6. (A) Partial-thickness tear of UCL sublime tubercle. The arrow shows discontinuity of the anterior bundle of the UCL at the sublime tubercle attachment. (B) US-guided PRP injection for symptomatic, low-grade, partial-thickness UCL tear. The arrow shows the needle tip placed at the UCL tear site within injection of echogenic PRP.
a study investigating competitive athletes with clinical symptoms of jumper’s knee, 60% of the examined tendons displayed structural tendon changes with neovascularization and increased blood flow whereas 26% had structural changes alone and 14% were normal.45 This neovascularization may indicate that a patient could benefit from recently described therapies, such as US-guided sclerosis of neovessels using polidocanol.46 Cystic abnormalities about the knee can be identified and treated with US as well. Baker cysts represent distention of the semimembranosusemedial gastrocnemius bursa and are a significant source of pain and disability. Ward et al.47 showed that Baker cysts could be diagnosed with 100% accuracy as confirmed by MRI. US can also categorize cysts as either simple or complex. These categories were used to predict treatment outcomes in a prospective study of 32 patients.48 US has also been used in the treatment of Baker cysts by guiding both aspiration and localized corticosteroid injections. Bandinelli et al.49 showed that US-guided direct aspiration of a Baker cyst followed by US injection of steroid directly
Fig 7. Biceps brachii tendon with distal musculotendinous tear. A long-axis US image of the biceps brachii shows a hypoechoic tear (arrow) at the musculotendinous junction (Br, brachialis; H, humerus).
into the cyst resulted in a significantly smaller cyst compared with intra-articular injection. When one is aspirating a Baker cyst, it is critical to also aspirate any knee joint effusion, given potential communication between the Baker cyst and knee joint (Fig 9). Ganglion cysts, though less common than Baker cysts, have also been described in and around the knee. They may be intra-articular or extra-articular and may not have a definable connection with the joint. They can occur in atypical locations, including the proximal tibiofibular joint, tendon sheaths, cruciates, or peripheral nerves.50 Jose et al. have reported success with aspirations of atypical symptomatic ganglion cysts, including an intraneural cyst of the tibial nerve51 and 1 associated with the popliteus tendon.52 Parameniscal cysts can be identified on US when a hypoechoic cyst is in contact with the meniscus.53 Macmahon et al.54 performed US-guided percutaneous drainage of parameniscal cysts in 18 patients. Ten patients reported complete resolution of symptoms and returned to high-level sports, and all had a pain-free interval of at least 1 week. A coexisting meniscal tear is present in approximately 85% of cases and may also be visualized with US.53 Shetty et al.55 performed a prospective study investigating the accuracy of diagnosing meniscal tears by US in comparison with MRI, as confirmed by arthroscopy. For US, there was a sensitivity of 86.4%, a specificity of 69.2%, a positive predictive value of 82.6%, and a negative predictive value of 75%. This compared with a sensitivity of 86.4%, a specificity of 100.0%, a positive predictive value of 100.0%, and a negative predictive value of 81.3% for MRI. The similar sensitivity between modalities implies that US can be applied to confirm the clinical diagnosis but MRI remains the standard of care because US is limited with regard to a comprehensive evaluation of the meniscus. However, in patients who cannot undergo MRI, US is a viable alternative. Intra-articular knee injections are commonly performed in clinical practice. The placement of these injections can be significantly improved with US guidance compared with freehand.56,57 A systematic review by Berkoff et al.56
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Fig 8. Iliopsoas complex with snapping hip syndrome. (A) A short-axis US image of the iliopsoas tendon shows the medial fibers of the iliacus (MFI) with a segment of iliacus muscle (arrow) entrapped between the psoas major tendon (PMT) and superior pubic ramus (SPR) with the hip in abduction, flexion, and external rotation. (B) The entrapped muscle is then released with the hip in a fullextension position, causing an abrupt snapping movement of the psoas major tendon to contact the superior pubic ramus (right side of image is medial).
found that sonography-guided intra-articular knee injections improved accuracy to 95.8% compared with accuracy of 77.8% for anatomic guidance. In addition, it has been found that accurate intra-articular injections have significantly improved clinical outcomes.24
Foot and Ankle Achilles tendon abnormalities that have been diagnosed by US include tendinosis, partial- and full-thickness tears, and Haglund syndrome. Surrounding structures that may also be identified during examination include the plantaris tendon, retrocalcaneal bursa, retro-Achilles bursa, and gastrocnemius musculature and aponeurosis.58 Achilles tendinopathy can be both diagnosed and treated with the use of sonography. US of Achilles tendinopathy has resulted in the development of a grading scheme that has been shown to predict healing times.59 In a placebocontrolled study of US-guided peritendinous steroid
Fig 9. A transverse image shows the needle (arrow) within a Baker cyst, inserted from a posteromedial approach. The patient underwent US imaging in a prone position.
injection in athletes with Achilles tendinopathy, Fredberg and Ostgaard60 found that the steroid group had reduced pain and tendon thickening compared with the placebo group. Koenig et al.61 investigated color Dopplereguided injections of glucocorticoids in 6 tendons. They concluded that color Doppler significantly contributes to Achilles tendonitis diagnosis, location, and follow-up. Early studies of sclerotherapy of neovessels using US-guided polidocanol injections have achieved encouraging results.62-64 One study of polidocanol injections at 3 months’ followup showed significantly reduced tendon pain when compared with controls.64 Clinical follow-up at 2 years showed good results with a significant reduction in the mean tendon thickness, as well as a reduction in the number of neovessels in treated tendons.63 A recent technique has been described for US-guided injection of PRP into the tendon and paratenon in the presence of Achilles tendinopathy.65 Other modalities using US guidance with some degree of success include high-volume saline solution injections,66 electrocoagulation of neovessels,67 intratendinous injection of hyperosmolar dextrose,68 and percutaneous tenotomy.69 US is also valuable in the diagnosis and characterization of traumatic Achilles tendon injuries. US is reliably used to diagnose complete Achilles tendon tears, estimate the severity and location of the abnormality, and assist in preoperative planning by identifying the location of the tear.70 Recent studies have evaluated the use of dynamic US in acute complete Achilles tendon rupture as a method of evaluating the reduction of the tendon gap, as well as better determining whether to recommend operative versus nonoperative management.70,71 Qureshi et al.71 evaluated 125 patients with acute Achilles tendon ruptures with dynamic US. Patients with a gap of 5 mm or more in equinus on US underwent surgery, whereas those with a gap of less than 5 mm received nonoperative treatment. There were 2 reruptures in the nonoperative group and 1 in
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Table 2. Commonly Used Transducers for Musculoskeletal Diagnostic and Interventional Procedures Transducer Linear probe
Image Shape Rectangle
Frequency (MHz) 5-17
Depth of Field (cm) 3-4
Resolution Increased
Curved probe
Pie/sector
1-8
3-12
Decreased
the surgery group, and no significant difference between the groups for any complication was noted. With the ongoing controversy regarding operative versus nonoperative management of Achilles ruptures, sonography in this setting can assist the sports medicine physician to better assess the optimal treatment plan. US is also well suited for the evaluation of other tendons and ligament injuries about the ankle. The resolution of modern US allows for detailed evaluation of tendon architecture (Table 2). Skilled radiologists are able to identify a spectrum of pathology based on findings, including tendinosis, tenosynovitis, and tears. Waitches et al.72 have shown 100% sensitivity and 88% specificity in the diagnosis of tears involving the peroneal, posterior tibial, and flexor digitorum longus tendons. More recently, Grant et al.73 found US to have a sensitivity of 100% and specificity of 85% in diagnosing peroneal tendon tears with surgical correlation. A cadaveric study comparing MRI and US in diagnosing surgically created posterior tibial tendon tears found the 2 imaging modalities to be equally sensitive and accurate, with US being more specific.74 This study suggests that US can be more appropriate than MRI in the evaluation of posterior tibial tendon tears. A preliminary study recently investigated the accuracy of
Fig 10. Peroneal tendons with intrasheath subluxation and peroneus brevis tear. A short-axis US image of the peroneus brevis (PB) and peroneus longus (PL) tendons shows a hypoechoic partial-thickness tear (arrow) of the peroneus brevis. With dynamic imaging, the peroneus brevis and longus tendons snapped against each other within the tendon sheath. The convex posterior border of the fibula (F) should be noted.
Musculoskeletal Uses Small footprint probe (2.5 cm): wrist, hand, foot, and pubic symphysis Traditional footprint probe (5 cm): arm, shoulder, forearm, calf, elbow, wrist, knee, and ankle Obese patients, thigh, hips, greater trochanteric region, pelvis, and piriformis fossa
dynamic US in the diagnosis of ankle syndesmotic injury in professional athletes and found a sensitivity and specificity of 100%, as confirmed by MRI.75 Identification of tendon subluxation is important not only to explain patient symptoms but also to allow prompt treatment. Neustadter et al.76 evaluated 13 consecutive patients in whom peroneal tendon subluxation was clinically suspected with dynamic US. Of the 13 patients, 12 had sonographic findings of peroneal tendon subluxation that was confirmed by subsequent surgery. Sonography showed peroneus brevis tendon tears in 5 patients and a peroneus longus tear in 1 patient; all findings were confirmed at surgery, with no false-positive sonograms. A study of 14 patients with 2 subtypes of intrasheath subluxation yielded results of 100% sonographic accuracy after intraoperative confirmation (Fig 10).77 Plantar fasciitis is a diagnosis commonly encountered in orthopaedics. Studies have proven the diagnostic efficacy of sonography in the evaluation of plantar fasciitis.78,79 Findings included hypoechoic plantar fascia as well as significantly increased fascia thickness in patients with symptomatic heels when compared with patients with asymptomatic heels and a control group. With advances such as power Doppler US, additional information on neovascularity can aid in the diagnosis and treatment. Walther et al.80 compared 20 patients with a diagnosis of unilateral plantar fasciitis and 20 healthy volunteers and found moderate hyperemia in 40% of the symptomatic heels compared with 5% of the asymptomatic heels. McMillan et al.81 randomized 82 patients with plantar fasciitis to US-guided injections of corticosteroid or normal saline solution. At 4 weeks, there was a significant reduction in pain scores in the steroid group. Corticosteroid injections are often used, but palpation-guided injections are not always accurate.82 With inaccurate injections of corticosteroid, the complications can include heel fat pad atrophy and fascia rupture, emphasizing the importance of accurate injection.83 In a study of 4 patients who were unresponsive to palpation-guided injection, Kane et al.82 used US-guided injections and found complete relief at 24 months in 4 of 5 heels. Tsai et al.83 confirmed these findings in a subsequent study of 14 patients with unilateral plantar fasciitis; after US-guided injections, the patients had significantly improved VAS scores, decreases in thickness, and improved echogenicity, as well as no change in the properties of the heel fat pad. A
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subsequent study by Tsai et al.84 showed that although both US-guided and blind injections produced decreases in thickness, improved echogenicity, and improved VAS scores, the US-guided group had a significantly decreased recurrence rate (8%) compared with the palpation-guided group (46%). Other injections of the foot and ankle may also be facilitated by US guidance. Wisniewski et al.85 injected 40 cadaveric ankles, randomizing between US guidance and a blind anterior technique. The accuracy rate for guided tibiotalar joint injections was 100% versus 85% for blind injections. The accuracy rate for sinus tarsi injections was 90% for guided injections versus 35% for blind injections. This shows the accuracy of USguided injections over conventional blind injection techniques using superficial anatomic landmarks alone.
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Conclusions Sonography is an excellent imaging modality for the diagnosis and treatment of common musculoskeletal injuries that avoids the risk of ionizing radiation or contrast material. It is useful in the presence of metallic hardware and offers equal or higher diagnostic sensitivity and specificity compared with MRI in a wide variety of musculoskeletal disorders. It is particularly useful in the identification of pain generators that are evident with dynamic, provocative maneuvers. USguided injection of intra-articular and periarticular structures is reliable and improves accuracy compared with conventional blind techniques. Close communication between the orthopaedic surgeon and the sonographer is essential for a successful and meaningful evaluation, but the combination of clinical examination and dynamic imaging can offer great synergy for improved diagnostic accuracy and clinical outcomes after US-assisted procedures.
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39. Troelsen A, Mechlenburg I, Gelineck J, Bolvig L, Jacobsen S, Søballe K. What is the role of clinical tests and ultrasound in acetabular labral tear diagnostics? Acta Orthop 2009;80: 314-318. 40. Jung JY, Kim GU, Lee HJ, Jang EC, Song IS, Ha YC. Diagnostic value of ultrasound and computed tomographic arthrography in diagnosing anterosuperior acetabular labral tears. Arthroscopy 2013;29:1769-1776. 41. Hua Y, Yang Y, Chen S, et al. Ultrasound-guided establishment of hip arthroscopy portals. Arthroscopy 2009;25: 1491-1495. 42. Labrosse JM, Cardinal E, Leduc BE, et al. Effectiveness of ultrasound-guided corticosteroid injection for the treatment of gluteus medius tendinopathy. AJR Am J Roentgenol 2010;194:202-206. 43. Smith J, Hurdle MF, Weingarten TN. Accuracy of sonographically guided intra-articular injections in the native adult hip. J Ultrasound Med 2009;28:329-335. 44. Fokin A, Wodicka R, Jose J, Page C, Lesniak BP. Review of athletic pubalgia and role of ultrasound-guided corticosteroid injections as a treatment modality. Presented at the American College of Sports Medicine Annual Meeting, San Francisco, CA, May 2012. 45. Hoksrud A, Öhberg L, Alfredson H, Bahr R. Color Doppler ultrasound findings in patellar tendinopathy (jumper’s knee). Am J Sports Med 2008;36:1813-1820. 46. Hoksrud A, Öhberg L, Alfredson H, Bahr R. Ultrasoundguided sclerosis of neovessels in painful chronic patellar tendinopathy: A randomized controlled trial. Am J Sports Med 2006;34:1738-1746. 47. Ward EE, Jacobson JA, Fessell DP, et al. Sonographic detection of Baker’s cysts: Comparison with MR imaging. AJR Am J Roentgenol 2001;176:373-380. 48. Koroglu M, Callioglu M, Eris HN, et al. Ultrasound guided percutaneous treatment and follow-up of Baker’s cyst in knee osteoarthritis. Eur J Radiol 2012;81:3466-3471. 49. Bandinelli F, Fedi R, Generini S, et al. Longitudinal ultrasound and clinical follow-up of Baker’s cysts injection with steroids in knee osteoarthritis. Clin Rheumatol 2012;31:727-731. 50. Burk DL Jr, Dalinka MK, Kanal E, et al. Meniscal and ganglion cysts of the knee: MR evaluation. AJR Am J Roentgenol 1998;150:331-336. 51. Jose J, Fourzali R, Lesniak B, Kaplan L. Ultrasoundguided aspiration of symptomatic intraneural ganglion cyst within the tibial nerve. Skeletal Radiol 2011;40: 1473-1478. 52. Jose J, Silverman E, Kaplan L. Symptomatic ganglion cyst of the popliteus tendon treated with ultrasound-guided aspiration and steroid injection: A case report. Sports Health 2011;3:393-395. 53. Rutten MJ, Collins JM, van Kampen A, Jager GJ. Meniscal cysts: Detection with high-resolution sonography. AJR Am J Roentgenol 1998;171:491-496. 54. Macmahon PJ, Brennan DD, Duke D, Forde S, Eustace SJ. Ultrasound-guided percutaneous drainage of meniscal cysts: Preliminary clinical experience. Clin Radiol 2007;62: 683-687. 55. Shetty AA, Tindall AJ, James KD, Relwani J, Fernando KW. Accuracy of hand-held ultrasound
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