Normal Ultrasound Anatomy

of the Musculoskeletal System

Enzo Silvestri • Alessandro Muda •
Luca Maria Sconfienza
Editors

Normal Ultrasound
Anatomy of the
Musculoskeletal
System

A pratical guide

Presentazione di
Lisa Licitra, Patrizia Olmi

123
Editors
Enzo Silvestri Luca Maria Sconfienza
Ospedale Evangelico Internazionale IRCCS Policlinico San Donato
Unit of Radiology Unit of Radiology
Genoa, Italy San Donato Milanese (MI), Italy

Alessandro Muda
University Hospital “San Martino”
Unit of Radiology
Genoa, Italy

Contributors
Emanuele Fabbro, MD
Giulio Ferrero, MD
Chiara Martini, MD
Davide Orlandi, MD
Post Graduate School of Radiodiagnostic
University of Genoa
Genoa, Italy

ISBN 978-88-470-2456-4 ISBN 978-88-470-2457-1 (eBook)

DOI 10.1007/978-88-470-2457-1

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Preface

The use of Ultrasound has become widely accepted as an imaging modal-

ity in assessment of the musculoskeletal system, as it is quick, cheap, and
readily available. Also, recent technological improvements in this field have
demonstrated that this imaging modality can provide extremely useful infor-
mation to diagnose and treat musculoskeletal diseases.
When first approaching musculoskeletal ultrasound, many obstacles may
be encountered: for example, it may be difficult at first to position the probe
correctly, or the ultrasound images may not be correctly interpreted. Also,
the high number of artifacts and pitfalls that can be encountered in clinical
practice may further complicate the approach to this imaging modality. Fi-
nally, most medical professionals find it difficult to remember the normal
anatomy of the musculoskeletal system.
For these reasons, we decided to prepare this handbook, which aims to
be a quick and practical reference in daily routine. It is based on a distance-
learning project, prepared in 2010 for Italian radiologists, orthopedists, and
rheumatologists. We wanted to keep the text as concise as possible, to allow
plenty of space for anatomical schemes, pictures of anatomical landmarks
for a better understanding of the correct placement of the probe, and ultra-
sound images, highlighting the most relevant anatomical structures of the
main joints: shoulder, elbow, hand and wrist, hip, knee, ankle and foot. In
addition, an initial chapter dealing with basic principles of musculoskeletal
ultrasound is included.
Finally, we acknowledge the hard work of our colleagues Emanuele Fab-
bro, Giulio Ferrero, Chiara Martini, and Davide Orlandi, whose help with
drawing most anatomical schemes and acting as models for anatomical pic-
tures made an invaluable contribution to this book.

Genoa, November 2011 Enzo Silvestri

Alessandro Muda
Luca Maria Sconfienza

v
Contents

01 Basic Principles of Musculosketal Ultrasound . . . . . . . . . . 1

1.1 Tendons . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
1.2 Ligaments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
1.3 Peripheral nerves . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
1.4 Cartilage and bone . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
1.5 Muscles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

02 Shoulder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
2.1 Long Head of Biceps Brachii Tendon (LHBBT) . . . . . . 9
2.2 Subscapularis Tendon . . . . . . . . . . . . . . . . . . . . . . . . . . 14
2.3 Supraspinatus Tendon and Subacromial-Subdeltoid
Bursa (SASD) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
2.4 Coracoacromial Ligament . . . . . . . . . . . . . . . . . . . . . . . 20
2.5 Infraspinatus and Teres Minor Tendons . . . . . . . . . . . . . 21
2.6 Acromion-Clavicular Joint . . . . . . . . . . . . . . . . . . . . . . 21

03 Elbow . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
3.1 Anterior Compartment . . . . . . . . . . . . . . . . . . . . . . . . . . 27
3.1.1 Distal Tendon of Biceps Brachii . . . . . . . . . . . . . . 27
3.1.2. Anterior Joint Recess . . . . . . . . . . . . . . . . . . . . . . 30
3.1.3 Median Nerve . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
3.1.4 Radial and Posterior Interosseous Nerves . . . . . . 30
3.2 Lateral Compartment . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
3.2.1 Common Extensor Tendon . . . . . . . . . . . . . . . . . . 35
3.2.2 Humeral-Radial Joint . . . . . . . . . . . . . . . . . . . . . . 35
3.3 Medial Compartment . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
3.3.1 Common Flexor Tendon . . . . . . . . . . . . . . . . . . . . 38
3.3.2 Medial Collateral Ligament . . . . . . . . . . . . . . . . . 38
3.4 Posterior Compartment . . . . . . . . . . . . . . . . . . . . . . . . . 41
3.4.1 Triceps Brachii Muscle and Tendon . . . . . . . . . . . 41
3.4.2 Olecranon Fossa and Posterior Olecranon Recess 41
3.4.3 Cubital Tunnel and Ulnar Nerve . . . . . . . . . . . . . . 41

04 Wrist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
4.1 Palmar Side . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
4.1.1 Carpal Tunnel and Median nerve . . . . . . . . . . . . . 45

vii
viii Contents

4.1.2 Guyon Tunnel and Ulnar Nerve . . . . . . . . . . . . . . 50

4.2 Dorsal Side . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
4.2.1 Extensor Tendon Compartments . . . . . . . . . . . . . . 51
4.2.1.1 First Compartment . . . . . . . . . . . . . . . . . . . . . 51
4.2.1.2 Second Compartment . . . . . . . . . . . . . . . . . . . 54
4.2.1.3 Third Compartment . . . . . . . . . . . . . . . . . . . . . 56
4.2.1.4 Fourth and Fifth Compartment . . . . . . . . . . . . 58
4.2.1.5 Sixth Compartment . . . . . . . . . . . . . . . . . . . . . 60
4.2.2 Distal Radio-Ulnar Joint . . . . . . . . . . . . . . . . . . . . 60

05 Hand . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
5.1 Ventral Side . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
5.1.1 Palmar Aponeurosis . . . . . . . . . . . . . . . . . . . . . . . 63
5.1.2 Flexor Digitorum Tendons . . . . . . . . . . . . . . . . . . 64
5.1.3 Metacarpophalangeal and Interphalangeal Joints . 68
5.2 Dorsal Side . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
5.2.1 Extensor Digitorum Tendons . . . . . . . . . . . . . . . . 71

06 Hip . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
6.1 Anterior Hip . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
6.1.1 Sartorius and Tensor Fasciae Latae . . . . . . . . . . . . 76
6.1.2 Rectus Femoris . . . . . . . . . . . . . . . . . . . . . . . . . . . 76
6.1.3 Iliopsoas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82
6.1.4 Femoral Neurovascular Bundle . . . . . . . . . . . . . . 82
6.1.5 Hip Joint . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82
6.2 Medial Hip . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85
6.2.1 Adductor Tendons and Muscles . . . . . . . . . . . . . . 85
6.3 Lateral Hip . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86
6.3.1 Gluteus Tendons and Muscles . . . . . . . . . . . . . . . 86
6.4 Posterior Hip . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89
6.4.1 Ischiocrural Tendons (Hamstrings) . . . . . . . . . . . . 89
6.4.2 Sciatic Nerve . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89

07 Knee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
7.1 Anterior Compartment . . . . . . . . . . . . . . . . . . . . . . . . . . 93
7.1.1 Quadriceps Tendon . . . . . . . . . . . . . . . . . . . . . . . . 93
7.1.2 Suprapatellar and Paracondylar Recesses . . . . . . . 96
7.1.3 Femoral Trochlea . . . . . . . . . . . . . . . . . . . . . . . . . 96
7.1.4 Patellar Retinacula . . . . . . . . . . . . . . . . . . . . . . . . 96
7.1.5 Patellar Tendon or Ligament . . . . . . . . . . . . . . . . . 100
7.2 Medial Compartment . . . . . . . . . . . . . . . . . . . . . . . . . . . 102
7.2.1 Medial Collateral Ligament . . . . . . . . . . . . . . . . . 102
7.2.2 Goose’s Foot Tendons . . . . . . . . . . . . . . . . . . . . . . 102
7.3 Lateral Compartment . . . . . . . . . . . . . . . . . . . . . . . . . . . 105
7.3.1 Iliotibial Tract . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105
7.3.2 Lateral Collateral Ligament . . . . . . . . . . . . . . . . . 105
7.4 Posterior Compartment . . . . . . . . . . . . . . . . . . . . . . . . . 108
Contents ix

7.4.1 Medial Tendons . . . . . . . . . . . . . . . . . . . . . . . . . . . 108

7.4.2 Semimembranosus Bursa . . . . . . . . . . . . . . . . . . . 108
7.4.3 Popliteal Neurovascular Bundle . . . . . . . . . . . . . . 110
7.4.4 Posterolateral Corner and Biceps Femoris Tendon 111
7.4.5 Peroneal Nerve . . . . . . . . . . . . . . . . . . . . . . . . . . . 112
0
08 Ankle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115
8.1 Lateral Compartment . . . . . . . . . . . . . . . . . . . . . . . . . . . 115
8.1.1 Anterior Talo-Fibular Ligament . . . . . . . . . . . . . . 116
8.1.2 Anterior Tibio-Fibular Ligament . . . . . . . . . . . . . 118
8.1.3 Calcaneo-Fibular Ligament . . . . . . . . . . . . . . . . . 119
8.1.4 Peroneal Tendons . . . . . . . . . . . . . . . . . . . . . . . . . 119
8.2 Medial Compartment . . . . . . . . . . . . . . . . . . . . . . . . . . . 122
8.2.1 Deltoid Ligament . . . . . . . . . . . . . . . . . . . . . . . . . 122
8.2.2 Tarsal Tunnel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125
8.3 Posterior Compartment . . . . . . . . . . . . . . . . . . . . . . . . . 127
8.3.1 Achilles Tendon . . . . . . . . . . . . . . . . . . . . . . . . . . 127
8.3.2 Posterior Tibio-Talar Recess . . . . . . . . . . . . . . . . . 129
8.4 Anterior Compartment . . . . . . . . . . . . . . . . . . . . . . . . . . 130
8.4.1 Anterior Tendons and Deep Peroneal Nerve . . . . 130
8.4.2 Anterior Tibio-Talar Recess . . . . . . . . . . . . . . . . . 132

09 Foot . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133
9.1 Hindfoot . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133
9.1.1 Plantar Aponeurosis . . . . . . . . . . . . . . . . . . . . . . . 133
9.2 Forefoot . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134
9.2.1 Plantar Side . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134
9.2.2 Dorsal Side . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137

Recommended Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139

 Basic Principles of Musculosketal
Ultrasound 1

Contents
1.1 Tendons
1.2 Ligaments
1.3 Peripheral Nerves
1.4 Cartilage and Bone
1.5 Muscles

1.1 Tendons that envelops the whole tendon (Fig. 1.1).

Tendons are critical biomechanical units in
the musculoskeletal system, the function of
which is to transmit muscular strength to
mobile skeletal segments. Tendons are
extremely resistant to traction, almost like
bone, being able to bear up to 1000 kg per 10
mm2 transverse section. Conversely, tendons
are not very elastic, being only able to toler-
ate a maximum elongation of 6% before
being damaged. Tendons have very slow
metabolism, even during action, and it can
only be significantly increased by inflamma-
tory conditions and traumas. Tendons macro-
scopically appear as ribbon-like structures,
with extremely variable shape and dimen-
sions, characterized by the presence of dense
fibrous tissue arranged in parallel bundles.
Primary bundles are assembled to form sec-
ondary bundles (representing the tendon’s
functional unit), which are in turn clustered in
tertiary bundles. The endotenon is a thin con-
nective strip surrounding the primary, sec-
ondary and tertiary bundles, and also sepa-
rates them. Small vessels and nerves run
within the endotenon thickness. The epitenon
is a thin band of stronger connective tissue
From a functional and anatomical point of
view, tendons can be divided into two types:
supporting (or anchor) and sliding tendons.
Anchor tendons (such as the Achilles and the
patellar tendon) are typically bigger and
stronger than sliding tendons, they are not
provided with a synovial sheath, but they are
surrounded by a connective lamina external
to the epitenon, called the peritenon. Sliding
tendons are wrapped in a covering sheath
(teno-synovial sheath) whose function is to
guarantee better sliding and protection to the
tendons when they run adjacent to irregular
osseous surfaces, sites of potential friction.
The sites of union between tendon and mus-
cle or tendon and bone are named myotendi-
nous or osteotendinous junctions, respec-
tively. This latter is also called enthesis. The
myotendinous junction is usually well-
defined: at this level the tendon fibers are
interspersed with the endomysial fibers.
Conversely, the enthesis has a more compli-
cated structure, as it can be either fibrous or
fibrocartilaginous according to the tendon
mobility, the angle formed between the ten-
don fibers and the bone, and the presence of
an underlying retinaculum.

E. Silvestri, A. Muda, L. M. Sconfienza, Normal Ultrasound Anatomy of the Musculoskeletal System, 1

© Springer-Verlag Italia 2012
2 1 Basic Principles of Musculosketal Ultrasound
Ultrasonography (US) represents the gold
standard technique for tendon assessment.
With the advent of high resolution transducers
and specific image processing software, eval-
uation of the inner structure of tendons was
made easier. Also, US is the only imaging
modality that allows for a dynamic evaluation
of tendons and joints. When imaged on a lon-
gitudinal view (long axis), the tendon appears
as a hyperechoic ribbon-like structure. The
tendon has an inner fibrillar echotexture that
can be appreciated as a succession of thin
hyperechoic fibrillar bands, slightly wavy,
which tend to grow apart from one another
when the tendon is released and to move clos-
Fig. 1.1 Anatomical drawing of a tendon. I, primary
bundle; II, secondary bundle; III, tertiary bundle; E,
epitenon; e, endotenon
Fig. 1.2 The fibrillar echotexture of a normal
tendon is created by the interfaces between
collagen fibers and endotenon septa (long axis
scan). Arrowheads, tendon
er when the tendon is tense. This fibrillar
echotexture is caused by the specular reflec-
tions within the tendon, determined by the
existing acoustic interface between the
endotenon septa. The tendon is surrounded by
hyperechoic bands that correspond to the
paratenon (Fig. 1.2).
In a transverse view (short axis), the ten-
dons appear as round- or oval-shaped struc-
tures, characterized by several homogeneously-
scattered spotty echoes (Fig. 1.3).
Transverse scans are optimal to measure
tendon thickness, as it can be overestimated
when measured on longitudinal scans.
In clinical practice, ultrasound evaluation
Ligaments
Fig. 1.4 Long axis US scan sonogram of the lateral collateral ligament of the knee showing the fibrillar pattern of lig-
aments, with linear, homogeneous, hyperintense bands. Arrowheads, lateral collateral ligament; F, lateral condyle of
femur; Fi, fibular head; Ti, tibia
of tendons can be affected by anisotropy arti-
facts. When the US beam is not orthogonal to
the course of tendon fibers, both a decrease of
reflected and an increase of the diffracted
echoes occur, thus resulting in a significant or
partial reduction of tendon echotexture.
1.2 Ligaments
Ligaments have a structure that is very sim-
ilar to tendons. However, they are thinner
and contain a higher amount of elastin. This
is a necessary component to supply liga-
ments with higher degrees of elasticity that
is needed to provide high degrees of joint
stability, without compromising the range
of motion. Ligaments can be differentiated
3
Fig. 1.3 Short axis sonogram showing the characteristic
hyperechoic pattern of tendons, with scattered spotty
echoes. M, metacarpal head; white arrowheads, flexor
digitorum superficialis tendon; void arrowheads, flexor
digitorum profundus tendon
into intrinsic and extrinsic ligaments. The
former are rather capsular thickening than
true ligaments and are designed to provide
capsular strengthening; the latter are inde-
pendent from the fibrous capsule and can
be further classified as extracapsular and
intracapsular ligaments.
Ligaments are generally thinner and shorter
than tendons. Also, their inner structure can be less
homogeneous than tendons. US examination of
ligaments, unlike tendons, is mainly performed
on a long axis view, while transverse views (short
axis) have poor diagnostic value. With US, liga-
ments appear as homogeneous bands, 2–3 mm
thick, lying close to the bone (Fig. 1.4). They usu-
ally appear hyperechoic, although echogenicity
may vary according to ligament course.
4 1 Basic Principles of Musculosketal Ultrasound
Fig. 1.5 Peripheral nerves. Schematic
drawing illustrating the inner structure
of a peripheral nerve. NF, nerve fascicle;
E, epineurium; P, perineurium;
e, endoneurium; IE, interfascicular
epineurium
Fig. 1.6 Peripheral nerves. Longitudinal 5–12 MHz US image obtained over the median nerve (white arrows) at the
middle third of the forearm. The nerve is made of parallel linear hypoechoic areas, the fascicles, separated by hyper-
echoic bands, the interfascicular epineurium
1.3 Peripheral Nerves
Peripheral nerves are characterized by a
complex internal structure made of nervous
fibers (containing axons, myelin sheaths,
and Schwann cells) grouped in fascicles, and
loose connective tissue (containing elastic
fibers and vessels) (Fig. 1.5). A closer look
at nerve sheaths demonstrates an external
sheath, the outer epineurium, which sur-
rounds the nerve fascicles. Each fascicle is
invested in turn with a proper connective
sheath, the perineurium, which encloses a
variable number of nerve fibers separated by
the endoneurium. The connective tissue
interspersed between the outer nerve sheath
and the fascicles is commonly referred to as
the inter-fascicular epineurium and houses
the nerve vasculature.
With the current generation of high-frequency
superficial transducers and compound technology,
US has become a well-accepted and widespread
imaging modality for the evaluation of peripheral
nerves. US provides low-cost, quick, and non-in-
vasive imaging. US provides higher spatial reso-
lution over MR imaging and the ability to explore
long segments of nerve trunks in a single study, al-
so allowing the examination of nerves in both
static and dynamic conditions.
On long axis scans, nerves typically
assume an elongated appearance with multiple
hypo/hyperechoic parallel lines, which corre-
spond to the neuronal fascicles running longi-
tudinally (Fig. 1.6).
On short axis planes, high-resolution US
depicts nerves as honeycomb-like structures
composed of hypoechoic rounded areas (the fas-
cicles) embedded in a hyperechoic background
(interfascicular epineurium) (Fig. 1.7).
Cartilage and Bone 5

Fig. 1.7 Nerve echotexture. Transverse US image of the

ulnar nerve at the forearm. The nerve (white arrowhead)
is characterized by a honeycombing appearance made
of round hypoechoic areas in a homogeneous hypere-
choic background

The number of fascicles in a nerve may

tered in a firm gel-like substance (extracellu-
vary depending on the occurrence of nerve
lar matrix) consisting of collagen and proteo-
branching. In nerve bifurcations, the nerve
glycans. Collagen forms a network of fibrils,
trunk divides into two or more secondary
which resists the swelling pressure generated
nerve bundles, whereas each fascicle enters
by the proteoglycans. In the musculoskeletal
only one of the divisional branches without
system, cartilage is classified as either hyaline
splitting. The outer boundaries of nerves are
or fibrous. Compared to hyaline, fibrocarti-
usually undefined due to the similar hypere-
lage contains more collagen and is more
choic appearance of both the superficial
resistant to tensile strength. Fibrocartilage is
epineurium and the surrounding fat.
found in intervertebral disks, symphyses, gle-
Careful scanning technique of nerves based
noid labra, menisci, the round ligament of
on the precise knowledge of their position and
the femur, and at sites connecting tendons
analysis of their anatomical relationships with
or ligaments to bones. Hyaline cartilage is
surrounding structures is essential. Systematic
the most common variety of cartilage. It is
scanning on short axis planes is preferred to
found in costal cartilage, epiphyseal plates,
follow the nerves contiguously throughout the
and covering bones in joints (articular carti-
limbs. Once detected, the nerve is kept in the
lage). The free surfaces of most hyaline car-
center of the US image in its short axis and
tilage (but not articular cartilage) are cov-
then followed proximally and distally shifting
ered by a layer of fibrous connective tissue
the transducer up or down according to its
(perichondrium). Hyaline cartilage is strat-
course. With this technique, called the “lift
ified and divided into four zones: superfi-
technique”, the examiner is able to explore
cial, middle, deep, and calcified, hardly
long segments of a nerve in a few seconds
detectably by US (Fig. 1.8).
throughout the limbs and extremities.
The orientation of collagen fibers varies
through the four zones of articular cartilage
in order to give better tensile strength. The
1.4 Cartilage and Bone
fibrillar framework seems to have an
arcade-like arrangement
Cartilage is a greatly specialized type of con-
nective tissue, mainly composed of water
Hyaline cartilage is easily detectable by
(70–80% by wet weight). It is avascular and
US as a homogeneously hypoanechoic layer
aneural. The solid component of cartilage is
delimited by thin, sharp and hyperechoic mar-
formed of cells (chondrocytes) that are scat-
gins.
6 1 Basic Principles of Musculosketal Ultrasound

Fig. 1.8 Suprapatellar longitudinal scan of the articular cartilage of the lateral femoral condyle obtained with an 8–16
MHz broadband linear transducer. The transverse suprapatellar scan of the knee demonstrates that, in healthy subjects,
the femoral cartilage (arrowheads) typically appears as a clear-cut, wavy hypoanechoic layer, with upper concavity,
which is thicker at the level of the intercondyloid fossa. TF, trochlea femoris

Normal articular cartilage appears as a

well-defined layer with the following distin-
guishing features:
1. high degree of homogeneous transparency
due to its high water content;
2. sharp and continuous synovial space-carti-
lage interface (superficial margin);
3. sharp hyperechoic profile of the bone-car-
tilage interface (deep margin).
The synovial space-cartilage interface is
slightly thinner than the bone-cartilage inter-
face. Both margins are best visualized when
the direction of the US beam is perpendicular
to the cartilage surface.
The marked difference in chemical struc-
ture between articular cartilage and subchon-
dral bone allows easy detection of the deep
margin, whilst the superficial margin requires
careful examination techniques for clear iden-
tification.
Optimization of the visualization of the
cartilage margins is essential for measuring its
thickness.
Cartilage thickness ranges from 0.1 mm on
the articular surface of the head of the proxi-
mal phalanx to 2.6 mm on the lateral femoral
condyle of the knee joint.
Sharp margins and homogeneous echotex-
ture are hallmarks of normal cartilage (Fig. 1.8)
1.5 Muscles
Muscle is made of bundles of contractile
elementary units, the striated muscle fibers,
with their major axis lying along the con-
traction direction.
Muscular fibers are arranged parallel
one to another and they are supported by a
structure of connective tissue. Muscle is
externally surrounded by a thick connective
sheath called the epimysium; from the
internal aspect of this sheath several septa
depart to constitute the perimysium, which
surrounds several bundles of muscular
fibers, named fascicles. Blood vessels and
nerves run within the perimysium, which
also contains the neuromuscular spindles.
Very light and thin septa arising from the
perymysium spread into the fascicles to sur-
round every single muscular fiber and thus
form the endomysium (Fig. 1.9).
The extremity of a muscle may continue
as a tendon or insert onto the periosteum,
aponeurosis, or the dermis. Wherever a
muscle attaches, the insertion is highly
resistant, as tensile forces turn into tangen-
tial forces that are more easily born.
The macroscopic shape of muscles
varies according to their function. Each
Muscles
Fig. 1.9 Longitudinal US scan of a pennate muscle. The
characteristic pennate appearance is given by the conver-
gence of perimysial septa (void arrowheads). White
arrowheads, muscular aponeurosis
Fig. 1.10 Transverse US scan shows the polygonal
arrangement of the muscular fascicles and hyperechoic
perimysial septa
muscle presents at least one muscular belly
and two tendons, one at the origin and the
other at the insertion. Muscles with fibers
parallel to the longitudinal axis (muscles of
the abdomen, head and neck) are made for
7
bearing reasonable weights for long dis-
tance activities. Conversely, the uni-, bi-,
and circum-pennate structures (muscles of
the limbs) can bear greater weights for a
shorter period of time.
The internal structure of muscles can be eas-
ily assessed by US. The epimysium appears as a
hyperechoic external band 2–3 mm thick, contin-
uing without interruption along the correspon-
ding tendon profile on longitudinal US scans.
The perimysium can be appreciated as hyper-
echoic lines separating the contiguous hypoe-
choic muscular fascicles from one another.
The typical pennate structure of muscles can
be easily assessed in longitudinal axis views
where the hyperechoic fibro-adipose septa con-
verge, with a mainly parallel course, on a cen-
tral aponeurosis, appearing as a thin, highly
reflective band (Fig. 1.9).
US evaluation of muscle fiber direction rep-
resents an important parameter to measure the
pennation angle. This angle is measured
between the muscular fibers’ direction and the
central aponeurosis axis (usually corresponding
to the longitudinal muscular axis). The value of
the angle varies depending on the function of
the muscle and, within the same muscle, on the
functional state (contraction/ relaxation).
In transverse views, the muscle is sectioned
according to a plane that is orthogonal to the
muscular longitudinal axis, with a typical US
structure appearance. The 1st and 2nd order fasci-
cles present an irregular polygonal shape,
defined by thin, elongated, hyperechoic septa,
corresponding to the perimysial fibro-adipose
septa (Fig. 1.10).
When studying both muscles and tendons,
the US beam should be as perpendicular as pos-
sible, in order to avoid the appearance of hypoe-
choic artifactual zones that can be misinterpret-
ed by inexperienced operators.
US examination can also take advantage of a
comparison with the contralateral muscle and
with active and passive dynamic maneuvers,
both during contraction and at rest, thus allow-
ing for a functional evaluation of the muscle.
 Shoulder
2

Contents
2.1 Long Head of Biceps Brachii Tendon
2.2 Subscapularis Tendon
2.3 Supraspinatus Tendon and Subacromial-Subdeltoid Bursa
2.4 Coracoacromial Ligament
2.5 Infraspinatus and Teres Minor Tendons
2.6 Acromion-Clavicular Joint

The protocol includes anterior, lateral, and The patient is sitting opposite to the exam-
posterior scans. iner, the forearm is flexed 90° with the arm
resting on the thigh, slightly internally rotat-
ed, palm facing up (Fig. 2.2).
2.1 Long Head of Biceps Brachii
Tendon (LHBBT)

The biceps brachii muscle consists of two

heads, a long and a short one, which merge
distally into a single muscle belly. The long
head arises from the supraglenoid tuberosity
of the scapula and from the glenoid labrum
as a long and cylindrical tendon, which runs
into the joint cavity of the shoulder, between
the humeral head and the joint capsule. Then
it runs in the bicipital groove, surrounded by
an extension of the synovial capsule. The
tendon joins the short head (that arises from
the coracoid) at the median third of the arm.
The distal tendon of the biceps brachii,
Fig. 2.1 Anatomical scheme of the intra- and extra-artic-
divided in two branches, is inserted on the
ular sections of the long head of biceps tendon (*). H,
bicipital tuberosity of radius (Fig. 2.1). humerus; G, scapular glenoid; A, acromion; C, coracoid

E. Silvestri, A. Muda, L. M. Sconfienza, Normal Ultrasound Anatomy of the Musculoskeletal System, 9

© Springer-Verlag Italia 2012
10
2 Shoulder

Holding the transducer in a horizontal

position (Fig. 2.3a), localize the bicipital
groove (between small and large tuberosity of
the humerus). This structure shall be used as a
landmark to assess the long head of biceps
brachii tendon on an axial scan (Fig. 2.3b).
To avoid any anisotropy artifacts, the
transducer must be kept as perpendicular as
possible to tendon surface (Fig. 2.4a-f).

Fig. 2.2 Upper limb position to assess the long head of

biceps tendons

Fig. 2.3b Axial scan of LHBBT (arrowheads). GT, greater

Fig. 2.3a Probe position to evaluate the bicipital groove tuberosity; LT, lesser tuberosity; D, deltoid muscle
Long Head of Biceps Brachii Tendon (LHBBT) 11

a d

b e

c f

Fig. 2.4 Anisotropy artifacts affecting the long head of biceps tendon due to wrong probe positioning. In the wrong po-
sitions (a and c) the “empty bicipital groove” sign can be seen in the corresponding ultrasounds (d and f). This appear-
ance is due to the prevalence of diffracted echos over reflected ones. When the US beam is perfectly perpendicular to
the tendon, there is a prevalence of reflected echoes and the LHBBT tendon can be correctly evaluated (b and e).
12
The probe must then slide caudally to evalu-
ate the vertical part of the LHBBT up to the
myotendinous junction, located under the humer-
al insertion of the pectoralis major tendon (Figs.
2.5a, b). In case of complete rupture of LHBBT,
this area is where the retracted tendon stump can
usually be seen.
2 Shoulder
Then the probe must be rotated 90° clockwise
to evaluate the LHBBT along its long axis (Figs.
2.6a, b). Note that the LHBBT has an oblique
course, from up to down and from anterior to pos-
terior. For such reason, optimal visualization of the
tendon can be obtained by slightly pressing the dis-
tal edge of the probe on the skin (Fig. 2.6c).
Fig. 2.5a Probe position on the humeral insertion of
pectoralis major muscle
Fig. 2.5b The axial scan shows
the humeral insertion aponeuro-
sis of the pectoralis major mus-
cle (arrowheads). H, humerus;
B, biceps brachii
Long Head of Biceps Brachii Tendon (LHBBT) 13

Fig. 2.6a Probe position to evaluate the LHBBT

according to its longitudinal axis

Fig. 2.6b Longitudinal scan of

LHBBT (arrowheads) in bicipital
groove

Fig. 2.6c Anisotropy artifact

affecting the LHBBT on longitudinal
scan, due to the wrong orientation
of the US beam
14 2 Shoulder

2.2 Subscapularis Tendon

The subscapularis muscle arises from the

subscapular fossa; most fibers are directed
upwards and laterally, running under the
coracoid, anterior to the glenohumeral
joint, and insert on the humeral lesser
tuberosity. The coracohumeral ligament
appears like a fibrous lamina, arising from
the coracoid. It is divided into two bundles.
The thicker one inserts on the humeral
greater tuberosity and merges with the joint
capsule, while the thinner is directed later-
ally and merges with the humeral insertion
of the subscapularis tendon (Fig. 2.7).

Keeping the probe on the bicipital groove,

the forearm should be extrarotated to expose
the subscapularis tendon. Note that the elbow
must be as close as possible to the thoracic
wall (Figs. 2.8 and 2.9a).
On the long axis, the subscapularis tendon
should be evaluated sliding the US transducer cau-
dally (Figs. 2.9a, b). Including the coracoid in the
scan also allows evaluation of coracohumeral lig-
ament. The subscapularis must then be evaluated
on the short axis (Fig. 2.10a), turning the probe 90°
Fig. 2.7 Anatomical scheme of subscapularis tendon
(SS). H, humerus; C, coracoid; A, acromion;
*, long head of biceps tendon
clockwise (Fig. 2.10b). This scan shows the com-
plex anatomy of the subscapularis tendon, formed
by an alternation of tendinous and muscular fibers.
This scan is particularly helpful in the case of par-
tial tears to assess the longitudinal extension of the
split.

Fig. 2.8 Position of the upper limb to

evaluate the subscapularis tendon
Subscapularis Tendon 15

Fig. 2.9a Probe position to evaluate

the subscapularis tendon

Fig. 2.9b Longitudinal

scan of the subscapularis
tendon (*). H, humerus;
Co, coracoid;
Arrowheads,
coraco-humeral ligament
16 2 Shoulder

Fig. 2.10a Probe position to evaluate

the subscapularis tendon along its
short axis

Fig. 2.10b The short axis

scan shows the typical
appearance of the subscapu-
laris tendon, formed by an
alternation of tendinous
(arrowheads) and muscular
fibers. H, humerus
Supraspinatus Tendon and Subacromial-Subdeltoid Bursa (SASD) 17

his “back pocket”). Note that the flexed elbow

2.3 Supraspinatus Tendon and should be as medial as possible (Fig. 2.12).
Subacromial-Subdeltoid Bursa
(SASD)
The supraspinatus muscle is located in the
fossa supraspinata of the scapula. It arises
from the medial third of the supraspinata
fossa and from the homonymous fascia
(Fig. 2.11). Its bundles are directed lateral-
ly, run behind the clavicle lateral edge,
behind the acromion and the coracoacromi-
al ligament, inserting on the superior bor-
der of the humeral greater tuberosity.
The subacromial-subdeltoid bursa (SASD)
is a wide mucous bursa that lies over the
supraspinatus tendon. It is formed by a sub-
acromial part (located between the superior
face of the joint capsule and the inferior face
of the acromion) and a deltoid part (located
deep to the deltoid muscle).
Fig. 2.11 Anterior view of the shoulder. The supraspina-
Move patient upper limb from the position tus tendon (*) runs within the subacromial space up to its
insertion on the humeral greater tuberosity. Arrowheads,
used to evaluate the subscapularis tendon so his subacromial-subdeltoid bursa; D, deltoid muscle; H,
hand is on the posterior region of the iliac wing (on humerus; G, glenoid; A, acromion; C, clavicle

Fig. 2.12 Position of the upper limb to evaluate

the supraspinatus tendon
18
Once the tendon is identified, the probe
should be oriented along the long axis of the
tendon (Fig. 2.13a). A correct scan is obtained
when the humeral head cartilage, the anatomi-
cal neck of the humerus and the greater humer-
al tuberosity are seen together (Fig. 2.13b). The
2 Shoulder
tendon is limited anteriorly by the LHBBT.
Anisotropy artifacts could particularly affect
the insertional area of the tendon on the humer-
al neck. To avoid these artifacts, slightly tilt the
probe laterally to have the US beam as perpen-
dicular as possible to tendon fibers.
Fig. 2.13a Probe position to evaluate the supraspinatus
tendon along its longitudinal axis
Fig. 2.13b The scan shows
the supraspinatus tendon
(longitudinal axis); *,
insertional area; arrowheads,
cartilage; arrow, anatomical
humeral neck; empty arrow-
heads, subacromial-subdel-
toid bursa; H, humerus
Supraspinatus Tendon and Subacromial-Subdeltoid Bursa (SASD)
US can only show the portion of the sub-
acromial-subdeltoid bursa located superficial-
ly to the supraspinatus tendon and deep to the
deltoid muscle (Fig. 2.13b), while the portion
located deeply to the acromion cannot be
evaluated. For a complete evaluation of the
19
bursa, anterior, posterior, and lateral scans
should be performed.
After evaluating the supraspinatus tendon
along its longitudinal axis, the probe should
be rotated 90° clockwise (Fig. 2.14a) to
assess the short axis (Fig. 2.14b).
Fig. 2.14a Probe position to evaluate the supraspinatus
tendon along its short axis
Fig. 2.14b *, supraspinatus tendon;
H, humerus; L, LHBBT
20 2 Shoulder

2.4 Coracoacromial Ligament

The coracoacromial ligament is a thin trian-

gular fibrous band, which links the acromion
with the lateral edge of the coracoid, being
part of the bony-fibrous roof above the
glenohumeral joint. Its medial end inserts on
the lateral edge of the coracoid, while its lat-
eral end inserts on the lateral edge of the
acromion (Fig. 2.15). The superficial side of Fig. 2.15 Anatomical scheme of the coraco-acromial lig-
the ligament is covered by the deltoid mus- ament (*). A, acromion; C, coracoid; H, humerus
cle, while the lower is adjacent to the sub-
acromial-subdeltoid bursa and the supraspina-
tus tendon and muscle.

The patient sits opposite the examiner, with

the arm along the body.
Position the probe with the medial edge on
the coracoid and turn the lateral edge medially
and cranially to the acromion (Fig. 2.16a) to see
the coracoacromial ligament (Fig. 2.16b).

Fig. 2.16a Probe position to assess the coracoacromial

ligament on the longitudinal axis. The medial edge of the probe
is located on the coracoid (C) and the lateral edge is rotated up
to the acromion (A)

Fig. 2.16b Longitudinal

scan of the coracoacromial
ligament (arrowheads).
Co, coracoid;
Ac, acromion
Infraspinatus and Teres Minor Tendons
2.5 Infraspinatus and Teres Minor
Tendons
The infraspinatus is a flat, triangular shaped
muscle, arising from the medial part of the
fossa infraspinata and from the infraspinatus
fascia. Its fascicles run laterally and the mus-
cle becomes a tendon that courses under the
acromion, inserting on the posterior facet of
the humeral greater tuberosity (Fig. 2.17).
The teres minor is a long, flat muscle. It aris-
es from the fossa infraspinata and runs up and
laterally, inserting on the posteroinferior face
of the humeral greater tuberosity. Some fibers
also merge with the glenohumeral joint cap-
sule (Fig. 2.18).
The patient sits opposite the examiner,
with their elbow flexed and palm on the oppo-
site shoulder (Fig. 2.19).
The probe should be oriented vertically to
localize the scapular spine, which separates
the fossa supraspinata from the fossa infra-
spinata (Fig. 2.20a). Within the fossa infra-
spinata, infraspinatus and teres minor mus-
Fig. 2.17 Posterior view of the infraspinatus muscle and
tendon (IS). A, acromion; S, spine of the scapula; H,
humerus
21
cles can be seen. The probe should then be
slid laterally to assess both tendons on a short
axis view (Fig. 2.20b).
Turn the probe by 90° and asses each ten-
don along its longitudinal axis (Figs. 2.21a-c,
2.22a-c).
For a better view of insertional region of
the tendon it is useful to have the patient’s
arm slightly externally rotated.
US can also be used to assess the gleno-
humeral joint posterior recess. Slide the probe
medially on the posterior side of the joint and
extrarotate patient’s arm (in the same position
used to evaluate the subscapularis tendon)
(Fig. 2.23).
2.6 Acromion-Clavicular Joint
The acromion-clavicular joint (Fig. 2.24a)
can be assessed by placing the probe on a
coronal-oblique plane on the top of the shoul-
der (Fig. 2.24b). From this position, abduct
the patient’s upper limb flexed to 90 degrees
to evaluate the presence of subacromial
impingement of the supraspinatus tendon.
Fig. 2.18 Posterior view of the teres minor muscle and
tendon (TM). A, acromion; S, spine of the scapula; H,
humerus
22 2 Shoulder

Fig. 2.19 Position of the upper limb to evaluate the

infraspinatus and the teres minor tendons

Fig. 2.20a Probe position to evaluate the infraspinatus

and the teres minor muscles and tendons on a short
axis view

Fig. 2.20b Extensor

tendons myotendi-
nous junctions. IS,
infraspinatus; TM,
teres minor
Infraspinatus and Teres Minor Tendons 23

Fig. 2.21a Probe position to evaluate the

infraspinatus tendon on the long axis

Fig. 2.21b *, infraspinatus

tendon insertional area;
H, humerus

Fig. 2.21c Infraspinatus tendon

course (arrowheads).
*, myotendinous junction;
H, humerus
24 2 Shoulder

Fig. 2.22a Probe position to evaluate the teres

minor on its long axis

Fig. 2.22b Teres minor tendon

insertional area (arrowheads).
H, humerus

Fig. 2.22c Teres minor tendon

course (arrowheads). TM, teres
minor muscle belly; G, glenoid;
L, posterior glenoid labrum; *,
posterior joint recess;
H, humerus
Acromion-Calvicular Joint 25

Fig. 2.23 Glenohumeral joint posterior

recess. H, humerus; G, glenoid; *,
posterior joint recess; arrowheads,
posterior glenoid labrum

Fig. 2.24a Probe position to evaluate the

acromion-clavicular joint

Fig. 2.24b Coronal scan of the acromion-

clavicular joint. Arrowheads, joint capsule;
Ac, acromion; Cl, clavicle
 Elbow
3

Contents
3.1 Anterior Compartment
• Distal Tendon of Biceps Brachii
• Anterior Joint Recess
• Median Nerve
• Radial and Posterior Interosseous Nerves
3.2 Lateral Compartment
• Common Extensor Tendon
• Humeral-Radial Joint
3.3 Medial Compartment
• Common Flexor Tendon
• Medial Collateral Ligament
3.4 Posterior Compartment
• Triceps Brachii Muscle and Tendon
• Olecranon Fossa and Posterior Olecranon Recess
• Cubital Tunnel and Ulnar Nerve

US evaluation of the elbow is divided into
four compartments: anterior, lateral, medial
and posterior.
3.1 Anterior Compartment
Anatomical scheme of the compartment is
presented in Figs. 3.1 and 3.2. The patient sits
opposite the examiner, with the elbow on the
table and the arm extended (Fig. 3.3).
3.1.1 Distal Tendon of Biceps Brachii
To maximally expose the tendon, patient fore-
arm should be as supinated as possible. The
tendon should first be evaluated on its long
axis up to the insertion on the radial tuberosi-
ty (Figs. 3.4a, b). The tendon has a very
oblique course, being deeper distally when it
inserts on the radial tuberosity. For this rea-
son, the distal edge of the probe should be
slightly pressed on the patient’s skin to have
the US beam as perpendicular as possible to
the tendon fibers. The distal biceps tendon is
surrounded by the bicipitoradial bursa, which
is visible only when distended by fluid.

E. Silvestri, A. Muda, L. M. Sconfienza, Normal Ultrasound Anatomy of the Musculoskeletal System, 27

© Springer-Verlag Italia 2012
28
The median nerve arises from the brachial
plexus, runs within the axillary cavity to
the medial region of the anterior compart-
ment of the arm, firstly next to the coraco-
brachialis muscle and then on the medial
side of the biceps brachii muscle. It cross-
es the crease of the elbow and reaches the
Fig. 3.1 Anatomical scheme of the anterior compartment.
1, biceps brachii muscle belly; 2, distal tendon of the
biceps brachii; *, lacertus fibrosus; 3, radial nerve; 3a,
posterior interosseous nerve; 3b, subcutaneous sensory
branch of the radial nerve; 4, median nerve
Fig. 3.3 Position of the elbow to evaluate the anterior compartment
3 Elbow
forearm, where it passes between the ulnar
and the humeral head of the pronator teres
muscle, and distally deeper to the flexor
digitorum superficialis muscle. In the fore-
arm, the nerve runs between the flexor dig-
itorum superficialis and flexor digitorum
profundus muscles.
Fig. 3.2 Anatomical scheme of the biceps brachii distal
tendon (2). 1, biceps brachii muscle; *, lacertus fibrosus;
R, radius; U, ulna; H, humerus
Anterior Compartment 29

Fig. 3.4a Probe position to evaluate biceps brachii along its longitudinal axis

Fig. 3.4b Longitudi-

nal scan of biceps
brachii distal tendon
(arrowheads). R, radi-
al tuberosity
30
3.1.2 Anterior Joint Recess
On longitudinal scans, the coronoid fossa
appears like a concavity containing a fat pad.
Articular cartilage can be seen covering the
underlying bone (Figs. 3.5a and 3.5c).
On axial scans, the distal humeral epiphysis
appears like a curved hyperechoic line, with a
thin hypoechoic line above it, representing the
cartilage. The lateral side of the humerus (capit-
ulum humeri) articulates with the radial head,
while the medial side (trochlea) articulates with
the ulna (Figs. 3.5a, b).
3.1.3 Median Nerve
The median nerve arises from the brachial
plexus, runs within the axillary cavity to the
medial region of the anterior compartment of
the arm, firstly next to the coracobrachialis
muscle and then on the medial side of the
biceps brachii muscle. It crosses the crease of
the elbow and reaches the forearm, where it
passes between the ulnar and the humeral
head of the pronator teres muscle, and distally
deeper to the flexor digitorum superficialis
muscle. In the forearm, the nerve runs
between the flexor digitorum superficialis and
flexor digitorum profundus muscles.
The probe must be placed on a transverse
plane on the anterior face of the elbow.
The median nerve runs in the anterior
compartment of the elbow, medial to the
brachial artery. Medially to the brachial artery,
the biceps brachii tendon can be seen (Figs.
3.6a, b).
3 Elbow
The median nerve must be evaluated along
its whole course, sliding the probe upwards
and downwards. Then the probe must be rotat-
ed by 90° to evaluate it on its longitudinal
axis. Nerve visualization can be improved
slightly by pressing the distal edge of the
probe, due to its curvilinear course.
3.1.4 Radial and Posterior
Interosseous Nerves
The radial nerve arises from the secondary
rear trunk of the brachial plexus, running in
the axillary cavity, and then obliquely along
the humeral artery. It courses within the long
and medial head of the triceps brachii muscle,
then distally through the brachialis and bra-
chioradialis muscles. It then reaches the ante-
rior compartment where it splits into a deep
radial branch (mainly motor) and a superficial
radial branch (mainly sensitive).
The probe must be placed a few inches
proximally of the elbow crease. The radial
nerve must be followed distally in the antero-
lateral direction (Fig. 3.7). Follow the nerve
between the brachioradialis and brachialis
muscle up to its split into the sensitive super-
ficial branch and interosseous posterior nerve
(Figs. 3.8, 3.9a, b). The posterior interosseous
nerve can be seen until it pierces the supinator
muscle and passes through the Fröhse arcade
(Figs. 3.9a and 3.9c). The posterior
interosseous nerve is more easily assessed
with the probe fixed on the supinator muscle
while the patient pronates and supinates the
forearm.
Anterior Compartment 31

Fig. 3.5a Probe position to evaluate the anterior joint recess

Fig. 3.5b Transverse

scan of the anterior
recess. Br, brachialis
muscle; Ch, capitu-
lum humeri;
Tr, trochlea;
*, cartilage

Fig. 3.5c Longitudi-

nal scan of the
anterior recess.
Br, brachialis muscle;
Ch, capitulum
humeri; R, radius
32 3 Elbow

Fig. 3.6a Probe position to evaluate the median nerve along its short axis

Fig. 3.6b Anterior compart-

ment on an axial scan.
Arrowheads outline the median
nerve; T, biceps brachii tendon;
A, brachial artery

Fig. 3.6c Longitudinal scan of

the median nerve (arrowheads)
Anterior Compartment 33

Fig.3.7 Anatomical scheme of the radial nerve

(RN) in longitudinal axis. BB, biceps brachialis
muscle; R, radius; SS, supinator muscle superfi-
cial head; DS, supinator muscle deep head;
U, ulna; *, posterior interosseous nerve; circle,
cutaneous branch of radial nerve; H, humerus

Fig. 3.8 Axial scheme of the

posterior interosseous nerve
(*). Br, brachialis muscle;
R, radius; SS, supinator
muscle superficial head;
DS, supinator muscle
deep head
34 3 Elbow

Fig. 3.9a Probe positions to evaluate the radial and the posterior interosseous nerves

Fig. 3.9b Scan of the radial nerve splitting in-

to the posterior interosseous nerve (empty ar-
rowhead) and sensitive superficial branch
(white arrowhead). R, radius

Fig. 3.9c Scan of the Fröhse arcade.

Arrowhead, posterior interosseous nerve;
S, supinator muscle; R, radius
Lateral Compartment
3.2 Lateral Compartment
The patient must be positioned with the fore-
arm slightly flexed on the arm (Fig. 3.10).
3.2.1 Common Extensor Tendon
This group of tendons must be evaluated on an
axial scan, placing the proximal edge of the
probe on the lateral epicondyle (Figs. 3.11,
3.12a, b). A short axis scan can be used to pre-
cisely locate the site of a possible tear.
The lateral collateral ligament can rarely
be differentiated from the tendon, due its sim-
ilar echotexture and its deep location.
35
3.2.2 Humeral-Radial Joint
Look for the humero-radial synovial meniscus
that fills in the gap of the lateral surface of
humeral-radial joint (Figs. 3.13 and 3.14a).
The patient must be asked to pronate and
supinate the forearm to correctly assess the
radial head and the annular ligament (Fig.
3.14b).
The annular ligament takes part in passive
stabilization of the elbow joint; it arises
from the anterior edge of the radial notch of
ulna, coursing around the radial neck, and
inserts on the posterior edge of the radial
notch.
Fig. 3.10 Position
of the elbow
to evaluate
the lateral
compartment
Fig. 3.11 Anatomical scheme of the common extensor
tendon. ECU, extensor carpi ulnaris; *, extensor digiti
quinti; EDC, extensor digitorum communis;
ECRB, extensor carpi radialis brevis
36 3 Elbow

Fig. 3.12a Probe position to

evaluate the common exten-
sor tendon

Fig. 3.12b Longitudinal

scan of the common exten-
sor tendon (arrowheads).
R, radius; LE, lateral
epicondyle

Fig. 3.13 Anatomical scheme of the humeral-radial joint.

*, annular ligament; CH, capitulum humeri; R, radius;
U, ulna
Lateral Compartment 37

Fig. 3.14a Longitudi-

nal scan of the
humeral-radial joint.
*, humero-radial
synovial meniscus;
R, radius;
Ch, capitulum humeri

Fig. 3.14b Axial scan

of annular ligament
(arrowheads).
R, radius
38 3 Elbow

3.3 Medial Compartment The medial collateral ligament arises

from the lower surface of the medial epi-
The patient must be positioned with the fore- condyle and then divides into three bun-
arm slightly flexed on the arm, externally dles: the anterior one inserts on the ulnar
rotated (Fig. 3.15). coronoid process; the middle one inserts on
the semilunar notch; and the posterior one
inserts on the olecranon.
3.3.1 Common Flexor Tendon

To assess the common flexor tendon (Fig.

3.16) on a longitudinal scan, the proximal
edge of the probe must be placed on the medi-
al epicondyle (epitrochlea) (Figs. 3.17a, b).
Note that this tendon is shorter and wider than
the common extensor tendon.

3.3.2 Medial Collateral Ligament

The anterior bundle of the medial collateral

ligament can be seen more deeply than the
common flexor tendon (Fig. 3.18).
This ligament can be more effectively
detected with the patient lying in a supine
position, with the arm abducted and external-
ly rotated, and the elbow flexed at 90° (Figs
3.19a, b).
Medial collateral ligament laxity can be
effectively detected with dynamic scans per- Fig. 3.16 Anatomical scheme of the common flexor ten-
don. PT, pronator teres; FCR, flexor carpi radialis; *, fle-
formed while applying a valgus stress (Fig. xor digitorum superficialis; circle, palmaris longus;
3.20). FCU, flexor carpi ulnaris; ME, medial epicondyle

Fig. 3.15 Position of the elbow to evaluate the medial compartment

Medial Compartment 39

Fig. 3.17a Probe

position to evalu-
ate the common
flexor tendon

Fig. 3.17b Longitudinal

scan of the common flexor
tendon (arrowheads).
U, ulna; *, humeral-ulnar
joint; ME, medial
epicondyle

Fig. 3.18 Anatomical scheme of the medial collateral

ligament (*). R, radius; U, ulna; H, humerus
40 3 Elbow

Fig. 3.19a Position of the elbow and probe to evaluate the medial collateral ligament

Fig. 3.19b Longitudinal scan of the anterior bundle of the medial collateral ligament (arrowheads). ME, medial epi-
condyle; U, ulna

Fig. 3.20 Valgus stress maneuver

Posterior Compartment
3.4 Posterior Compartment
Except for the ulnar nerve, the anatomy of the
posterior compartment can be evaluated with
the elbow flexed 90° and the palm placed on a
table (Fig. 3.21).
Fig. 3.21 Elbow position to evaluate the posterior com-
partment
3.4.2 Olecranon Fossa and Posterior
Olecranon Recess
Deeper than the triceps brachii tendon, the ole-
cranon fossa and the posterior olecranon
recess can be seen. Dynamic scans are needed to
detect the presence of intrarticular effusion.
3.4.3 Cubital Tunnel and Ulnar Nerve
The upper limb must be extended and inter-
nally rotated (Fig. 3.24).
The ulnar nerve is located within the
cubital tunnel, between the medial epicondyle
and the olecranon (Fig. 3.25) and cubital tun-
nel (Fig. 3.26).
41
3.4.1 Triceps Brachii Muscle
and Tendon
The triceps brachii muscle and tendon (Fig.
3.22) must be evaluated on both the long
(Figs. 3.23a, b) and short axis. The distal ten-
don can be affected by anisotropy.
Fig. 3.22 Anatomical scheme of the triceps brachii
muscle and tendon (*). O, olecranon; LE, lateral epi-
condyle; R, radius
Ulnar nerve stability can be assessed by
forced hyperflexion of the forearm on the arm
(Fig. 3.27).
The ulnar nerve courses in the axillary
cavity from the secondary trunk of the
brachial plexus. It is directed to the anteri-
or compartment of the arm, running along
the humeral artery and the median nerve.
Then it pierces the medial intermuscular
septum and reaches the posterior compart-
ment of the arm. In the elbow, it runs medi-
ally to the triceps brachii until the epi-
condyle-olecranon tunnel. Distally, it
enters the cubital tunnel.
42 3 Elbow

Fig. 3.23a Probe position to evaluate the triceps

brachii tendon along the longitudinal axis

Fig. 3.23b Longi-

tudinal scan of tri-
ceps brachii tendon
(arrowheads).
O, olecranon

Fig. 3.24 Probe posi-

tion to evaluate the ul-
nar nerve
Posterior Compartment 43

Fig. 3.25 Transverse scan of the

epicondyle-olecranon tunnel.
Ulnar nerve (arrowheads); ME,
medial epicondyle; O, olecra-
non

Fig. 3.26 Transverse scan of the cubital tunnel. White arrowheads, ulnar nerve; 1, humeral head of the flexor carpi ul-
naris muscle; 2, ulnar head of the flexor carpi ulnaris muscle; void arrowhead, Osborne retinaculum; U, ulna; H, humerus

Fig. 3.27 Dynamic evaluation to assess

ulnar nerve stability
 Wrist
4

Contents
4.1 Palmar Side
• Carpal Tunnel and Median Nerve
• Guyon Tunnel and Ulnar Nerve
4.2 Dorsal Side
• Extensor Tendon Compartments
• Distal Radio-Ulnar Joint

Wrist evaluation can be started either on the
palmar or the dorsal side. The patient must be
sitting in front of the examiner, with the upper
limb lying on the table.
4.1 Palmar Side
Anatomical scheme of the palmar side of the
wrist is presented in Figs. 4.1a, b. For evaluation
of the palmar compartment, the hand lies on the
table with the palm facing up (Fig. 4.2).
4.1.1 Carpal Tunnel and Median
Nerve
The probe must be placed at the base of the
hand and the bony landmarks of the proximal
carpal tunnel must be looked for (the
scaphoid tubercle on the radial side and the
pisiform on the ulnar side). The probe must be
tilted correctly to obtain the right insonation
of the underlying tendons and nerves (Figs.
4.3a, b).
At this level, the proximal flexor retinaculum
and the flexor digitorum tendons can be seen.
Dynamic scans during finger flexion and
extension can help to detect tendons abnormal-
ities (e.g., muscular lesions or tenosynovitis).
On the radial side of the carpal tunnel, the
flexor carpi radialis tendon can be seen.
Severe anisotropy artifacts can be encoun-
tered at this level (Figs. 4.4a-d).
Then, the probe must be moved distally to
evaluate the distal section of the carpal tun-
nel (the tubercle of the trapezium on the radi-
al side and the hook of the hamate on the ulnar
side) (Fig. 4.5a, b).
Note that the median nerve must be
assessed along its whole course, since com-
pression can occur at both the proximal and
distal retinaculum.
A common anatomical variant of the medi-
an nerve is a bifid median nerve, sometimes
accompanied with the persistence of the medi-
an artery. This is normal and must not be con-
fused with a pathologic condition. Conversely,
the median nerve can be compressed by both
the proximal and distal retinaculum, thus
causing the occurrence of the carpal tunnel
syndrome.
A short axis scan allows for evaluation of
shape changes and mobility alteration while
the patient flexes and extends his fingers.
A long axis scan allows for a panoramic
evaluation of the nerve before, within, and
after the carpal tunnel (Fig. 4.6).

E. Silvestri, A. Muda, L. M. Sconfienza, Normal Ultrasound Anatomy of the Musculoskeletal System, 45

© Springer-Verlag Italia 2012
46 4 Wrist

Fig. 4.1a Scheme of the proximal carpal tunnel. FCR, flexor carpi radialis tendon; FCU, flexor carpi ulnaris tendon;
m, median nerve; a, ulnar artery; u, ulnar nerve; FPL, flexor pollicis longus tendon; circles, flexor digitorum superfi-
cialis tendons ; *, flexor digitorum profundus tendons; arrowheads, retinaculum; ST, scaphoid tubercle; Pi, pisiform;
L, lunate; T, triquetral bone

Fig. 4.1b Scheme of the distal carpal tunnel. FCR, flexor carpi radialis tendon; m, median nerve; a, ulnar artery; s,
superficial sensitive branch of the ulnar nerve; d, deep motor branch of the ulnar nerve; FPL, flexor pollicis longus
tendon; circles, flexor digitorum superficialis tendons; *, flexor digitorum profundus tendons; arrowheads, retinacu-
lum; T, tubercle of trapezium; t, trapezoid; C, capitate; H, hook of the hamate
Palmar Side 47

Fig. 4.2 Position of the wrist to

evaluate the ventral compart-
ment

Fig. 4.3a Probe position to eval-

uate the proximal section of the
carpal tunnel

Fig. 4.3b Axial scan of the proximal section of carpal tunnel. Sc, scaphoid; Pi, pisiform; L, lunate. The arrow shows
the median nerve between flexor retinaculum (arrowheads) and flexor digitorum superficialis (circles) and profundus
(*) tendons. Note the “arched” appearance of the retinaculum and at the oval shape of the median nerve. FCR, flexor
carpi radialis tendon; ua, ulnar artery; UN, ulnar nerve; FPL, flexor pollicis longus tendon; FCU, flexor carpi ulnaris
tendon
48 4 Wrist

Fig. 4.4 This image series shows that a wrong

tilting of the probe (in a) can change the
echotexture of the relevant tendons and nerves
due to severe anisotropy artifacts (in b).
c and d show the correct probe position
and US image, respectively

d
Palmar Side 49

Fig. 4.5a Probe position to eval-

uate the distal part of the carpal
tunnel

Fig. 4.5b Axial scan of the

distal carpal tunnel.
Arrow, median nerve;
H, hamate; T, trapezium.
The distal part of the tunnel
is smaller than the proximal
part, the flexor retinaculum
(arrowheads) is more flat
and the median nerve has a
smaller antero-posterior di-
ameter. a, ulnar artery;
FPL, flexor pollicis longus
tendon; circles, flexor digi-
torum superficialis tendons;
*, flexor digitorum
profundus tendons

Fig. 4.6 Longitudinal scan of the carpal tunnel shows the median nerve (*) over the flexor tendons (tt). Ca, capitate;
L, lunate
50 4 Wrist

4.1.2 Guyon Tunnel and Ulnar Nerve
On the ulnar side of the carpal tunnel, the ulnar
artery can easily be detected (Figs. 4.7a, b).
The ulnar nerve courses along the artery with-
in the fibro-fibrous Guyon tunnel. Distally,
the ulnar nerve splits into a superficial sensi-
tive and deep motory branch (the latter run-
ning along the hook of the hamate).

Fig. 4.7a Probe position to eval-

uate the Guyon tunnel

Fig. 4.7b Axial scan of ulnar nerve (arrowheads) between ulnar artery (Doppler signal in red) and pisiform (Pi)
Dorsal Side
4.2 Dorsal Side
4.2.1 Extensor Tendon Compartments
To maintain an anatomical order, the dorsal
extensor compartments are described below
from the radial to ulnar side, from the first to
sixth compartment (Fig. 4.8). However, note
that inexperienced operators should begin the
US evaluation of the dorsal aspect of the wrist
from a small bony landmark of the distal
radius (the Lister’s tubercle) that separates the
second and the third compartment. This is par-
ticularly true when common anatomical vari-
ants that change the number of tendons con-
tained in each compartment are encountered
(see below).
Palm must be placed on the table, in a neu-
tral position (Fig. 4.9), except for the evalua-
tion of the I and the VI compartments (see
below). A small pillow can be placed under
the wrist to improve the visibility of extensor
tendons (Fig. 4.10).
The probe must be placed on a transverse
plane on the dorsal side of wrist to detect the
six extensor tendon compartments on the short
axis. Compartments are numbered from I to
VI beginning from the radial side.
Each tendon must be scanned on the short
axis, followed up to its distal insertion and
also scanned during dynamic maneuvers (fin-
ger flexion and extension).
4.2.1.1 First Compartment
The first compartment contains the abductor
pollicis longus (radial) and extensor pollicis
brevis (ulnar) tendons (Fig. 4.11).
The position of tendons contained in the
first compartment can be easily detected by
51
visual inspection, as they form the radial edge
of the anatomical snuff box (Fig. 4.12a). The
wrist must be kept in an intermediate position
between pronation and supination and the
probe must be placed on the lateral side of
radial styloid (Fig. 4.12b). The retinaculum
contains the two tendons (Fig. 4.12c). Follow
the abductor pollicis longus up to its inser-
tion onto the scaphoid and check if there is an
accessory tendon.
Sometimes the tendon sheath is split into
two parts by a fibrous hyperechoic septum
that separates the two tendons. This septum
can be seen when evaluating the compartment
on the short axis.
The detection of accessory tendons and of
the fibrous septum is important as they can
favor the occurrence of tenosynovitis.
The abductor pollicis longus is the most lat-
eral of the deep muscles in the posterior com-
partment of the forearm. It arises from the
dorsal side of ulna, distally to the supinator
crest, from the interosseous membrane and
from the dorsal side of the radius. Its distal
tendon crosses the second extensor tendon
compartment and takes insertion on the first
metacarpal bone. Some fibers also insert onto
the trapezium and others join the extensor pol-
licis brevis tendon.
The extensor pollicis brevis is a deep mus-
cle of the posterior compartment of the
forearm. At this level, it is medial to the
abductor pollicis longus muscle. It arises
from the ulna, the interosseous membrane,
and the dorsal side of the radius. Its distal
tendon crosses the second extensor tendon
compartment and inserts on the proximal
phalanx of the thumb.
52 4 Wrist

Fig. 4.8 Panoramic anatomical scheme of the extensor tendon compartments. APL, abductor pollics longus tendon;
EPB, extensor pollicis brevis tendon; ECRL, extensor carpi radialis longus tendon; ECRB, extensor carpi radialis bre-
vis tendon; EPL, extensor pollicis longus tendon; EIP, extensor indicis proprius tendon; EDC, extensor digitorum
communis tendon; EDQ, extensor digiti quinti tendon; ECU, extensor carpi ulnaris tendon; R, radis; U, ulna

Fig. 4.9 Wrist position to

evaluate the dorsal side

Fig. 4.10 Position of the wrist on a small

pillow to improve the visibility of the
extensor tendons
Dorsal Side 53

Fig. 4.12a Anatomical

snuff box (*). Radial side:
abductor pollicis longus
and extensor pollicis bre-
vis (arrowheads); ulnar
side: extensor pollicis
longus (arrows)

Fig. 4.11 Anatomical scheme of the first extensor

compartment; APL, abductor pollicis longus tendon;
EPB, extensor pollicis brevis tendon; R, radius

Fig. 4.12b Probe position

to evaluate the first exten-
sor compartment

Fig. 4.12c Axial scan of

the first compartment:
APL, abductor pollicis
longus tendon; EPB,
extensor pollicis brevis
tendon; V, cephalic vein;
R, radius. Note that the
location of the cephalic
vein can be extremely
variable
54 4 Wrist

4.2.1.2 Second Compartment

The second compartment (Fig. 4.13) contains
the extensor carpi radialis longus (radial)
and the extensor carpi radialis brevis (ulnar)
tendons.
The wrist must be set with the palm placed
on the table. The probe must be aligned on an
axial plane on the radial side (Figs. 4.14a, b).
Move the probe cranially up to the
myotendinous junction, where tendons of the
first compartment cross over the tendons of
the second compartment (Fig. 4.15). This
intersection is critical, especially in subjects
that perform repetitive movements of the hand
(e.g., oarsmen), who develop the so-called
“intersection syndrome”. The presence of a
small bursa can also be detected. This patho-
logic condition can be confused with the more
common De Quervain tenosynovitis that typi-
cally affects the first compartment.
The extensor carpi radialis longus muscle
arises from the anterior aspect of the later-
al side of the humerus, the lateral epi-
condyle, and the lateral intermuscular sep-
tum. The muscle is very small and immedi-
ately becomes a tendon that runs on the lat-
eral side of the radius, reaching the second
extensor tendon compartment, finally
inserting on the dorsal aspect of the second
metacarpal bone.
The extensor carpi radialis brevis muscle
arises from the anterior aspect of the later-
al epicondyle, the antebrachial fascia, the
radial collateral ligament, and the intermus-
cular septum. The muscle is very small and
immediately becomes a tendon that runs on
the lateral aspect of the radius along with
the extensor carpi radialis longus tendon.
Distally, it inserts on the dorsal aspect of
the third metacarpal bone.

Fig. 4.13 Anatomical scheme of the second extensor

compartment: ECRL, extensor carpi radialis longus
tendon; ECRB, extensor carpi radialis brevis tendon
Dorsal Side 55

Fig. 4.14a Probe position to evaluate the second exten-

sor compartment

Fig. 4.14b Axial scan of the second compartment. ECRB, extensor carpi radialis brevis tendon; ECRL, extensor carpi
radialis longus tendon; EPL, extensor pollicis longus tendon; L, Lister’s tubercle

Fig. 4.15 Axial scans at the distal third of the forearm show the intersection between the first (I) and second (II) exten-
sor tendon compartment
56 4 Wrist

Moving the probe distally, the extensor

4.2.1.3 Third Compartment
The third compartment (Fig. 4.16) contains
the extensor pollicis longus tendon.
The Lister’s tubercle separates the second from
the third compartment (Figs. 4.17a, b).
pollicis longus tendon crosses the tendons of
the second compartment to reach its distal
insertion (Fig. 4.18). This crossing point can
represent another site of friction that can be
rarely encountered in clinical practice.

Fig. 4.16 Anatomical scheme of the third extensor tendon compartment; EPL, extensor
pollicis longus tendon; R, radius
Dorsal Side 57

Fig. 4.17a Probe position to evaluate the third

extensor compartment

Fig. 4.17b Axial scan of the third compartment. EPL, extensor pollicis longus tendon; ECRB, extensor carpi radialis
brevis tendon; ECRL, extensor carpi radialis longus tendon; L, Lister’s tubercle

Fig. 4.18 Axial scans at the distal third of the forearm show intersection between the third (arrowheads) and second
(II) extensor tendon compartment; LT, Lister’s tubercle
58 4 Wrist

4.2.1.4 Fourth and Fifth Compartments

continue with one tendon each. The fourth ex-
The fourth compartment (Fig. 4.19) contains
tensor compartment also contains a part of the
the extensor indici tendon (radial) and the
myotendinous junctions of these tendons. They
extensor digitorum tendons (ulnar).
insert on the dorsal aspect of the proximal
The fifth compartment (Fig. 4.19) contains
phalanx of the I, II, III, and IV finger where
the extensor digiti minimi (or extensor digiti
each splits into three branches: the lateral and
quinti).
the medial insert on the distal phalanx of each
The probe must be moved slightly towards
finger, while the median branch inserts on the
the ulnar side of the wrist (Fig. 4.20a). The
intermediate phalanx.
extensor indici tendon is the most radial within
the fourth compartment. Dynamic scans are
The extensor indici muscle arises from the
useful to differentiate it from the extensor dig-
posterior aspect of the ulna and interosseous
itorum tendons.
membrane. Its distal tendon enters the fourth
In order to differentiate the two tendons of
extensor compartment, then joins the extensor
the fourth compartment (Fig. 4.20b) and the
digitorum tendon of the second ray over the
extensor of the little finger tendon (Fig. 4.20c),
corresponding metacarpophalangeal joint.
make dynamic scans while patient flexes and
extends fingers.
The extensor digiti minimi is a superficial
The extensor of the little finger tendon runs
muscle lying in the posterior compartment of
in a space between the radium and ulna and
the forearm, medial to the extensor digitorum
does not have a bony plane below it.
muscle. It arises together with the extensor
digitorum from the posterior aspect of the
The extensor digitorum is a superficial mus-
lateral epicondyle and the antebrachial fas-
cle lying in the posterior-lateral compartment
cia. It enters the fifth extensor compartment,
of the forearm. It arises from the posterior
then joins the extensor digitorum tendon of
side of the lateral epicondyle, the radial collat-
the fifth ray over the corresponding metacar-
eral ligament, the annular ligament and the
pophalangeal joint. Note that the floor of the
antebrachial fascia. At the middle third of the
fifth compartment is made by a fibrous band
forearm, it splits into three bundles: the later-
and the tendon does not lie on the bone, like
al separates into two tendons, while the others
the other five compartments.

Fig. 4.19 Anatomical scheme of the

fourth and fifth extensor compart-
ments. EIP, extensor indici pro-
prius tendon; EDC, extensor digito-
rum communis tendon; R, radius;
U, ulna
Dorsal Side 59

Fig. 4.20a Probe position to evaluate the fourth

and fifth compartments

Fig. 4.20b Axial scan on the dorsal wrist. Arrowheads, extensor digitorum tendons; *, extensor indici proprius ten-
don; R, radius; EPL, extensor pollicis longus (third compartment); LT, Lister’s tubercle; ECRB, extensor carpi radi-
alis brevis; ECRL, extensor carpi radialis longus

Fig. 4.20c Axial scan of the fifth compartment. U, ulna; void arrowhead, extensor of the little finger tendon; R, radi-
um; IV, tendons of fourth compartment
60 4 Wrist

4.2.1.5 Sixth Compartment

The triangular fibrocartilage complex is
The sixth compartment (Fig. 4.21) contains
located in the ulnar-carpal space and con-
the extensor carpi ulnaris tendon.
curs to wrist stability on the ulnar side, also
The probe must be moved slightly towards
acting as a shock absorber for axial loads.
the ulnar side and the wrist must be slightly
The complex includes the triangular fibro-
bent on the radial side (Figs. 4.22a, b).
cartilage itself, the homologous meniscus,
Moving the probe on a coronal plane, the
the ulnar collateral ligament, the dorsal and
triangular fibrocartilage complex can be seen
ventral radio-ulnar ligaments and the exten-
between the ulnar styloid process and the tri-
sor carpi ulnaris deep sheath.
quetrum (Fig. 4.23).

The extensor carpi ulnaris is a superficial

4.2.2 Distal Radio-Ulnar Joint
muscle lying in the posterior compartment of
the forearm, arising medially to the extensor
The probe must be moved proximally over the
digiti minimi muscle, with branches also
distal aspect of the radius and ulna (Figs. 4.24,
inserting on the posterior aspect of the ulna.
4.25a, b).
Its bundles are directed medially and its distal
tendon enters the sixth compartment, then
inserts on the fifth metacarpal bone.

Fig. 4.21 Anatomical scheme of the sixth

extensor tendon compartment. ECU,
extensor carpi ulnaris tendon; U, ulna
Dorsal Side 61

Fig. 4.22a Probe position to evaluate the sixth extensor com-

partment

Fig. 4.22b Axial scan of the sixth compartment. Arrowheads indicate the extensor carpi ulnaris
tendon on the short axis; U, ulna

Fig. 4.23 TFC, triangular fibrocartilage; ECU, extensor carpi ulnaris (long axis);
U, ulnar styloid process; P, pyramidal
62 4 Wrist

Fig. 4.24 Anatomical

scheme of distal radio-
ulnar joint. R, distal
radial epiphysis; U,
distal ulnar epiphysis;
*, joint space and
articular recesses

Fig. 4.25a Probe position to evaluate the distal radio-

ulnar joint

Fig. 4.25b Axial scan of

the distal radio-ulnar joint.
R, radius; U, ulna; *, joint
space
 Hand
5

Contents
5.1 Ventral Side
• Palmar Aponeurosis
• Flexor Digitorum Tendons
• Metacarpophalangeal and Interphalangeal Joints
5.2 Dorsal Side

The exam can be commenced either from the
dorsal or the palmar side of the hand.
5.1 Ventral Side
The hand lies on the table with the ventral side
facing up (Fig. 5.1).
5.1.1 Palmar Aponeurosis
The palmar aponeurosis is barely detectable
on US when normal. However, this anatomical
structure is important, as it can be thickened
in a number of common pathologic condi-
tions.

Fig. 5.1 Hand position to evaluate the palmar side

of the hand

E. Silvestri, A. Muda, L. M. Sconfienza, Normal Ultrasound Anatomy of the Musculoskeletal System, 63

© Springer-Verlag Italia 2012
64
The palmar aponeurosis covers muscles
and tendons of the palm and consists of
central, lateral, and medial bundles. The
central bundle has a triangular shape, with
the apex located over the transverse carpal
ligament, and is the strongest and the thick-
est of the palmar aponeurosis bundles. Its
base divides into four slips, one for each
finger, with expansions for proximal pha-
lanx bones, flexor tendon sheaths, and skin.
The lateral and medial bundles of the pal-
mar aponeurosis are thin, fibrous layers,
which cover the thumb and little finger
muscles, on the radial and the ulnar side,
respectively.
5.1.2 Flexor Digitorum Tendons
Evaluation of flexor tendons should be com-
menced at the carpal tunnel level (see above).
The changing relationship between superficial
and deep flexor tendons (Figs. 5.2a, b) can be
appreciated moving the transducer distally
with axial scans (Figs. 5.3a, b).
5 Hand
Longitudinal scans are useful for passive
dynamic evaluation.
Reflection pulleys can be seen on both
axial and longitudinal scans (Figs 5.4a, b).
The flexor digitorum profundus tendon
originates from the anterior and medial
aspects of the ulna. The flexor digitorum
superficialis has two heads, the humero-
ulnar and the radial. Both muscles originate
from long tendons that enter the carpal tun-
nel and then insert on the fingers. In partic-
ular, deep tendons run straight up to the dis-
tal phalanges, where they insert on the
bases. Conversely, superficial tendons run
up to the middle of the proximal phalanges,
where they split into two branches that sur-
round the deep tendons and insert on the
head of the middle phalanges. The superfi-
cial and deep tendons have common tendon
sheaths. Note that the flexor digitorum
superficialis tendon of the little finger can
frequently be absent.
Ventral Side 65

Fig. 5.2a Anatomical scheme of flexor digitorum tendons. *, flexor digitorum profundus tendon; circles, flexor digi-
torum superficialis tendons; M, metacarpal bone; P1, P2, P3, proximal, middle and distal phalanges, respectively

Fig. 5.2b Anatomical scheme of axial section over the metacarpal heads. M, metacarpal bones; FDS, flexor digito-
rum superficialis tendon; FDP, flexor digitorum profundis tendon; L, lumbrical muscles; IO, interosseous muscles;
N, common digital nerve; A, common digital artery
66 5 Hand

Fig. 5.3a Probe position to evaluate the flexor digitorum

tendons on the short axis

Fig. 5.3b US axial scan of the hand palm. FDS, flexor digitorum superficialis tendon; FDP, flexor digitorum profun-
dus tendon; M, metacarpal bone; L, lumbrical muscle; white arrowheads, common digital nerve; void arrowheads,
common digital arteries (Doppler signal in red); *, interosseous muscles
Ventral Side 67

Fig. 5.4a Probe position to evaluate the flexor digitorum

tendons on the long axis

Fig. 5.4b US longitudinal scan of the third flexor digitorum tendon. FDS, flexor digitorum superficialis tendon;
FDP, flexor digitorum profundus tendon; M, metacarpal bone
68 5 Hand

5.1.3 Metacarpophalangeal and be seen by placing the probe on a longitudinal

Interphalangeal Joints
The metacarpophalangeal and interphalangeal
joints must be assessed using longitudinal scans
(Figs. 5.5a, b, 5.6a, b). Collateral ligaments can
plane on both the radial and ulnar side of the
joints (Figs. 5.7a, b). The most common liga-
ment injury affects the ulnar collateral ligament
of the thumb. Note that small avulsion frag-
ments can easily be detected using US.

Fig. 5.5a Probe position to evaluate the metacarpopha-

langeal joints on the long axis

Fig. 5.5b Longitudinal scan of the metacarpophalangeal joint, palmar side. M, metacarpal head; P1, proximal pha-
lanx; T, flexor tendons; *, palmar plate; circle, proximal synovial recess; arrowheads, A1 pulley
Ventral Side 69

Fig. 5.6a Probe position to evaluate the

interphalangeal joint on the long axis

Fig. 5.6b Proximal interphalangeal joint longitudinal scan, palmar side. P1, proximal phalanx; P2, middle phalanx;
T, flexor tendons; *, palmar plate

Fig. 5.6c Distal interphalangeal joint longitudinal scan, palmar side. P2, middle phalanx; P3, distal phalanx; T, flex-
or digitorum profundus tendon
70 5 Hand

Fig. 5.7a Probe position to evaluate the ulnar collat-

eral ligament of the thumb

Fig. 5.7b Ulnar collateral ligament of the thumb. M, metacarpal head; P1, proximal phalanx; arrowheads, ulnar col-
lateral ligament of the thumb
Dorsal Side
5.2 Dorsal Side
Dorsal compartment can be assessed with the
hand lying on the table, with the palm facing
down (Fig. 5.8). Anatomical scheme of dorsal
compartment of fingers is shown in Fig. 5.9.
71
5.2.1 Extensor Digitorum Tendons
Extensor digitorum tendons can be assessed
using axial scans, moving the transducer from
the carpus distally to the fingertips. Tendons
become very thin distally, then transform into
lamina extensoria (Figs. 5.10a-c, Figs. 5.11a-c).
Fig. 5.8 Probe position to evaluate the dorsal compart-
ment of the hand
Fig. 5.9 Anatomical
scheme of the dorsal com-
partment of the hand. Void
arrowheads, extensor digi-
torum communis tendon;
white arrowheads, extensor
digitorum superficialis ten-
don; *, extensor digitorum
rpofundus tendon; M,
metacarpal bone;
P1, proximal phalanx;
P2, middle phalanx
72 5 Hand

Fig. 5.10a Probe position to evaluate the metacarpopha-

langeal joint and extensor digitorum tendon

Fig. 5.10b Metacarpophalangeal joint longitudinal scan, dorsal side. M, metacarpal head; P1, proximal phalanx;
arrowheads, extensor tendon

Fig. 5.10c Longitudinal scan, dorsal side. Arrowheads indicate the course of the extensor tendon. P2, middle phalanx
Dorsal Side 73

Fig. 5.11a Probe position to evaluate the proximal

and distal interphalangeal joints

Fig. 5.11b Proximal interphalangeal joint longitudinal scan, dorsal side. P1, proximal phalanx; P2, middle phalanx;
arrowheads, extensor tendon

Fig. 5.11c Distal interphalangeal joint longitudinal scan, dorsal side. P2, middle phalanx; P3, distal phalanx; arrow-
heads, estensor digitorum profundus tendon
 Hip
6

Contents
6.1 Anterior Hip
• Sartorius and Tensor Fasciae Latae Muscles
• Rectus Femoris Muscle
• Iliopsoas Muscle
• Femoral Neurovascular Bundle
• Coxo-Femoral Joint
6.2 Medial Hip
6.3 Lateral Hip
6.4 Posterior Hip
• Ischiocrural Tendons (Hamstrings)
• Sciatic Nerve

The hip is divided into four compartments:

anterior, medial, lateral and posterior.

6.1 Anterior Hip

The patient lies supine, with the lower limb in

a neutral position (Fig. 6.1).

Fig. 6.1 Lower limb position to evaluate the anterior hip

E. Silvestri, A. Muda, L. M. Sconfienza, Normal Ultrasound Anatomy of the Musculoskeletal System, 75

© Springer-Verlag Italia 2012
76
6.1.1 Sartorius and Tensor Fasciae
Latae
With the patient supine, find the anterior-supe-
rior iliac spine (ASIS) with palpation and place
the probe on it in an axial position (Fig. 6.2a).
See the typical “pseudo-thyroid” aspect (Fig.
6.2b) with the hyperechoic ASIS at the centre,
next to the short tendinous insertions of the sar-
torius (medial) and the tensor fasciae latae
(lateral) muscles. The tensor fasciae latae muscle
courses distally on the lateral side of the thigh,
whereas the sartorius muscle can be seen with
medial orientation, superficially to the rectus
femoris muscle (Fig. 6.2c). Examine the muscle
bellies using both axial and longitudinal scans.
6.1.2 Rectus Femoris
Starting from the position previously described
at ASIS level shift the transducer caudally to
reach the anterior-inferior iliac spine (AIIS)
(Fig. 6.3a). There, the direct tendon of the rec-
tus femoris muscle inserts on the lateral side,
deeper than the iliopsoas muscle (Fig. 6.3b).
6 Hip
From this position, translate the transducer
caudally to reach the muscle belly of the rectus
femoris (Fig. 6.3c).
Rotate the transducer by 90° to evaluate, by
longitudinal scans, the myotendinous junctions
of the rectus up to the insertion onto the AIIS
(Figs. 6.4a, b).
Evaluate the direct and indirect tendon of
the rectus femoris (Fig. 6.5), using longitudinal
(Figs. 6.6a, b) and axial scans (Figs. 6.7a-d).
The rectus femoris muscle is characterized
by a complex organization of proximal
insertions, consisting of a direct tendon
inserting on the AIIS and an indirect ten-
don running distally as an aponeurosis into
the muscle belly. Proximally it runs under
the direct tendon then proceeds more exter-
nally, with an oblique trend compared to the
overhanging direct tendon that inserts into
the acetabular tubercle. The third small ten-
don anchors the insertional complex of rec-
tus reflecting distally in the proximity of the
greater tuberosity (reflected tendon).
Anterior Hip 77

Fig. 6.2a Probe position to evaluate the sartorius Fig. 6.2b US scan shows the tendinous insertions of sarto-
and tensor fasciae latae insertions rius (Sa) and tensor fasciae latae (TFL) muscles on the
anterior-superior iliac spine (ASIS)

Fig. 6.2c Anatomical scheme: proximal insertion of sarto-

rius (Sa) and tensor fasciae latae (TFL) and respective mu-
scle bellies anterior-superior iliac spine (ASIS)
78 6 Hip

Fig. 6.3a Probe position to evaluate the rectus Fig. 6.3c Anatomical scheme: proximal insertion of rec-
femoris proximal insertion tus femoris (RF) and its connections with psoas muscle
(Ps). AIIS, anterior-inferior iliac spine; F, femur

Fig. 6.3b The axial scan shows the tendinous insertion of the rectus femoris
(arrowheads) into the AIIS. Ps, iliopsoas muscle; AIIS, anterior-inferior iliac
spine
Anterior Hip 79

Fig. 6.4a Probe position to evaluate the rectus femoris Fig. 6.5Anatomical scheme: tendons of the rectus femo-
tendon insertion onto the AIIS ris muscle. d, direct tendon; i, indirect tendon; r, reflec-
ted tendon; RF, rectus femoris muscle; F, femur

Fig. 6.4b The ultrasound scan shows the tendinous insertion of rectus femoris
(arrowheads) onto the AIIS. RF, muscle belly of rectus femoris; Ps, psoas muscle;
AIIS, anterior-inferior iliac spine
80 6 Hip

Fig. 6.6a Probe position to evaluate the rectus femoris

tendon with longitudinal scans

Fig. 6.6b The longitudinal scan shows the direct (arrowheads) and indirect (*) tendons
of the rectus femoris muscle. Note the hypoechoic appearance of the indirect tendon
cranial portion, determined by the change in orientation of the tendon (anisotropy),
which courses externally and obliquely compared to the direct tendon
Anterior Hip 81

Fig. 6.7b Axial evaluation of the direct (arrowheads) and indi-

rect (*) tendons of the rectus femoris muscle. Sa, sartorius; F,
femur

Fig. 6.7a Probe position for the axial evaluation of

the rectus femoris direct and indirect tendons

Fig. 6.7d The axial scan shows the distal tendinous aponeuro-
sis (arrowhead) of the rectus femoris muscle (RF) shaped like
a “C”. Vi, vastus intermedius muscle; F, femur

Fig. 6.7c Probe position to evaluate the rectus

femoris distal aponeurosis
82
6.1.3 Iliopsoas
The iliopsoas muscle can be seen by means of
a series of axial scans, medial to the rectus
femoris. On these images, the hyperechoic ten-
don is located in an eccentric posterior-medial
position within the muscle belly (Figs. 6.8a, b).
The muscle can be followed using both axial
and longitudinal scans up to the insertion into
the lesser trochanter.
The iliopsoas muscle is often considered as
the only biarticular muscle, located in the
lumbo-iliac region and in the anterior region
of the thigh. Actually, it is formed by two
distinct portions: the psoas major muscle,
and the iliacus muscle. It arises from the
lateral side of the body of the last thoracic
vertebrae, from the first four lumbar verte-
brae and the interposed disc, and from the
base of the transverse processes of the first
four lumbar vertebrae. The muscle belly
runs obliquely down and outwards; it passes
under the inguinal ligament and ends on the
apex of the lesser trochanter on the thigh.
The femoral nerve runs between the iliacus
muscle and the psoas major.
The iliopsoas bursa is located anteriorly between
the joint capsule and the posterior surface of the
iliopsoas muscle. This is the largest synovial
bursa of the human body, which communicates
with the joint space in 15% of cases.
6 Hip
6.1.4 Femoral Neurovascular Bundle
Medial to the rectus femoris muscle, the neuro-
vascular bundle can be identified using axial
scans: lateral to medial, the femoral nerve, the
common femoral artery, and the common
femoral vein can be seen (Figs. 6.9a, b).
6.1.5 Hip Joint
Medially and distally to the ASIS, the hip joint
can be seen by an oblique sagittal scan to assess
the femoral acetabulum with the anterior por-
tion of the labrum, the anterior capsular profile
and the femoral head covered by the articular
cartilage (Figs. 6.10a, b). At the bottom of the
femoral there head is the anterior synovial
recess that is not detectable when normal.
Conversely, the anterior capsular profile is
almost always visualized as a hyperechoic
linear structure superficial to the joint space.
The joint capsule inserts proximally onto the
border of the acetabulum and the acetabular
labrum, distally onto the inter-trochanteric
line, and posteriorly onto a line located at
the border between the medium and lateral
third of the femoral neck. Therefore, the
anterior face of femoral anatomical neck is
intracapsular, whereas the posterior side is
only partially intracapsular.
Anterior Hip 83

Fig. 6.8b The axial scan shows the myotendineous junction

(*) of the psoas muscle (Ps). F, femoral head

Fig. 6.8a Probe position to evaluate the psoas

muscle myotendinous junction

Fig. 6.9b The axial scan shows the femoral neurovascular

bundle: fA, femoral artery; fV, femoral vein and fN, femoral
nerve. Pe, pectineus muscle

Fig. 6.9a Probe position to evaluate the femoral

neurovascular bundle
84 6 Hip

Fig. 6.10b The scan shows the femoral head (F) covered by the
articular cartilage, the acetabulum (Ac), the acetabular labrum
(*), and the anterior capsular profile (arrowheads). Ps, psoas
muscle

Fig. 6.10a Probe position to evaluate the coxo-

femoral joint
Medial Hip
6.2 Medial Hip
6.2.1 Adductor Tendons and Muscles
The patient is supine, with the lower limb
slightly externally rotated (Figs. 6.11 and 6.12).
With a sagittal scan, the bony landmark of
the anterior surface of the pubis can be seen to
Fig. 6.11 Lower limb position for medial hip eva-
luation
85
detect the insertional components of the adduc-
tor muscles (Figs. 6.13a, b). Three muscle
layers can be seen: from the most superficial to
the deepest, the adductor longus muscle, the
adductor brevis muscle and the adductor
magnus muscle. Turn the probe over the cour-
se of a single muscle belly, according to the
axial and longitudinal planes.
Fig. 6.12 Anatomical scheme: adductor muscles. The
adductor longus (AL) is the most superficial and it is
represented in shadow. The adductor brevis (AB) and
magnus (AM) are shown deeply. F, femur; P, pubic
ramus
86 6 Hip

Fig. 6.13b The longitudinal scan shows the tendon insertion

(*) of the adductor longus (AL), adductor brevis (AB), and
adductor magnus (AM) muscles in correspondence with the
pubic symphisis

Fig. 6.13a Probe position to evaluate the adduc-

tor muscles’ proximal insertion

tered with their myotendinous junctions: from

6.3 Lateral Hip
6.3.1 Gluteus Tendons and Muscles
With the patient lying on the contra-lateral hip
(Fig. 6.14), find the greater trochanter with an
axial scan and then slightly shift the probe cra-
nially (Fig. 6.16a). Similar to the shoulder rota-
tor cuff analysis, three muscles can be encoun-
the front to the back, the gluteus minimus
muscle (deep), the gluteus medius muscle,
and the gluteus maximus muscle (more super-
ficial) (Figs. 6.15 and 6.16b). Superficial to
these is the tendinous portion of the tensor
fasciae latae, which has a ribbon-like hypere-
choic appearance and is separated from the
cuff by a synovial bursa and adipose cleavage
planes (Figs. 6.17a, b).

Fig. 6.14 Patient in the lateral

position for the lateral hip
evaluation
Lateral Hip 87

Fig. 6.15 The anatomical pattern shows, in an anteroposte-

rior sense, minimus (GMi), medius (GMe), and maximus
(GMa) gluteus. GT, greater trochanter of the femur

Fig. 6.16a Probe position to

evaluate the gluteus muscles’
insertion onto the greater
trochanter

Fig. 6.16b The axial scan

shows the tendinous insertion
of the gluteus minimus (*),
medius (arrow), and maximus
(star) into the femoral greater
trochanter (GT). Arrowheads,
tensor fasciae latae tendon
88 6 Hip

Fig. 6.17a Probe position for

the longitudinal evaluation of
the tensor fasciae latae tendon

Fig. 6.17b The longitudinal scan shows the tensor fasciae latae tendon (arrowheads) superficial to the
greater trochanter (GT)
Posterior Hip
6.4 Posterior Hip
There are two trochanteric bursae: the trochan-
teric bursa of the gluteus medius that separa-
tes the homonymous tendon from the anterior-
superior side of the greater trochanter, and the
trochanteric bursa of the gluteus maximus,
often multilocular, that separates the deep side
of the gluteus maximus from the postero-late-
ral bony surface of the greater trochanter.
6.4.1 Ischiocrural Tendons
(Hamstrings)
Patient lies prone with the lower limb in a neu-
tral position (Fig. 6.18). Anatomical scheme of
ischiocrural tendons is presented in Fig. 6.19.
Fig. 6.18 Lower limb position for posterior hip
evaluation
89
With the patient prone and an axial orienta-
tion of the probe, find the ischiatic tuberosity
and visualize the conjoined tendon insertion of
the ischiocrural muscles on it (Figs. 6.20a, b,
6.21a, b).
From lateral to medial, the conjoined ten-
don of long head of the biceps femoris and the
semitendinosus can be seen. More medially, the
semimembranosus tendon is visible. It has a
very thin muscle and a very short proximal ten-
dinous component.
6.4.2 Sciatic Nerve
Lateral to the hamstring insertions, also exami-
ne the sciatic nerve axially and then longitudi-
nally (Figs. 6.22a-c).
Fig. 6.19 Anatomical scheme: ischiocrural tendon inser-
tion into ischiatic tuberosity and course of sciatic nerve. BF,
biceps femoris; SM, semimembranosus; ST, semitendino-
sus; S, sciatic nerve; IT, ischiatic tuberosity; F, femur
90 6 Hip

Fig. 6.20b The axial scan shows the tendinous insertion of the
long head of the biceps femoris (1), semitendinosus (2) and
semimembranosus (3) muscles. IT, ischiatic tuberosity

Fig. 6.20a Probe position to evaluate the ham-

strings’ insertion into the ischiatic tuberosity on an
axial plane

Fig. 6.21b The longitudinal scan shows the tendinous insertion

(*) of the semitendinosus (St) and semimembranosus (Sm) ten-
dons into the ischiatic tuberosity (IT)

Fig. 6.21a Probe position to evaluate the ham-

strings’ insertion into the ischiatic tuberosity on a
longitudinal plane
Posterior hip 91

Fig. 6.22b The axial scan shows the sciatic nerve (arrowheads)
on a short axis

Fig. 6.22a Probe position to evaluate the sciatic

nerve on an axial plane

Fig. 6.22c Longitudinal scan of the sciatic nerve (arrowheads);

ST, semitendinosus muscle belly; BF, biceps femoris muscle belly
 Knee
7

Contents
7.1 Anterior Compartment
• Quadriceps Tendon
• Suprapatellar and Paracondylar Recesses
• Femoral Trochlea
• Patellar Retinacula
• Patellar Tendon or Ligament
7.2 Medial Compartment
• Medial Collateral Ligament
• Goose’s Foot Tendons
7.3 Lateral Compartment
• Iliotibial Tract
• Lateral Collateral Ligament
7.4 Posterior Compartment
• Medial Tendons
• Semimembranosus Bursa
• Popliteal Neurovascular Bundle
• Posterolateral Corner and Biceps Femoris
• Peroneal Nerve

The knee can be divided into four compart-
ments: anterior, medial, lateral and posterior.
7.1 Anterior Compartment
The patient lies supine with the knee flexed at
about 30–45° to correctly stretch the patellar
and the quadriceps tendons (Fig. 7.1).
Anatomical scheme of the anterior compart-
ment of the knee is reported in Fig. 7.2.
7.1.1 Quadriceps Tendon
The quadriceps tendon must be scanned on
both a long and short axis. The longitudinal
view is obtained by orienting the probe on a
sagittal plane and placing the distal edge on the
patella (Figs. 7.3a, b). The typical multi-lay-
ered appearance of the tendon is due to the
overlap of the different tendinous aponeuroses
that concur to build the quadriceps tendon
(Figs. 7.4a, b). This appearance may be more or
less clear close to the insertional region, as the
amount of adipose tissue interspersed between
tendon layers may vary.
Moving the probe cranially, the myotendi-
nous junctions of the quadriceps femoris can be
seen. Note that the rectus femoris junction is
located more proximally than the others (Figs.
7.5a, b).

E. Silvestri, A. Muda, L. M. Sconfienza, Normal Ultrasound Anatomy of the Musculoskeletal System, 93

© Springer-Verlag Italia 2012
94
The quadriceps muscle is made up of four
separate heads: vastus lateralis, vastus
intermedius, vastus medialis (mono-articu-
lar muscles) and the rectus femoris muscle.
This latter is the only bi-articular muscle.
With its fibers, it forms a sort of sleeve
around the femoral shaft and it relates to
the hamstrings and the adductor muscles
distally.
7 Knee
The four heads join about 8–10 cm proximally
to the insertion on the patella, contributing to
form a three-layered tendon in which the super-
ficial layer is a prosecution of the rectus femoris,
the intermediate layer belongs to the vastus me-
dialis, and the vastus lateralis, and the deep lay-
er belongs to the vastus intermedius. Some ten-
don fibers insert on the patella, while the others
continue to form the patellar tendon, then in-
sert on the anterior tibial apophysis.
Fig. 7.1 Lower limb position to
evaluate the anterior compartment
of the knee
Fig. 7.2 Anatomical scheme of quadriceps (QT) and
patellar tendons (PT). F, femoris; T, tibia; Fi, fibula;
P, patella (under PT)
Anterior Compartment 95

Fig. 7.3a Probe position to Fig. 7.3b US scan shows the characteristic layered appearance of
evaluate the quadriceps ten- the quadriceps tendon (arrowheads). P, upper pole of patella
don on a longitudinal scan

Fig. 7.4a Position of the probe Fig. 7.4b Quadriceps tendon on its short axis (arrowheads). F, femur
for evaluation of quadriceps ten-
don along the short axis
96 7 Knee

Fig. 7.5a Probe position to Fig. 7.5b Quadriceps femoris myotendinous junctions. VL, vastus lateralis; RF,
evaluate the quadriceps femoris rectus femoris; *, rectus femoris myotendinous junction; VM, vastus medialis;
myotendinous junctions VI, vastus intermedius ; F, femur

7.1.2 Suprapatellar and Paracondylar 7.1.3 Femoral Trochlea

Recesses
The lower limb must be kept in the same posi-
tion described above to evaluate the quadriceps
tendon.
The suprapatellar fat pad (Figs. 7.6a, b) is
located under the quadriceps tendon and proxi-
mally to the superior pole of the patella. The
suprapatellar synovial recess can be seen as a
large hypoechoic space between the suprapatel-
lar fat pad and the prefemoral fat pad that lies
deeply, over the distal third of the femur.
In physiological conditions, the amount of
synovial fluid contained within the suprapatel-
lar synovial recess is very low. To detect the
presence of intrarticular effusion, dynamic
scans can be performed, asking the patient to
flex the knee completely or to contract the
quadriceps muscle. Paracondylar recesses can
be assessed performing longitudinal and axial
scans of the lateral and medial sides of the
quadriceps tendon (Fig. 7.6c).
The knee must be positioned in full flexion. On
the axial scan, the femoral trochlea and the
overlying articular cartilage (Fig. 7.7a) can be
seen. When normal, the articular cartilage is
characterized by a hypo/anechoic and homoge-
neous echotexture, while the bony surface of
the trochlea is represented by an underlying
hyperechoic line (Fig. 7.7b).
7.1.4 Patellar Retinacula
Anatomical scheme of the patellar retinacula is
showed in Fig. 7.8. Medial and lateral retinacula
can be evaluated by axial scans on the medial and
lateral side of the patella, respectively. They
appear as bilayered structures that can hardly be
differentiated from the underlying joint capsule
(Figs. 7.9a, b).
Anterior Compartment 97

Fig. 7.6a Probe position to

evaluate the suprapatellar
recess

Fig. 7.6b The sonogram shows the

physiological fluid distension of the
suprapatellar recess (*) under the
quadriceps femoris tendon (arrowheads).
F, femur; P, proximal patellar pole;
ffp, prefemoral fat pad; pfp, suprapatellar
fat pad

Fig. 7.6c Paracondylar recess (arrow-

heads) distended by a minimal
amount of fluid. C, femoral condyle
98 7 Knee

Fig. 7.7a Lower limb and probe position to evaluate the

femoral trochlear cartilage

Fig. 7.7b The sonogram shows the femoral trochlear cartilage (arrowheads). TF, femoral trochlea
Anterior Compartment 99

Fig. 7.8 Anatomical scheme of patellar retinacula.

MR, medial retinaculum; LR, lateral retinaculum;
PT, patellar tendon; F, femoris; T, tibia; F, fibula;
P, patella (under PT).

Fig. 7.9a Probe position to Fig. 7.9b The sonogram shows the medial retinaculum (arrowheads). P, patella;
evaluate the lateral and medial mfc, medial femoral condyle; ifc, lateral femoral condyle
retinacula
100 7 Knee

7.1.5 Patellar Tendon or Ligament
The lower limb is placed in the same position
used to evaluate the quadriceps tendon. The
patellar tendon must be evaluated using both
long and short axis scans, covering its whole
length (Figs. 7.10, 7.11b, 7.12a, b).
The Hoffa fat pad lies deep to the patellar
tendon. The deep infrapatellar bursa is located
at the lower pole of the Hoffa fat pad. In phys-
iological conditions, the bursa is distended by a
small amount of fluid and appears as a small
hypoechoic triangular area. The superficial
infrapatellar bursa is located over the distal
enthesis of the patellar tendon and cannot be
seen in physiological conditions.

Fig. 7.10 Anatomical scheme of quadriceps (QT) and

patellar (PT) tendons. F, femoris; T, tibia; Fi, fibula;
P, patella (under PT)

Fig. 7.11a Probe position to Fig. 7.11b Patellar tendon scan on its short axis (arrowheads). The tendon has
evaluate the patellar tendon on a typical oval elongated section (lateral-medial is larger than the antero-poste-
the short axis rior one)
Anterior Compartment 101

Fig. 7.12a Probe position to evaluate the patellar

tendon on its long axis

Fig. 7.12b Two coulplead images showing the patellar tendon in all its extension (arrowheads). P, lower patellar
pole; T, anterior tibial apophysis; HFP, Hoffa’s fat pad
102
7.2 Medial Compartment
7.2.1 Medial Collateral Ligament
Anatomical scheme of medial collateral liga-
ment is shown in Fig. 7.13. The patient is
supine with the knee flexed to 20–30° and the
leg externally rotated (Fig. 7.14).
The medial collateral ligament is a double-
layered ligament with a slightly oblique course,
from the medial femoral condyle anteriorly to
the medial tibial aspect posteriorly. The probe
must be placed on a coronal oblique scan to
assess the ligament along its extension. Both
superficial and deep portions of the ligament
(meniscus-femoral and meniscus-tibialis bun-
dles) must be assessed (Figs. 7.15a, b).
7.2.2 Goose’s Foot Tendons
Anatomical scheme of goose’s foot tendons is
reported in Fig. 7.16. Slightly anterior to the
distal insertion of the medial collateral liga-
ment, the three tendons (sartorius, gracilis,
Fig. 7.13 Anatomical scheme of the medial collateral
ligament (arrowheads). ME, medial epicondyle;
P, patella; T, tibia; Fi, fibula
7 Knee
semitendinosus) that concur to form the
goose’s foot can be seen (Figs. 7.17a, b). The
goose’s foot bursa cannot be seen in physiolog-
ical conditions. When the bursa is not distend-
ed, tendons cannot be easily distinguished one
from another.
The sartorius is a superficial muscle arising
from the anterior superior iliac spine that
runs obliquely in the anterior thigh up to the
medial tibial tubercle, where its fibers melt
with those belonging to the gracilis and
semitendinosus muscle
The gracilis lies in the medial region of the
thigh, deep to the adductor longus and mag-
nus. It arises from the pubic symphysis and
inserts on the medial tibial tubercle.
The semitendinosus is a superficial muscle
located in the posterior medial region of the
thigh. It arises from the ischiatic tuberosity
with a tendon in common with the long head
of biceps femoris and inserts on the medial
tibial tubercle.
Medial Compartment 103

Fig. 7.14 Position of lower limb for

evaluation of medial compartment

Fig. 7.15a Probe position to evaluate

the medial collateral ligament

Fig. 7.15b Superficial bundle of the medial collateral ligament (arrowheads). The asterisk shows the deep bundle of
the medial collateral ligament. m, medial meniscus.; Ti, tibia; F, femur
104 7 Knee

Fig. 7.16 Anatomical scheme of the

goose’s foot tendons. 1, sartorius; 2, gra-
cilis; 3, semimembranosus; 4, semitendi-
nosus; GM, medial head of the gastrocne-
mius muscle; GL, lateral head of the gas-
trocnemius muscle; T, tibia; PT, patellar
tendon

Fig. 7.17a Probe position to evaluate the

goose’s foot tendons on the long axis

Fig. 7.17b Tibial insertion of goose’s foot tendons (arrowheads). Ti, tibia
Lateral Compartment
7.3 Lateral Compartment
7.3.1 Iliotibial Tract
Anatomical scheme of the iliotibial tract is
shown in Fig. 7.18. Patient is supine with the
knee flexed to 20–30° and slightly internally
rotated (Fig. 7.19).
The iliotibial tract can be seen by perform-
ing a longitudinal coronal oblique scan on the
lateral distal side of the knee and can be fol-
lowed up to the tibial insertion on the Gerdy’s
tubercle (Figs. 7.20a, b). Turning the probe by
90° allows for evaluation of the iliotibial tract
on the short axis (Figs. 7.21a, b).
The tensor fasciae latae muscle arises from
the outer border of the iliac crest. It courses
in the anterior lateral thigh, inserting distal-
ly on the Gerdy’s tubercle with a tendon
common to the iliotibial tract.
Fig. 7.18 Anatomical scheme of the iliotibial tract
(arrowheads). F, femur; P, patella; T, tibia; Fi, fibula
105
7.3.2 Lateral Collateral Ligament
Anatomical scheme of the lateral collateral lig-
ament and popliteus muscle is shown in Fig.
7.22. The lateral collateral ligament can be
evaluated by placing the distal edge of the
probe on the fibular head and performing a
coronal oblique scan (Figs. 7.23a, b). The liga-
ment cannot be evaluated completely with just
one scan, the probe must be moved upwards
and downwards. Deep to the proximal insertion
of the ligament, the popliteus tendon can be
seen running into its femoral groove (popliteal
hiatus).
The popliteus is a flat muscle located deep
to the plantar and the gastrocnemius mus-
cles. It arises from the external aspect of the
lateral femoral condyle and inserts on the
superior lip and the posterior surface of the
tibia.
Fig. 7.19 Lower limb position to evaluate the lateral
compartment
106 7 Knee

Fig. 7.20a Probe position to evaluate the iliotibial

tract on its long axis

Fig. 7.20b The iliotibial

tract on the long axis
(arrowheads). F, external
condyle of femur;
T, Gerdy’s tubercle

Fig. 7.21a Probe position to evaluate the inser-

tional region of iliotibial tract on the short axis

Fig. 7.21b Iliotibial tract on the

short axis (arrowheads) close to the
tibial surface (Ti)
Lateral Compartment 107

Fig. 7.22a Anatomical Fig. 7.22b Anatomical

scheme of the lateral scheme of the lateral
collateral ligament (lateral collateral ligament and the
view). *, lateral collateral popliteus muscle and
ligament; LE, lateral tendon (posterior view).
epicondyle; Fi, fibula; *, lateral collateral
T, tibia ligament; Po, popliteus
muscle; LE, lateral
epicondyle; Fi, fibula;
T, tibia

Fig. 7.23a Probe position to evaluate the lateral

collateral ligament on the long axis

Fig. 7.23b Two coupled images showing the lateral collateral ligament (arrowheads) on a long axis scan. LE, lateral
epicondyle of femur; Fi, fibular head; T, tibia; *, popliteus tendon
108
7.4 Posterior Compartment
Anatomical scheme of the posteromedial com-
partment of the knee is shown in Fig. 7.24. To
evaluate the posterior compartment of the knee,
the patient must lie prone with the knee extend-
ed (Fig. 7.25).
7.4.1 Medial Tendons
The posteromedial corner of the knee includes
tendons that distally become part of the medial
compartment. From medial to lateral, the sar-
torius, gracilis, semitendinosus, and semi-
membranosus tendons can be seen on axial
scans (Figs. 7.26a, b).
7.4.2 Semimembranosus Bursa
The semimembranosus bursa can be seen on
axial scans between the semimembranosus ten-
Fig. 7.24 Anatomical detail of the semimembranosus bur-
sa (*) and posterior-medial tendons. 1, sartorius (myotendi-
nous junction); 2, gracilis; 3, semitendinosus; 4, semi-
membranosus; GM, medial head of the gastrocnemius
muscle; mfc, medial femoral condyle
7 Knee
don (medial) and the medial head of gastrocne-
mius (lateral) (Figs. 7.27a, b).
The semimembranosus muscle arises from
the ischiatic tuberosity medial to the biceps
femoris and semitendinosus. The distal ten-
don splits into three branches: the descend-
ing, inserting on the posterior side of tibial
medial condyle; the recurrent, inserting on
the lateral femoral condyle ending in the
popliteal ligament and the reflex, inserting
on the anterior part of medial tibial condyle.
The gastrocnemius is the most superficial
muscle of the posterior region of the leg. Its
medial head arises from the medial femoral
epicondyle and from the posterior side of the
knee joint capsule. The lateral head arises
from the lateral femoral epicondyle and from
the posterolateral side of knee joint capsule.
Their distal tendons blend with the soleus to
form the Achilles tendon that inserts on the
posterior aspect of the calcaneal tuberosity.
Fig. 7.25 Lower limb position to evaluate the posterior
compartment of the knee
Posterior Compartment 109

Fig. 7.26a Probe position to eval- Fig. 7.26b Transverse scan of the posterior-medial tendons. 1, semi-
uate the posteromedial membranosus; 2, semitendinosus; 3, gracilis; 4, sartorius
tendons on short axis

Fig. 7.27a Probe position to evaluate Fig. 7.27b SM, semimembranosus; MHG, medial head of gastroc-
the semimembranosus bursa nemius; *, bursa
110
7.4.3 Popliteal Neurovascular Bundle
Move the probe on the popliteal hiatus to
detect the popliteal artery (deep and medial),
the popliteal vein (intermediate), and the tib-
ial nerve (superficial and lateral) (Figs. 7.28a, b).
Turn the probe by 90° to assess the neurovas-
cular bundle on the longitudinal axis
(Figs. 7.29a, b). Due to prone decubitus, the
popliteal vein usually collapses. To assess it
properly, patient’s calf could be gently
squeezed.
Fig. 7.28a Probe position to evaluate
the popliteal neurovascular bundle
7 Knee
The tibial nerve is the prolongation of the
sciatic nerve. After its origin, it moves to the
popliteal hiatus, where it is located laterally
to popliteal vessels. Here some bundles form
the medial cutaneous nerve of the calf that
becomes superficial and joins a small branch
coming from the common peroneal nerve to
form the sural nerve. In the leg, the tibial
nerve runs under the arch of the soleus and
then it runs between the triceps surae and
deep muscles. Here it gives small branches
for all posterior muscles of the leg. Distally,
the nerve moves medially, passing posterior-
ly to the medial malleolus, where it gives
sensitive cutaneous branches. Finally, it
divides into the medial and the plantar
nerves that innervate the skin and the mus-
cles of the plantar side of the foot.
Fig. 7.28b Axial scan on the popliteal neurovascular bundle.
A, popliteal artery; V, popliteal vein; arrowheads, tibial nerve
Posterior Compartment 111

Fig. 7.29a Probe position to evaluate Fig. 7.29b A, popliteal artery; star, inferior genicular artery; *, ante-
the popliteal neurovascular bundle on rior tibialis artery
its longitudinal axis

7.4.4 Posterolateral Corner and

Biceps Femoris Tendon

Anatomical scheme of the distal myotendinous

junction of the biceps femoris is shown in Fig.
7.30. By moving the transducer to the postero-
lateral side of the knee, the biceps femoris can
be seen. The tendon must be evaluated on both
the longitudinal and axial scan and must be fol-
lowed distally up to its insertion on the per-
oneal head (Figs. 7.31a-c).

The biceps femoris muscle is located in the

posterolateral compartent of the thigh and
consists of two heads. The long head, common
to the semitendinosus muscle, arises from the
upper tubercle of the ischiatic tuberosity. The
short head arises from the middle third of the
lateral lip of the linea aspera and from the
lateral intermuscular septum. The two heads
join into a common belly that inserts on the
fibular head with a few fibers also inserting on Fig. 7.30 Anatomical scheme of the myotendinous junc-
tion (*) of biceps femoris muscle (lateral view). F, femur;
the tibial lateral condyle.
T, tibia; Fi, fibula
112 7 Knee

7.4.5 Peroneal Nerve

The common peroneal nerve is one collat-
eral branch of the sciatic nerve. Arising
With the patient lying in the same position used
around the upper lateral corner of the
to evaluate the popliteal neurovascular bundle,
popliteal hiatus, it runs down and laterally
move the transducer proximally to find the sci-
along the medial edge of the biceps femoris.
atic nerve and its subdivision into the tibial
Then it leaves the popliteal hiatus, crossing
(central) and the common peroneal nerve (lat-
the biceps femoris tendon and the lateral
eral). Follow the nerve distally (Figs. 7.32a, b)
head of the gastrocnemius. Finally, it sur-
up to the fibular head and neck. The two
rounds the fibular neck and it splits into two
branches of the nerve (superficial and deep)
terminal branches (superficial peroneal and
surround the fibula and pass deeply to the prox-
deep peroneal nerves).
imal insertion of the peroneus longus.

Fig. 7.31a Probe position to evaluate

the posterolateral corner

Fig. 7.31b Scan of the posterior-lateral

corner. 1, popliteal tendon; 2, LCL; 3
biceps femoris tendon; hp, popliteal hia-
tus; Fe, femur

Fig. 7.31c Myotendinous junction

(arrowheads) and biceps femoris inser-
tion on the peroneal head. Fe, femoral
lateral condyle; Fi, fibula
Posterior Compartment 113

Fig. 7.32a Probe position to evalu- Fig. 7.32b The US scan shows the superficial peroneal (white arrowhead)
ate the common peroneal nerve and deep peroneal (void arrowhead) nerves on the short axis, at the level of
the fibular head (Fi)
 Ankle
8

Contents
8.1 Lateral Compartment
• Anterior Talo-Fibular Ligament
• Anterior Tibio-Fibular Ligament
• Calcaneo-Fibular Ligament
• Peroneal Tendons
8.2 Medial Compartment
• Deltoid Ligament
• Tarsal Tunnel
8.3 Posterior Compartment
• Achilles Tendon
• Posterior Tibio-Talar Recess
8.4 Anterior Compartment
• Anterior Tendons and Deep Peroneal Nerve
• Anterior Tibiotalar Recess

The standard US protocol includes the evalua- knee flexed at about 90°, with the foot slightly
tion of four compartments of the ankle: lateral, intra-rotated (Fig. 8.1). The anatomical scheme
medial, posterior, and anterior. of the lateral compartment of the ankle is
shown in Fig. 8.2.

8.1 Lateral Compartment

The patient lies supine on the table with the

Fig. 8.2 Anatomical scheme of the anterior talo-fibular

Fig. 8.1 Position of the ankle to evaluate the lateral com- ligament (*). F, fibula; T, talus; Ti, tibia; C, calcaneus; S,
partment tarsal scaphoid; Cu, cuboid; II, III, IV, V, metatarsal bones

E. Silvestri, A. Muda, L. M. Sconfienza, Normal Ultrasound Anatomy of the Musculoskeletal System, 115
© Springer-Verlag Italia 2012
116
8.1.1 Anterior Talo-Fibular Ligament
The proximal edge of the probe must be placed
over the distal tip of the fibular malleolus and
the distal edge must be placed over the lateral
aspect of the talus (Fig. 8.3a, b).
The correct scanning plane can be easily
found placing the proximal edge of the probe
on the fibular tip with a semi-oblique scan and
slowly rotating the probe to reach an axial
plane.
Fig. 8.3a Probe position to evaluate the anterior talo-fibu-
lar ligament
Fig. 8.3b Longitudinal scan of the anterior talo-fibular ligament (*). T, talus; F, fibula
8 Ankle
Anterior talo-fibular ligament functionality
can be tested using the ultrasonographic anteri-
or drawer test. This test consists of a forced
plantar flexion and internal rotation of the foot
and allows the assessment of the presence of a
ligament tear by separating its extremities
(Figs. 8.4a, b). Also, dynamic analysis can
detect a widening of the anterolateral recess in
the case of a full-thickness tear.
Lateral Compartment 117

Fig. 8.4a Initial position of the ankle

Fig. 8.4b Stress position to test the anterior talo-

fibular ligament using the anterior drawer test
118 8 Ankle

8.1.2 Anterior Tibio-Fibular Ligament or edge of the probe on the lateral malleolus tip
and cranially rotate the distal edge until the
Anatomic scheme of the anterior tibiofibular anterior tibio-fibular ligament can be seen
ligament is shown in Fig. 8.5. Hold the posteri- (Figs. 8.6a, b).

Fig. 8.5 Anatomical scheme of the anterior tibiofibular

ligament (*). F, fibula; Ti, tibia; T, talus; C, calcaneus;
S, scaphoid; Cu, cuboid; II, III, IV, V, metatarsal bones

Fig. 8.6a Probe position to evaluate the

anterior tibio-fibular ligament

Fig. 8.6b Anterior tibio-

fibular ligament (*)
appears like a hyperechoic
fibrillar band connecting
the tibia (T) and the fibula
(F)
Lateral Compartment 119

8.1.3 Calcaneo-Fibular Ligament

Anatomical scheme of the calcaneo-fibular liga-

ment is shown in Fig. 8.7. The foot is placed flat
on the table. The probe is placed on a coronal
plane with the proximal edge over the fibular
malleolus tip (Figs. 8.8a, b). The ligament lies
deep to the peroneal tendons but its visibility is
impaired by its curvilinear course. To assess the
ligament correctly, the patient must be asked to
dorsally flex the ankle (Fig. 8.9a). A superficial
displacement of the peroneal tendons (Fig. 8.9b)
allows for differentiating partial from complete
Fig. 8.7 Anatomical scheme of the calcaneo-fibular liga-
tears of the calcaneo-fibular ligament.
ment (*). F, fibula; Ti, tibia; T, talus; C, calcaneus; S, tarsal
scaphoid; Cu, cuboid; II, III, IV, V, metatarsal bones

8.1.4 Peroneal Tendons

The peroneal tendons must be evaluated on a

short axis scan (Fig. 8.10). The evaluation must
be commenced with horizontal axial scans of the
proximal to lateral malleolus. At this level, the
peroneal muscles and their distal myotendinous
junction can be seen. Then, the probe must be
moved following a curvilinear line that turns
around the lateral malleolus tip (Figs. 8.11a, b).
The peroneus brevis tendon has a typical cres-
cent appearance and is located deep to the per-
oneus longus tendon, which has a typical oval
shape. A long axis scan is not useful in the eval-
uation of peroneal tendons, except when assess-
ing their distal bone insertions.
Sometimes an accessory tendon can be seen
(peroneus quartus tendon), it is usually located
posteriorly and medially to the peroneal ten-
dons.
oneal malleolus, then crosses the foot plant
medially, and inserts on the tuberosity of the
first metatarsal bone, as well as on the first
cuneiform and on the second metatarsal
bone.
The peroneal tendons have a common sheath
around their malleolar reflection and are sta-
bilized by a retinaculum.
The peroneus quartus may arise from the
peroneus brevis muscle, or from the fibula,
or from distal fibers of the peroneus longus.
In most cases, this tendon courses posterior-
ly to the peroneal tendons. Its possible inser-
tions are the calcaneal tubercle, the fifth
metatarsal bone, and the cuboid.

The peroneus brevis tendon arises from the

peroneus brevis muscle, located in the later-
al compartment of the leg. It courses distal-
ly under the peroneus longus tendon, turns
around the peroneal malleolus, and inserts
on the base of the fifth metatarsal bone.
The peroneus longus tendon arises from the
peroneus longus muscle, adjacent to the per-
oneus brevis. It courses distally over the per-
oneus brevis tendon, turns around the per-
120 8 Ankle

Fig. 8.8a Probe position to evaluate the calcaneo-

fibular ligament

Fig. 8.8b Long axis evalua-

tion of the calcaneo-fibular
ligament (*). F, fibula;
C, calcaneus; ttP, peroneal
tendons

Fig. 8.9a Dynamic assessment of the

calcaneo-fibular ligament in dorsal flexion

Fig. 8.9b Dynamic evalua-

tion of the calcaneo-fibular
ligament (*) with the ankle
in full dorsal flexion.
Peroneal tendons (ttP) are
displaced superficially due
to calcaneo-fibular liga-
ment integrity. F, fibula; C,
calcaneus
Lateral Compartment 121

Fig. 8.10 Anatomical scheme of the peroneal tendons.

PB, peroneus brevis tendon; PL, peroneus longus tendon;
F, fibula; T, talus; C, calcaneus; Cu, cuboid;
V, fifth metatarsal

Fig. 8.11a Probe position sequence to

evaluate the peroneal tendons

Fig. 8.11b Short axis scan of the peroneal tendons behind the fibular malleolus. PL, peroneus
longus; PB, peroneus brevis; F, fibula
122
8.2 Medial Compartment
The patient lies supine on the bed, with the
knee flexed at about 90°, and the foot is slight-
ly externally rotated (Fig. 8.12). Anatomical
scheme of the deltoid ligament is shown in Fig.
8.13.
Fig. 8.12 Ankle position to evaluate the medial compart-
ment
Fig. 8.13 Anatomical scheme of the deltoid ligament:
1a, tibio-navicular ligament (anterior superficial bundle);
1b, anterior tibio-talar ligament (anterior deep bundle);
2, tibio-calcaneal ligament (middle bundle); 3, posterior
tibio-talar ligament (posterior bundle); C, calcaneus;
S, scaphoid; T, talus; St, substentaculum tali; Ti, tibia
8 Ankle
8.2.1 Deltoid Ligament
The anterior tibio-talar ligament can be assessed
with the ankle in a neutral position (Figs. 8.14a, b).
The middle and posterior bundles must be
assessed with the ankle in full dorsal flexion. The
middle bundle is evaluated with the probe orient-
ed on a coronal plane and one edge positioned on
the medial malleolus tip (Figs. 8.15a, b).
To assess the posterior bundle, the distal
edge of the probe must be moved posteriorly
(Figs. 8.16a, b).
The deltoid ligament has a triangular shape.
It arises from the tibial malleolus, then it
splits into four bundles: two of them are
anterior, one is median, and one is posterior.
Anterior bundles
• Tibio-navicular ligament: superficial,
inserts on the dorsal aspect of the scaphoid
• Anterior tibio-talar ligament: deep to the
tibio-navicular ligament, inserts on the
medial aspect of the talus
Median bundle
• Tibio-calcaneal ligament: inserts on the
substentaculum tali
Posterior bundle
• Posterior tibio-talar ligament: inserts pos-
teriorly on the medial aspect of the talus.
Medial Compartment 123

Fig. 8.14a Probe position to evaluate the anterior

tibio-talar ligament

Fig. 8.14b Scan of the anterior

tibio-talar ligament (arrow-
heads). mm, medial tibial
malleolus; T, talus

Fig. 8.15a Ankle and probe position to evaluate

the tibio-calcaneal bundle

Fig. 8.15b Scan of the tibio-cal-

caneal ligament (arrowheads),
deep to the posterior tibial ten-
don (TP) seen on short axis.
mm, medial tibial malleolus;
T, talus; C, calcaneus
124 8 Ankle

Fig. 8.16a Ankle and probe position to evaluate

the posterior tibio-talar ligament

Fig. 8.16b Scan of the posteri-

or tibiotalar ligament showing
its superficial (circle) and
deep (*) components;
mm, tibial medial malleolus;
T, talus; TP, posterior tibial
tendon
Medial Compartment
8.2.2 Tarsal Tunnel
The structures that are contained into the tarsal
tunnel (medial to lateral) are the posterior tib-
ial tendon, the tibial neurovascular bundle,
the flexor digitorum longus tendon, and the
flexor hallucis longus tendon (Fig. 8.17).
The tarsal tunnel can be assessed on axial
scans placing one edge of the probe on the tip
of the medial malleolus and the other on the
Achilles tendon. The posterior tibial tendon
must be evaluated along its whole course with
axial scans, up to its main insertion on the nav-
icular bone. This area must be assessed careful-
ly, also with longitudinal scans, due to the com-
plexity of the enthesis that could produce
125
anisotropy artifacts. The presence of an acces-
sory navicular bone is an extremely common
finding. The flexor digitorum longus and flex-
or hallucis longus tendons must be scanned
with the same approach described for the pos-
terior tibial tendon.
The tibial neurovascular bundle can be easily
seen between the posterior tibial tendon and the
flexor digitorum longus tendon (Figs. 8.18a-c).
The tibial nerve runs in the tarsal tunnel. This
is the site where extrinsic compressions can
occur. Distally, it splits into two terminal branch-
es: the lateral and the medial plantar nerve.
Fig. 8.17 Anatomical scheme of the struc-
tures running into the tarsal tunnel. 1, poste-
rior tibial tendon; 2, flexor digitorum longus
tendon; 3, flexor hallucis longus tendon; *,
tibial nerve; Ti, tibia; C, calcaneus;
T, talus; S, scaphoid
126 8 Ankle

Fig. 8.18a Probe position and movements to evaluate

the tarsal tunnel

Fig. 8.18b Axial scan of the tarsal

tunnel. TP, posterior tibial tendon;
FDL, flexor digitorum longus ten-
don; arrowheads, tibial nerve;
FHL, flexor hallucis longus ten-
don; mm, tibial medial malleolus

Fig. 8.18c Longitudinal scan of

posterior tibial tendon’s insertion
(arrowheads) on navicular bone (Sc)
Posterior Compartment
8.3 Posterior Compartment
8.3.1 Achilles Tendon
Anatomical scheme of the Achilles tendon is
shown in Fig. 8.19. The patient lies prone with
the ankle hanging out of the bed. The Achilles
tendon is assessed using both short and long
axis scans, from the myotendinous junction to
the enthesis. However, tendon thickness must
be measured on short axis only (Figs. 8.20a, b,
8.21a, b).
Dynamic long axis scans are useful to eval-
uate biomechanical relationships among the
127
enthesis, the retrocalcaneal bursa, the Kager’s
fat pad, and the postero-superior calcaneal
tubercle.
Dynamic scans in passive plantar and dorsal
flexion of the ankle allow for a differential
diagnosis between incomplete and complete
rupture.
On the medial side of the Achilles tendon,
the plantaris gracilis tendon can be fre-
quently seen. This is a very thin accessory
tendon that can be confused with residual
fibers of the Achilles tendon in the case of
full-thickness tears.
Fig. 8.19 Anatomical scheme of Achilles tendon: T,
Achilles tendon; K, Kager’s fat pad;
*, precalcaneal bursa; arrowhead, retrocalcaneal bursa;
C, calcaneus
128 8 Ankle

Fig. 8.20b Longitudinal scan of Achilles tendon (arrowheads)

Fig. 8.20a Probe position to evaluate

the Achilles tendon on long axis

Fig. 8.21b Axial scan of the Achilles tendon (arrowheads)

Fig. 8.21a Probe position to eval-

uate the Achilles tendon on short
axis
Posterior Compartment 129

8.3.2 Posterior Tibio-Talar Recess

The posterior tibio-talar recess can be assessed

using coronal oblique scans on the medial side
of the Achilles tendon (Figs. 8.22a-b).

Fig. 8.22a Probe position to evaluate the

posterior tibio-talar recess

Fig. 8.22b *, posterior tibio-talar recess; arrowheads, flexor hallucis longus tendon;
Ti, tibia; T, talus
130
8.4 Anterior Compartment
The foot must placed in the same position used
to assess the lateral compartment. Anatomical
scheme of the anterior compartment of the
ankle is shown in Fig. 8.23.
Fig. 8.23 Anatomical scheme of the anterior compart-
ment: 1, tibialis anterior tendon; 2, extensor hallucis
longus tendon; *, deep peroneal nerve; 3, extensor digi-
torumlongus tendon
Fig. 8.24 Ankle position to evaluate the anterior compart-
ment
8 Ankle
8.4.1 Anterior Tendons and Deep
Peroneal Nerve
Ankle position for anterior compartment evalu-
ation is shown in Fig. 8.24. The probe must be
placed on an axial plane on the anterior side of
the ankle. There, the tibialis anterior tendon,
the extensor hallucis longus tendon, and the
extensor digitorum longus tendon can be
seen. The tendons must be followed distally up
to their insertion on the first cuneiform and on
the fingers, respectively (Figs. 8.25a, b).
In 5% of cases, an accessory tendon (per-
oneus tertius) can be seen laterally to the
extensor digitorum longus tendon.
The deep peroneal neurovascular bundle
can be seen deeply between the extensor hallu-
cis longus and the extensor digitorum longus
tendons (Fig. 8.25c).
The peroneus tertius muscle lies laterally to
the extensor digitorum longus. It arises from
the medial aspect of the fibula and from the
interosseous membrane. Its tendon enters the
extensor retinaculum of the ankle and inserts
on the fifth metatarsal bone.
The deep peroneal nerve is one of the termi-
nal branches of the common peroneal nerve.
At the level of the fibular neck, it pierces the
anterior intermuscular septum reaching the
anterior compartment of the leg. Here, it runs
parallel to the anterior tibial artery, between
the extensor hallucis longus and the tibialis
anterior tendons. Distally, it crosses posterior-
ly the extensor hallucis longus tendon and
enters the anterior retinaculum between the
extensor hallucis longus and the extensor dig-
itorum longus, ending in the subcutaneous tis-
sues, innervating the skin of the first and the
second fingers.
Anterior Compartment 131

Fig. 8.25a Probe position to evaluate the anteri-

or compartment of the ankle

Fig. 8.25b The anterior compartment on an axial scan. EDL, extensor digitorum longus
tendon; A, tibial artery; EHL, extensor hallucis longus tendon; TA, tibialis anterior tendon;
arrowheads, deep peroneal nerve

Fig. 8.25c The anterior compartment

on a longitudinal scan. Void arrow-
heads indicate the extensor
hallucis longus tendon; white arrow-
heads indicate the deep peroneal
nerve. Ti, tibia; T, talus
132 8 Ankle

8.4.2 Anterior Tibio-Talar Recess
The anterior tibio-talar recess can be assessed
performing a longitudinal scan on the anterior
aspect of the ankle, between the extensor ten-
dons.
The anterior tibio-talar recess appears like a
triangular hyperechoic area, when not distended
by fluid. A thin layer of cartilage of the talus can
be also seen (Figs. 8.26a-b).

Fig. 8.26a Probe position to evalu-

ate the anterior tibio-talar recess

Fig. 8.26b Longitudinal scan of the anterior tibio-talar recess (*). Ti, tibia; T, talus; c, cartilage
 Foot
9

Contents
9.1 Hindfoot
• Plantar Aponeurosis
9.2 Forefoot
• Plantar Side
• Dorsal Side

The exam can be started either from the dorsal or 9.1.1 Plantar Aponeurosis
from the plantar side of the foot.
The foot must be dorsally flexed with the first toe
extended (Fig. 9.1a).
9.1 Hindfoot The probe must be placed longitudinally over
the heel to evaluate the insertional region of
The patient lies supine or prone with the foot plantar aponeurosis on a longitudinal scan (Fig.
hanging out of the bed. 9.1b).

Fig. 9.1b Insertional region of the plantar aponeurosis on

Fig. 9.1a Position of foot for evaluation of the plantar
a longitudinal scan (arrowheads). C, calcaneus
aponeurosis

E. Silvestri, A. Muda, L. M. Sconfienza, Normal Ultrasound Anatomy of the Musculoskeletal System, 133
© Springer-Verlag Italia 2012
134 9 Foot

natural position. This can be done either by

9.2 Forefoot
9.2.1 Plantar Side
The probe must be oriented on an axial plane
over the metatarsal heads (Figs. 9.2, 9.3a-c). At
this level, the intermetatarsal spaces and flexor
digitorum tendons can be seen.
Soft tissues within the intermetatarsal spaces
must be evaluated displacing them from their
pressing the skin on the dorsal side of the foot or
by lateral compression of the whole forefoot
(Mulder’s maneuver). These maneuvers allow
for an improved detection of intermetatarsal bur-
sitis or Morton’s neuroma.
Flexor tendons and metatarsophalangeal
joints can be assessed using longitudinal scans
and passive mobilization of toes (Figs. 9.4a-c).
Dynamic scans allow also for detecting the
integrity of plantar plates.

Fig. 9.2 Anatomical scheme of a flexor digitorum tendon. P1, P2, P3, proximal, middle and distal phalanx; M, metatarsal
bone; FDS, flexor digitorum superficialis tendon; FDP, flexor digitorum profundus tendon; PP, plantar plate
Forefoot 135

Fig. 9.3a Probe position to evaluate the intermetatarsal spaces and flexor
digitorum tendons

Fig. 9.3b Axial scan of the plantar aspect of the foot. Arrowheads, flexor digitorum tendons;
II, III, second and third metatarsal bone; *, intermetatarsal space

Fig. 9.3c Axial scan at the level of the

sesamoid bones. MS, medial sesamoid bone;
LS, lateral sesamoid bone; *, flexor hallucis
longus tendon; M, first metatarsal head
136 9 Foot

Fig. 9.4a Probe position to evaluate flexor tendons on

the longitudinal axis

Fig. 9.4b Longitudinal

scan on the second
metatarsal-phalangeal
joint. M, metatarsal
head; P1,proximal
phalanx; arrowheads,
flexor tendon course;
*, plantar plate

Fig. 9.4c Longitudinal scan on the second flexor digitorum tendons (arrowheads) at its insertion
on the distal phalanx. P2, P3, middle and distal phalanxes; *, plantar plate
Forefoot 137

9.2.2 Dorsal Side intermetatarsal bursitis and Morton’s neuroma

The patient lies supine on the bed with the knee
flexed and the plantar side flat on the bed. The
probe must be oriented on an axial plane over the
metatarsal heads (Figs. 9.5a, b). The presence of
can also be detected from this position, perform-
ing the same maneuvers described for plantar
scans.
Short and long axis scans must be performed
to evaluate extensor tendons and laminae.

Fig. 9.5a Probe position to evaluate the intermetatarsal

spaces from the dorsal side

Fig. 9.5b Axial scan over the intermetatarsal spaces with a dorsal approach. *, intermetatarsal space; II, III, second
and third metatarsal bones; arrowheads, extensor tendons
 Recommended Reading
Textbooks
Bianchi S, Martinoli C (2007) Ultrasound of the Muscu-
loskeletal System. Springer, Milan
Martino F, Silvestri E, Grassi W, Garaschi G (2006) Mus-
culoskeletal Sonography. Springer, Milan
McNally EG (2005) Practical Musculoskeletal Ultrasound.
Elsevier/Churchill Livingstone, Philadelphia
Papers
Bancroft LW, Merinbaum DJ, Zaleski CG, Peterson JJ,
Kransdorf MJ, Berquist TH (2007) Hip ultrasound.
Semin Musculoskelet Radiol 11:126-136
Beggs I (2011) Shoulder ultrasound. Semin Ultrasound
CT MR 32:101-113
Fessell DP, Jacobson JA (2008) Ultrasound of the hindfoot
and midfoot. Radiol Clin North Am 46:1027-1043
Khoury V, Guillin R, Dhanju J, Cardinal E (2007) Ultra-
sound of ankle and foot: overuse and sports injuries.
Semin Musculoskelet Radiol 11:149-161
Lee KS, Rosas HG, Craig JG (2010) Musculoskeletal ul-
trasound: elbow imaging and procedures. Semin Mus-
culoskelet Radiol. 14:449-460
Paczesny Ł, Kruczy ski J (2011) Ultrasound of the knee.
Semin Ultrasound CT MR. 32:114-124
Tagliafico A, Rubino M, Autuori A, Bianchi S, Martinoli
C (2007) Wrist and hand ultrasound. Semin Muscu-
loskelet Radiol 11:95-104
139